Zolpidem has been available as a generic for the branded sleeping medication Ambien since the patent expired last year.  Zolpidem is among the shortest acting of the sleep aides available, and has been marketed as an extended release product, Ambien CR to try to extend the duration of sleep for patients who find zolpidem effective at inducing sleep but who reawaken earlier than they desire.  Now solpidem has been repackaged as a low dose sublingual product that is approved for use if in patients who tend to reawaken far too early after getting to sleep.  You can take Intermezzo to get back to sleep with the anticipation that as long as you have at least 4 hours until you need to wake up you can take the Intermezzo and not be overly sedated in the morning.

Patients have been taking a half dose of a 5 or 10 mg zolpidem for this purpose for some time, although it is not an FDA approved indication.  The effect of zolpidem taken orally in most people is only about 3-4 hours anyway, although in some people the effect can be longer. Does the sublingual route of administration make much difference?  It is possible that if the drug is absorbed directly into the bloodstream through the oral mucosa that the serum levels are achieved more quickly than with oral ingestion, and if so in theory the medication may be more quickly cleared from the bloodstream and the hypnotic effect may last slightly less time.

Zolpidem as a generic product is relatively inexpensive at $17.99/ 30 tablets for both the 5 mg and 10 mg doses on drugstore.com.  In cannot find a price online for Intermezzo but undoubtedly as a branded product it will be much higher than generic zolpidem.  I’ll be interested to hear if patients find Intermezzo more effective than low dose generic zolpidem for getting back to sleep after early awakening, but I suspect that a 2.5 mg or 5 mg dose orally will be pretty similar in efficacy, and much easier on the pocketbook.

Please leave a comment if you have tried Intermezzo, especially if you have also used oral zolpidem for the same symptoms.  Comparative experience will be interesting.

SAD was really only documented and make a diagnosis since 1984, and in the last couple of decades has become better understood.  It is great that we now have SSRI antidepressants to treat this with, but many patients either prefer not to take medication, have side effects from the drugs, or just want a more natural remedy.  Full sunlight wavelength light therapy has been shown to help in these patients, and although it is neither easy nor convenient, it does have good evidence of effectiveness.  Patients can purchase lights for therapy in many shapes and sizes, or can build their own light boxes.  I came across yet another great post by Tara Parker-Pope in the N.Y. Times you may enjoy and learn from:

Light Therapy for Dark Days

by Charles Boren

The ancient Greeks used running as a form of training and competition. It was a way to test personal fortitude and improve physical health. Many of the health benefits of running were known even in those ancient times. In modern times, many start running for the same reasons. They run to improve their physical endurance, lose weight and build muscle. While these common health benefits of running influence many to start running, runners are surprised to learn just how extensive the health benefits are. Running improves the quality of sleep, fights off depression and anxiety, and improves joint health and stability.

Sleep disorders affect a surprising percent of the population today. There is good news to those who suffer from them. Running can actually improve the decrease the symptoms of sleep disorders and improve the quality of sleep. It also appears to help people sleep more efficiently. That is, the amount of time spent actually sleeping while in bed increases. Running helps people fall asleep more quickly, toss-and-turn less through the night, and wake up more rested than those who do not run.

The runner’s high is a well-documented phenomenon, and major benefit, of running. This is a unique feeling often reported during long, strenuous amounts of exercise. The feeling can range from relaxed and peaceful to intensely euphoric. It is produced when endorphins flood the brain as part of a stress response to running. These endorphins are the natural drugs of the body. They reduce pain and are responsible for the happy and content feelings similar to many those produced by narcotics. While many runners experience this phenomenon, many do not realize the long-term positive effect that is has. Over time, the regular doses of endorphins to the brain can combat both anxiety and depression. In fact, many studies have shown that following a regular running program markedly reduces the symptoms of these disorders.

