Tag Archives: anxiety

Are There Any Side Effects From Psychotherapy?

The vast majority of people who receive psychotherapy through the Internet benefit from the treatment, though a small number do experience some kind of side effect.

Alexander Rozental, PhD, a psychologist, decided to explore the side effects of online cognitive behavioral therapy (CBT). Online CBT is similar to the CBT one would get from seeing a mental health professional directly or reading a self-help book, but support is given through email with a psychiatrist. The dissertation is thought to be the first examination of the side effects of Internet-based therapy.

Rozental’s research found that only 6% of 3,000 patients receiving Internet-based therapy got worse during treatment.

When he examined patients who received psychotherapy in an outpatient setting that were asked if they had negative effects of the treatment, one-third said they had a difficult memory resurface, had more anxiety or felt stressed. In addition, some said they had a poor relationship with their therapist or the treatment was subpar.

Rozental explained that what is needed in further research is a better understanding of therapy side effects, both to identify patients who become worse early in treatment and to shield patients from bad therapists.

“’I hope that psychologists and psychotherapists become more aware that there can actually be side effects and that they need to ask patients whether they are experiencing any,” he said.

Episode 13: The Best Way to Handle Holiday Stress

Put down the Xanax. This week, MedShadow Founder Su Robotti and Content Manager Jonathan Block talk about using easy forms of meditation to manage stress during the holidays.

Su Robotti: Hello and welcome to MedShatowTV. My name is Sue Robotti, and I’m the founder of MedShadow.

Jonathan Block: And I’m Jonathan Block. I’m the content manager for MedShadow.

SR: Today, we’re going to talk to you about stress. We’ve been feeling a lot of stress. The holidays are coming, and stress is caused by too much food, too many relatives, too much pressure, too much gift shopping, too much drinking.

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The key here is too much. Today, we want to help you take it down a notch, calm down, and we want to help you do that through meditation.

First of all, what is stress? The physical response to a stressful situation is adrenalin and cortisol enter your bloodstream. It increases your blood pressure, and your heart rate starts to go stronger. And if this isn’t dealt with easily or quickly, and it continues for a period of time, it can lead to gastrointestinal problems. It can lead to heart disease. It can lead to brain dysfunction like I’m having now. It can lead to a lot of long-term issues with heart disease and gastrointestinal problems among other things.

But Jonathan, what do you suggest we do? Should we pop a pill? That would be very quick.

JB: Absolutely, don’t. You’ve actually alluded to it, and that was through meditation, which is the main part of an idea known as mindfulness, which is defined as being aware of the present. I mean, I know what a lot of people are thinking — the same thing that I was thinking when I heard the word mindfulness. That just sounds like a whole bunch of new age hooey.

SR: Hooey?

JB: Hooey.

SR: Okay.

JB: I’m going old school. I can tell you from a personal experience as somebody who’s dealt with stress, and anxiety, and depression. Meditation associated with mindfulness actually does work. It works well.

And why don’t you take a pill? Because pills have side effects.

Mindfulness meditation — and we’ll be discussing this in a little bit — there are clinical studies that have demonstrated that mindfulness meditation can be used for a number of different conditions avoiding these sort of drugs, which as our MedShadow audience knows, most of which — if not all — are associated with side effects, drug interactions, or other nasty effects.

SR: In fact, is meditation as effective as antidepressants?

JB: Yes, it is. There’s been, I want to say, 40 to 50 clinical studies done just on comparing mindfulness and meditation with antidepressants. They’ve all come to the same conclusion. Mindfulness meditation is as effective as antidepressants.

So why — I know what you’re going to say. I’m going to read your thoughts. But why not just take a pill, right?

SR: Why not?

JB: I know that’s the easy way to go out. The thing is is that as I just mentioned, antidepressants and other antianxiety pills like the Xanax or the Valium that some people in our audience may be taking, have taken, or thinking about taking.

Mindfulness meditation is something that you can teach your brain how to think. It helps you relax without the use of drugs, and therefore you can learn how to deal with stress and anxiety over the long term. It’s actually much better for you, because you’ll actually train your brain how to better handle stress and anxiety but without the nasty side effects of a pill which means it is harder work.

But in the long term, the long-term efficacy of it has been demonstrated whereas with antidepressants, we know that people develop problems, and they lose their efficacy. And for some people taking antidepressants and anti-anxiolytic drugs, they just aren’t even effective anymore.

SR: So let’s take a breath.

JB: Yes.

SR: And how do you meditate? Do you have to sit cross legged? Do you have to hold your fingers in the air? Do you have to say, “Ohmm”?

JB: No, you’re thinking of some of the Buddhist meditation. But this type of meditation like the meditation that pretty much busy people or people that don’t want to go, “Ohmm,” want to do — can take as little as 10 minutes.

That’s what I do a day. I only do 10 minutes. I do some breathing exercises. There are also ways which if you learn more about mindfulness and we’ll provide you with some information about that in a second — the mindfulness, actually, you train your brain to relax. I know this sounds weird, because I didn’t believe it until I started doing it. And then in the words of a great Monkees song, “I’m a Believer,” and I’m a believer now about how effective mindfulness is and how effective mindfulness meditation is as well.

SR: So do you take classes? How do you learn to do this?

JB: I do a combination of things. I have read some books. There’s an excellent website that is operated by the fine people at UCLA known as the UCLA Mindfulness Awareness Research Center. That address is http://marc.ucla.edu. They actually have free relatively short meditations that you can download and listen to, and you can start on your own.