A common misconception is that the high-impact nature of running negatively affects the joints in the body. The truth is that running may actually improve joint health and stability. (1) This is done in a number of ways. First, running helps keep excess weight off. Just a ten-pound increase in body weight can cause a 45-pound increase in stress on the knees (2).  Second, running causes cartilage to expand and contract with the natural movements created while running. This forces nutrients and oxygen into the cartilage cells. Without this, the cells will slowly die from oxygen depletion and starvation. Third, running strengthens the tendons and ligaments that support and stabilize joints. This prevents injury in the long-term. Overall, running greatly improves joints and prevents the onset of arthritis.

Building muscle, losing weight, and strengthening the heart are the health benefits that motivate people to start running. However, it is the unspoken benefits that keep them running. As a whole, runners have better sleep, improved mental states, and healthier joints. Many runners feel that they are taking responsibility for their health by running. They physically feel better, less stressed and they have peace of mind. This is a reward all in itself.

Bio: Charles spends much of his free time running. On the side he also runs an automotive company, where he purchases vehicles.

The SSRI drugs prevent the reuptake of serotonin from the space between nerve endings, and lead to an increased concentration of serotonin in this space.  Viibryd in addition to this function is a partial serotonin agonist.  An agonist is any drug that simulates the activity of a chemical in the body.  This additional function could at least in theory alter the usually side effects of an SSRI as well as alter its potential benefits.

In two relatively small studies Viibryd was found to be effective as an antidepressant, but had a very low incidence of sexual dysfunction.  Specifically the incidence of orgasmic dysfunction in women and ejaculatory delay or dysfunction in men was less than 3% and very near the rates with placebo.  The published rates of these side effects with all of the currently available SSRIs, including fluoxitine (Prozac), sertraline (Zoloft), paroxitine (Paxil) and others, as well as with the SNRIs like venlafaxine (Effexor) and Cymbalta are greater than 15%, and in my experience prescribing these drugs are even higher.  By far the most common SSRI and venlafaxine side effects are various aspects of sexual dysfunction, especially orgasmic dysfunction.  These are common enough and annoying enough that I often see patients in the office who have stopped their antidepressant medications because of their sexual dysfunction side effects.

The major factor that Viibryd is going to have to overcome is that there are several highly effective generic SSRI antidepressants on the market that are available on the discount pharmacy $4./ month offerings.  As a branded antidepressant which will almost certainly be much higher priced Viibryd is going to have to show a clear benefit to gain traction in this highly competitive and saturated market.  If Viibryd is found by patients and physicians to be as effective as the currently available SSRIs at treatment of depression, and really not cause orgasmic dysfunction in women and have a very low incidence of sexual dysfunction overall it is going to be a nice addition to our options for treatment of depression.  I’ll reserve my judgement at this time, as prior releases of new SSRIs were touted as having lower likelyhood of these side effects.  I remember the claim that Celexa side effects of sexual dysfunction were low, but in aftermarket experience Celexa (citalopram) turned out to cause only minimal if any less frequent sexual dysfunction that the SSRIs already on the market.

Viibryd is reported to have a bit higher incidence of gastrointestinal side effects than most of the SSRIs, and to avoid these side effects it is recommended that patients taper up fairly quickly in dosage.  It will be interesting to see if this leads to taking an extra week or two for clinical efficacy.  One of the issues we face in prescribing antidepressants in general is that they don’t work immediately, rather tend to take 2-4 weeks to start to help.  Adding another week or two of ramp up in dosing may be a bit of a drawback to acceptance or Viibryd by patients.  I expect the role of Viibryd to be as a second choice of an antidepressant in patients who experience bothersome sexual dysfunction on another SSRI, and Viibryd is tried as a way to avoid that problem.

Viibryd was developed by Clinical Data which was acquired by Forrest Laboratories earlier this year.  Forrest also has Lexapro and Celexa as branded antidepressants, and is expected to make a big marketing push for this new product.  From the surge of drug reps at my office it certainly seems like they are throwing all of their weight behind I’m anxious to see if Viibryd lives up to its marketing hype and really does work without causing sexual dysfunction.  If so I expect it to be hugely successful.  The market for antidepressants is huge, with Effexor and Cymbalta, two branded SNRIs having sales of over $2 billion annually.  Expect the $1.1 billion Forrest paid for Clinical Data to be a bargain if Viibryd works as advertised.  I plan to go slow and see how this all pans out.

Meditation, when used as a health tool, can significantly increase an individual’s sense of well-being, while simultaneously reducing stress.  Abundant research has shown that meditation can lower blood pressure, ease chronic pain, reduce stress and depression, improve concentration, and even boost the immune system.  All of this from the basic practice of sitting and quieting the mind.  There are so many external stressors in today’s society that finding a way to slow down and focus the mind will do wonders for the body.

Charles L. Raison, MD is the clinical director of the Mind-Body program at Emery University School of Medicine in Atlanta and has participated in a study on just how meditation can improve physical and emotional responses to stress.  What he has found is that stress reduction is the key component of the health benefits of meditation.  No matter who the patient is they will benefit from stress reduction because it will enable their minds and bodies to better handle any health issues that may be present.  Even if the only concern is an inability to sleep, meditation can help with that too.

Stress is a contributor to all major modern killers like cancer.  When you think about it, it is actually quite hard to have a disease that does not include or create stress in some way.  In severe cases, stress can even be a cause of the ailment.  Finding a way to minimize or remove stress altogether can only be of great benefit to the entirety of a person’s health.

Many people view meditative practices as hippy dippy techniques, and don’t give them adequate credit for their proven positive impact on overall health.  Many are under the impression that sitting with legs crossed fingertips touching saying “ohm” is the only way to practice meditation, when in reality the only requirement of the practice is to narrow your mental focus and still the body.  This does not necessarily require a specific posture, although some are known to be more effective than others.  You can find alternative ways to achieve the same end.  Some popular, less demanding methods include counting breaths, staring at a candle, or sitting quietly – the only real challenge is finding a way that works for you.

It feels like common sense that taking ten or twenty minutes out of your day to sit quietly, breathing deeply is a great way to unwind and relax, but so many people are unable or unaware of the benefits of meditation.  Call it mediation, call it sitting, call it quiet time; taking a moment to focus your energy and calm the mind will reduce stress, promote well-being, and help bring you back into the present which is all your ever have anyway.  People that live in the present experience a greater sense of well-being, and are much less prone to stress. Try for yourself and experience the health benefits of medication personally.

About the author: Jenni Sunde is a freelance fashion writer and pop culture junkie. Jenni specializes in all things lifestyle-related. From home and design to health and beauty. With her love of art and all things beautiful, she delights in sharing her sense of style from her life to your computer monitor. Her title pegs her as an editor at a website that specializes in providing people with a car insurance quote, but her passion leads her into writing with a little more substance and a lot more heart.

From the Free online dictionary:

car·pe di·em

interj.

Used as an admonition to seize the pleasures of the moment without concern for the future.

In Latin it literally means “pluck the day” or “seize the day”

I have always been struck by Carpe Diem as a great phrase to keep front and center in the way to approach life.  As the various twists and turns of life strike out at us this focus will rarely serve us poorly.  As a family physician I see patients who spend much of their lives wracked with anguish and anxiety over the future.   It’s a cliché, but it’s so true that the only day we ever have is today.  Much of what family physicians do is to try to help patients live longer, i.e. have more tomorrows.  It is easy to lose focus on the present.  So how does Carpe Diem work in the practice of medicine?

Most of what we ask patients to do really doesn’t make today much better.  Sometimes it makes today a lot worse.  Most surgery patients feel worse immediately after surgery than they did before surgery.  Most medications don’t work immediately.  So how does health care align with the idea of making every day the very best it can be?

Sometimes it’s easy. Clearly when a condition is making the current day miserable, like appendicitis, diverticulitis, pneumonia, migraine headache, etc. interventions that lead to fairly quick resolution of symptoms fit the Carpe diem philosophy.  In the middle of the spectrum are things like high blood pressure and diabetes.  Treatment needs to be focused on disease control without making each day a dreaded affair of strict rules and medication side effects.  As we get to things like weight loss and smoking cessation you have to decide what you are seizing.  One way to think is do the most enjoyable things you can today, and don’t worry about the consequences of today’s behavior on tomorrow.  A healthier attitude might be to seize the opportunity today to improve yourself and to get healthier.  Eat five a day, quit smoking today, get a workout in today, and remember to take your medicine today.  Then keep it up again when tomorrow becomes today.

Like most things in life finding the right balance and using some degree of moderation is likely the best choice for most of us.  I think the whole trick is to be intentional in what you do today.  Don’t simply let today happen, rather make today a great day.  Make intentional decisions, and take purposeful steps to make today better than it would be if you passively let today slip by without being cherished.

So what can you do today to make it better?  It’s not likely that worrying about tomorrow, or putting off opportunities to laugh, love or smile will make today better.  Pluck the opportunities of the day and gobble them down.  Gorge yourself with all the small things you can do to improve yourself.  Make great decisions today and today will be better and all of your tomorrows are likely to be better too.

While you’re here be sure to follow @DrEdPullen on Twitter, like DrPullen.com on Facebook or subscribe so you don’t miss a post. Carpe diem.

How about Invasion of the Body Snatchers:

The feeling you get if you like these movies: Racing heart rate, chest tightness, and shortness of breath; these are part of the thrill of a good horror movie. The issue in patients with panic disorder is that they get a similar set of symptoms, related to the same physiologic phenomenon, release of large amounts of adrenalin, but at inopportune times and without apparent cause. This release of adrenalin, also known as epinephrine, from the adrenal glands leads to the things needed in a life threatening emergency. This is known as the fight-or-flight response, needed when a chainsaw murderer or ghoul is chasing you, exciting if you like a horror movie, but very frightening when it happens seemingly out of nowhere. In panic disorder patients repeatedly have the physical symptoms like racing heartbeat, increased respiration often leading to hyperventilation, chest pressure or pain, and a sense of impending doom. They often describe feeling like they are going to die. Even after understanding what is happening during these panic attacks patients are often unable to control these symptoms and the fear of having an attack can itself be extremely distressing. Panic disorder is very common. It’s estimated by the National Institute of Mental Health that in any given year 2.7% of adult Americans experience panic disorder, with a lifetime incidence of about 5%.

Epinephrine is a hormone naturally produced by the adrenal gland, and it is used therapeutically as an injected medication to stimulate the adrenergic receptors in the autonomic nervous system. (example – severe allergic food reactions or bee stings) There are several types of receptors that make up the adrenergic system. The alpha adrenergic receptors lead to constriction of the peripheral arterioles and elevation of blood pressure. The beta adrenergic receptors when stimulated lead to dilation of the bronchioles (Beta-2 receptors) and increased heart rate (Beta-1 receptors). Although we have medications to block these receptors they are not very effective in treating panic disorder.

We do have medications that are helpful in panic disorder. In addition psychotherapy to help patients learn to manage these attacks, we use the Selective Serotonin Reuptake Inhibitor (SSRI) medications to prevent these attacks, and the benzodiazapines to prevent the extreme anxiety that comes with these attacks. In addition beta-blockers are sometimes used if the attacks are primarily at predictable times like singing, musical performances or speaking, known as performance anxiety. One of the problems with benzodiazapines is that if they are used regularly a physical dependence develops, and the withdrawal symptoms mimic those of a panic attack. We try to avoid daily use of benzodiazapines in panic disorder if possible.

So this Halloween enjoy the brief and predictable adrenaline rushes of a good horror movie is you like, but if you have panic disorder symptoms that are not adequately controlled, see your physician and try to get some help.

Maybe you liked Night of the Living Dead:

This is good news for military dependents in the Tri-West region.  Look for similar programs in other Tri-Care regions also.  There is increasing concern about the suicide rates among active duty personnel in Iraq and Afghanistan.  In 2009, for the first time, the suicide rate among active duty males was higher than in age-matched civilians.  In 2009 through late November more active duty personnel died of suicide than were killed in either Afghanistan or Iraq (at least 234 suicides vs. 297 killed in Afghanistan and 144 killed in Iraq).  Numbers are not available for civilian dependents of active duty personnel, but this has to be a concern for them also.

If you know of any military dependents who may benefit from these services please forward this article to them, or let them know of this newly available service.  Our armed forces members and their families face tremendous stresses as the deployments happen over and over again.  They deserve the best we can offer, and this seems to be a step in the right direction.

We tend to think of cancer as a disease that you may get, have treatment for, and either be cured of the disease or die from the disease.  In a way that’s correct, but what’s easy to forget is that there are lots of people who get cancer, are treated, don’t get a cure, but for whom treatments  are fairly effective at holding the cancer in some degree of control and they live for long periods of time with cancer.  Living with cancer is different than living after cancer.  This is more common now than ever before, as new medications are developed that can treat cancer and often give short or moderate duration remissions, or simply prevent progression of the cancer. 

Several types of cancer are particularly common and also have treatments that while not curative can be effective enough to allow a person to live with their cancer for a long time.  Among others these include breast cancer, ovarian cancer and prostate cancer.  Living with cancer, as differentiated from living after having had cancer, requires rethinking how you approach life.  We tend to think of our lives as having a youth, an early adulthood, the mid-life years, the older active adult years, and old age.  Couples who have good relationships often plan to get old together, and think of a future in terms of decades, rather than in terms of years.  All of the online retirement planners ask you what you want to use as a life expectancy.  I’ve always entered something like 85 years, thre actuarially correct answer for a healthy 55 year old. 

When a person has a disease that they know they will die from in a few months it requires rethinking how to spend your last days.  This is a type of thinking that although painful and difficult, is a way that we intuitively understand.  What’s really important to me.  I cannot put off for tomorrow what needs to be done today. Short term planning and thinking is something that is conceptually concrete.  Most of us can wrap our brains around this scenerio.

When a person has a cancer they have been told cannot be cured, but that they have a good chance of living with for some ill-defined number of years, maybe 2-3, possibly 5-10 or even more, this requires a different type of thinking.  Oh, and by the way add that maybe you’ll be getting some sorts of treatments that will make you sick, or have low blood counts and require you to avoid being around lots of people, but we don’t know when or whether you’ll need these treatments.  Living with both the relative certainty that you have a cancer that is not curable and also many uncertainties (how long you have, how will you tolerate the treatments, how good will your quality of life be, how will your family and loved ones cope, ….) is different and has its own challenges.  Finding the right balance:

• living in the present vs. planning for the future
• addressing your feelings and needs to grieve while enjoying every day
• needing support and help but wanting to be treated normally
• laughing and crying
• Enjoying the everyday pleasures vs. doing the things you’ve always wanted to do but never made time for

Lots more I’m sure I haven’t thought of yet.

I don’t profess to be an expert on how to live this life. under these circumstances.  I expect I’ll learn more about it over the next few years.  I pray that I’ll be up to whatever decisions come my way, but right that’s about as specific as my prayers have evolved. 

Any advice, resources, and anecdotes are welcome in the comments.  If you’d like to submit a guest post on this or other subjects use the contact tab above to send the post to me to consider for this blog.

In about 1990 a group of meds known as second generation antipsychotics were developed.  The first of these was clozapine which is difficult to use because of the potential to cause agranulocytosis.  It was followed shortly by risperidol, olanzapine and others.  These were a huge improvement in our arsenal of antipsychotic meds, since they are much less sedating, often leave patients able to function in society, be fairly alert, and feel better on the meds than off.  Many schizophrenic patients are now stable on long term antipsychotics and function in society far better than was possible on the older medications. Also the tardive dyskinesias are almost unheard of with these medications.  Now we have to watch for other side effects like weight gain with some, and an increased risk of developing diabetes, but these are relatively tame side effects compared to treating a patient with a drug that made them nearly a walking zombie.  With these drugs many patients are treated successfully by primary care physicians, and function out of institutions free of the intrusive and destructive psychotic problems of their disease.  Even newer drugs continue to be developed and give us more options to fine tune treatment of major psychosis.

Also read: Depression: It Helps when the Treatment is Not Worse Than the Disease

Now when we see a depressed patient who is a candidate for medication, we can choose from several effective and well tolerated medications, and when discussing the side effects we can emphasize the only common annoyance, delayed orgasm from most of these meds.  We no longer have to feel apologetic for prescribing a medication expected to make things worse before helping.  I feel like depression is now one of the most gratifying problems that I see patients for in the office.  In the last few years with generic versions citalopram, fluoxetine, paroxetine and sertraline we have inexpensive options too.

Check out the first 3 posts in my series of observations in medical progress over the last 30 years:

Vasectomy: Faster, Safer and Better than before the No-Scalpel Technique

Now we have Effective Treatment of Congestive Heart Failure

Peptic Ulcer Disease – From Curse to Cure

Also enjoy: 30 Years of Progress – Antipsychotic Therapy

Sabotaging Success, but to What End?

By RICHARD A. FRIEDMAN, M.D.

Published: March 22, 2010

Hearts Actually Can Break

By RON WINSLOW    FEBRUARY 9, 2010

Dorothy Lee and her husband of 40 years were driving home from a Bible study group one wintry night when their car suddenly hit the curb. Mrs. Lee looked at her husband, who was driving, and saw his head bob a couple of times and fall on his chest.

In the ensuing minutes, Mrs. Lee recalls, she managed to avoid a crash while stopping the car, called 911 on her cellphone and tried to revive her husband before an ambulance arrived. But at the hospital, soon after learning her husband had died of a heart attack, Mrs. Lee’s heart appeared to give out as well. She experienced sudden sharp pains in her chest, felt faint and went unconscious.

It shows that dying of a broken heart isn’t just a metaphor. WSJ’s Ron Winslow talks with Simon Constable about studies that show real, and sometimes fatal, changes can occur in the heart after a traumatic breakup or death of a loved one.

When doctors performed an X-ray angiogram expecting to find and treat a blood clot that had caused Mrs. Lee’s symptoms, they were surprised: There wasn’t any evidence of a heart attack. Her coronary arteries were completely clear.

Doctors eventually determined that Mrs. Lee had suffered from broken-heart syndrome, a name given by doctors who observed that it seemed to especially affect patients who had recently lost a spouse or other family member. The mysterious malady mimics heart attacks, but appears to have little connection with coronary artery disease. Instead, it is typically triggered by acute emotion or physical trauma that releases a surge of adrenaline that overwhelms the heart. The effect is to freeze much of the left ventricle, the heart’s main pumping chamber, disrupting its ability to contract and effectively pump blood.

The phenomenon is a “concussion” of the heart, says Scott Sharkey, a cardiologist at Minneapolis Heart Institute. “It’s really a heart attack which is triggered by stress rather than by a blocked artery,” he says.

Achy Breaky Heart

Broken-heart syndrome mimics a heart attack and is brought on by acute emotion or physical trauma. Here are some triggers that doctors say prompted patients to suffer the malady.

Emotional stressors:

• Death of a spouse
• Patient’s dog caught in a raccoon trap
• Losing large amount of money in a casino
• Getting lost while driving in an unsafe neighborhood at night
• Feeling overwhelmed by new computer software

Physical stressors:

• Migraine headache
• Knee surgery
• Low blood sugar
• Adverse drug reaction
• Respiratory distress

For reasons that aren’t fully understood, the problem, formally known as stress-induced cardiomyopathy, afflicts mostly women after menopause. The syndrome is relatively uncommon, accounting for an estimated 1% to 2% of people—and about 6% of women—who are diagnosed with a heart attack. In addition to such common emotions as grief and anger, doctors say broken-heart syndrome has been triggered by a person’s anxiety over making a speech, a migraine headache or the emotional response to a surprise party. It can be fatal on occasion, but for the most part patients recover quickly, with no lasting damage to their hearts.

In a conventional heart attack, an obstructed artery starves the heart muscle of oxygenated blood, quickly resulting in the death of tissue and potentially permanently compromising heart function. In contrast, the heart muscle in broken-heart-syndrome patients is stunned in the adrenaline surge and appears to go into hibernation. Little tissue is lost. “The cells are alive, but mechanically or electrically disabled,” Dr. Sharkey says.

Mrs. Lee’s heart was so weakened by her episode in 2005 that she nearly died. The 63-year-old required a special balloon pump to support her left ventricle during the first couple of days in the hospital. But Mrs. Lee, who runs her own clothing repair business in a Minneapolis suburb, was discharged within five days. Despite cautions by her doctors, she attended her husband’s funeral a few days later. “I was able to work through my grief both positively and spiritually,” she says. “I have no effects of [the heart episode] today.”

Weak Pumping

When patients are hospitalized with broken-heart syndrome, their hearts might be pumping at as little as 20% efficiency, a mark of serious heart failure, says Chet Rihal, a cardiologist and director of the catheterization clinic at Mayo Clinic, Rochester, Minn. But within 48 to 72 hours, many recover to the 60% level that is considered healthy. “It’s remarkable how quickly this will occur and how quickly they will recover,” he says.

The phenomenon was first identified in the early 1990s by Japanese researchers, who named the condition “tako-tsubo” cardiomyopathy, because in X-ray images, the left ventricle affected by broken-heart syndrome takes the shape of a vase-like pot used in Japan to trap octopuses.

The first major studies in the U.S.—one from Dr. Sharkey and his colleagues and another by Ilan S. Wittstein and other researchers at Johns Hopkins University in Baltimore—appeared within 10 days of each other in 2005.

The researchers say that more than 90% of those affected by broken-heart syndrome are post-menopausal women—possibly because lower levels of the hormone estrogen make heart cells in some women more vulnerable to an adrenaline rush. But some men and younger women have also been diagnosed with the syndrome, complicating the estrogen argument. And just last month German researchers reported an episode in a 2-year-old girl who was undergoing surgery. (Her heart recovered fully.)

In any event, experience at the medical centers in Minnesota and Baltimore suggests that the problem afflicts a small portion of the people who arrive at the emergency room with heart-attack symptoms.

“It’s a small number, but it’s really important to learn how to recognize them,” says Dr. Rihal. “The treatment for these patients is really different” than that prescribed for patients with a conventional heart attack. For one thing, it’s risky to give a clot-buster drug to a patient without an arterial blockage, due to the potential to cause a stroke.

Doctors don’t yet understand the mechanism that causes broken-heart syndrome. Nor are there any established ways to identify people who might be susceptible to the condition or known strategies patients might adopt to reduce their risk.

While doctors use blood-pressure pills such as beta-blockers and ACE-inhibitors to help treat the condition, Dr. Sharkey says that about 20% of patients who suffer an attack of broken-heart syndrome are already on such medications.

“This is so powerful that with currently used doses, we haven’t found a way to block it,” he says. The problem recurs in about 10% of cases.

Triggers for broken-heart syndrome seem as varied as the number of people affected. While death of a spouse or other close family member or friend is a common cause, breakups such as a divorce or separation have also sparked the event, according to a study of 136 patients by Dr. Sharkey and his colleagues published Jan. 26 in the Journal of the American College of Cardiology.

For others, being overwhelmed by new software at work, seeing a poultry barn burn down, or losing money at a casino all have brought the condition on, doctors say.

Nonemotional Trigger

But physical stress can cause a broken heart as well. “The emotional aspects get all the press,” says Dr. Wittstein of Johns Hopkins. “But nonemotional triggers” are at least as common. A sudden drop in blood pressure, an asthma attack, a surgical procedure, an adverse drug reaction and withdrawal from alcohol are among such causes.

Pat Dorn’s trigger, like that of Mrs. Lee, was the health of her husband. She went to awaken him one morning in 2006 and found him in bed lying on his back with his hands crossed over his chest. “I kept slapping his face and calling to him and he didn’t respond,” she recalls. When an ambulance crew arrived, her husband regained consciousness but seemed disoriented; she worried he was having a stroke.

At Mayo Clinic’s St. Mary’s Hospital two hours later, she began suffering chest pains. But she was reluctant to tell anyone because she felt her husband still needed her to help describe his condition to doctors. In addition, the retired college English teacher exercised regularly and doubted she was having a heart attack.

Wrong Diagnosis

When she finally sought help, nurses at the hospital just looked at her and told her she was having a heart attack. An electrocardiogram supported the assessment. But an angiogram didn’t find any blockage and Mayo doctors quickly recognized the tell-tale shape of tako-tsubo shape of her left ventricle that was characteristic of broken-heart syndrome. She spent three days in the hospital and went home the same day as her husband, who recovered from an unusual episode of brain inflammation.

One explanation for broken-heart syndrome may lie in the interaction between adrenaline and heart-muscle cells. Adrenaline causes calcium to rush into heart cells, which is how they contract, Dr. Wittstein explains. Some abnormality in the relationship may result in a calcium overload that stuns the heart.

Researchers are also identifying gene variants that may predispose some people to suffering from the condition, he says.

Another question is why some events with strong emotion affect people while others don’t. One patient in Dr. Wittstein’s research suffered an episode after she entered a dark room and people jumped out to wish her a happy birthday. A year later, her brother died. “You’d think that would be much more stressful, but she didn’t get the syndrome.”

Remembering vs Reliving

We have all lived through things we wished we had not experienced, some of us more than others. Coping with these memories, images, or feelings can be quite difficult. Something I notice when people talk about their painful past experiences is that many seem to be transported back to the time period it happened in. This is referred to as “reliving“, and it is understandable why we put so much effort into avoiding this material if our only way to work with it is to experience it all over again. 

I hold reliving in contrast to “remembering“, which is when we can look at the past material from our current position, rather than be transported back in time. When we are able to do this, we are more likely to be able to recall old feelings without becoming trapped in the past. The steps I try to help people follow to move into remembering are:

1. Center yourself in the present: this means orienting yourself to you current age, place, and time. For example, “I am 37 years old, sitting in my living room in January 2010″. This can help if you close your eyes and really feelbeing here now.

2. Look backward at events that have passed: this means maintaining your current position in the present, in a safe place, looking back at what happened, and remembering what you felt and experienced then.

3. Making sense of it now: this is a crucial step, and it is putting the experience into context of everything that has happened since. For example, being able to say “I lived through that, it got me off track for awhile, but I have become a stronger person since.”

Most people doing this experience a change of reference that brings different thoughts and feelings about the old material that they had before, and it allows them to engage what happened in new and productive ways, and even forgive themselves or the others involved. This works best for situations that are not ongoing or are in the more distant past, but can be useful anytime you may find yourself trapped in painful old memories.

I also want to add that if some of this old painful stuff seems to just come up and take you into reliving before you can even choose, I would suggest pausing, and then orienting yourself to the present, just like in step 1. When successful, this allows you to maintain a different level of control over how you examine things.

Additionally, for serious traumatic experiences, there is often a lot of other work that needs to happen before this will work for you, which can occur in therapy.

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First what’s too much?  Hey, I like a nice beer or glass of wine, so what’s the problem.  Most experts agree that for men drinking less than 4 drinks on a given day, and less than 14 drinks on a given week, and for women less than 3 drinks on any given day, and less than 7 drinks in a week, is probably safe.  (no sexism here, just men metabolize alcohol faster and are generally bigger people) There is even some evidence that moderate amounts of alcohol may have beneficial effects on HDL cholesterol and heart disease.  None-the-less alcohol abuse is the third leading cause of preventable premature death in the US.  (behind tobacco use and poor eating and exercise lifestyles)  Most experts differentiate between at-risk-drinking, alcohol abuse, and alcohol dependence.  At risk drinking is defined as drinking above the 3-4 drinks in a day more than 12 times a year.  This is estimated to apply to about 21% of Americans.  Most people in this category just need to drink less and be careful not to put themselves in a position to have life-altering consequences.  (driving, handling firearms, etc.)   Often they can just modify their drinking behavior, and do not need to abstain.

Alcohol abuse (5% of Americans) and alcohol dependence (4% of Americans) together constitute what are called alcohol use disorders.  Here is a table from an article in American Family Physician July 1, 2009.

Diagnostic Criteria for Alcohol Abuse and Dependence

note: The threshold criterion for any alcohol use disorder is a dysfunctional pattern of substance use causing clinically significant impairment or distress.

In general people who meet the criterion for alcohol use disorders need to obtain help to find a way to abstain from alcohol.  Your physician can help you find resources to move toward this goal.

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