There’s another resource that I use a lot. This is a paid resource. It’s an app, and you can also do on your computer called Headspace. But I pay — I find it particularly effective. I looked at a lot of them, and I find Headspace — just to let the audience know, neither Headspace nor UCLA has asked us to mention them. This is just from my own personal experience.

SR: And then I’ll add one that’s free that I use; it’s called Breathe. But there are many, and you’ll find the one that you like if you just Google guided meditations, and you’ll find it.

I started meditating by simply becoming quiet and not using guided meditation — just setting a timer and trying to still my thoughts calmly for 3 minutes at a time. I got up to 5 minutes. And honestly, guided meditation is much easier.

JB: Oh, yes.

SR: And I would like to graduate to regular quiet meditation. But for now, I’m finding that I become more calm and happy using the guided meditation.

JB: And if you’re a novice — I still consider myself a novice — I find that the guided meditation works a lot better.

Just one other point because I know we’re talking a lot about this. It’s that mindfulness meditation is actually good not only for — works well, I should say — works not only well for depression, anxiety, and stress, but it’s been shown that people that want to lose weight through practice of mindfulness meditation, they can actually teach themselves to eat less.

SR: Eat less during meditation?

JB: No, afterwards, because they train their brain.

SR: You mean through their mindfulness.

JB: Right, because they think — like they ‘think before.’ You’ve heard the term, “Think before you act.”

SR: Uh-hum.

JB: You teach yourself how to think before you eat, and you’re more careful at what you eat. But just by taking a few — by doing 10 minutes of meditation every day and then when you go and decide to have your meal, people who have done meditation and mindfulness, they train their brain to think, “Maybe I don’t need that side of French fries. Maybe I should get a side of quinoa or something of that nature, something of a more healthy starch.”

SR: Yes. My downfall is more of when I’m in a family situation, and there’s cheese, and crackers, and nuts, and all these good stuff in front of me, and I find I’m eating without thinking. I think you’re going to tell me that that’s not mindful.

JB: It’s not mindful, but everybody is allowed during the holidays to cheat a little bit. The thing is not to make it a regular part of your life. And even if you just have a few — if you — let’s say you cut out — maybe you only eat nuts, but instead of reaching for the Ferrero Rocher chocolate, maybe in parties you might have had 3. Now, maybe you’ll only have 1. That’s even mindfulness just like making even a slight change. And then as you get better and better at mindfulness and meditation, you’ll learn to control yourself better.

SR: Okay. So instead of taking a pill, instead of eating chocolate, instead of taking a long hot soak in the tub, what we’re going to do is try meditating to de-stress.

JB: Actually, taking a long hot soak in the tub is actually very good.

SR: Soak in the tub — we’re saying yes to this.

JB: We are saying yes to that.

SR: What about taking a walk or a jog?

JB: Also excellent.

SR: Okay.

JB: Just lose the medications and go easy on the chocolate.

SR: Okay. Do that and have a great holiday.

JB: Yes. From all of us here at MedShadow, thank you for making MedShadowTV, which just premiered this year, such a wonderful success, and a happy holidays to you and your family. Take care.

High Percentage of Americans Taking Psychiatric Drugs

Nearly 17% of Americans — 1 in 6 adults — took a drug to treat a mental illness at least once in 2013, with antidepressants as the most common prescription filled.

About 12% of adults said they used antidepressants; 8.3% filled a prescription for an anxiolytic, sedatives or hyponotic; and 1.6% reported taking an antipsychotic.

White adults were the most likely to have taken a psychiatric medication. Nearly 21% of them did. Next were black adults at 8.7%, followed by Hispanic and Asian adults at, respectively, 8.7% and 4.8%

The analysis, published Dec. 12 in JAMA Internal Medicine, was based on data from the 2013 Medical Expenditure Panel Survey. The authors said that the use of these drugs could even be much higher as the prescription use data was self-reported.

Older age was also associated with higher psychiatric drug use. About 25% of adults 60 to 85 reported use compared with 9% of adults 18 to 39 years of age. Also, women were significantly more likely than men to take medication for a mental health issues.

“Safe use of psychiatric drugs could be improved by increasing emphasis on prescribing these agents at the lowest effective dose and systematically reassessing the need for continued use,” the authors noted.

If you are experiencing side effects with antidepressants, check out MedShadow’s feature on how to cope with them.

Coping with the Side Effects of Antidepressants

Headaches, nausea, feeling on edge, being exhausted and a low sex drive. The irony of antidepressants is that in some cases, side effects can cause the similar symptoms as the depression they are supposed to treat. In fact, those side effects are a key reason that people stop taking the drugs.

There are many ways to cope with depression — therapy, exercise, nutrition and more — but some people will find they need the boost of an antidepressant. Be warned, however, that finding the right antidepressant medicine may take some time. It usually takes weeks for a therapeutic effect and sometimes the first antidepressant an individual is prescribed doesn’t work. And when you are ready to stop taking an antidepressant, you’ll have to be weaned off it because they cause dependence.

An estimated 6.7% of adults in the United States — that’s nearly 16 million people — experience at least 1 episode of depression each year, and approximately 11% of Americans aged 12 and older take a prescribed antidepressant medication. Many patients who take these drugs, however, experience adverse side effects that may influence whether or not they continue taking them. In fact, negative side effects are the top reason that people stop taking antidepressants.

“Side effects for antidepressant medications are not unusual,” said Keith Humphreys, MD, a professor of psychiatry and behavioral sciences at Stanford School of Medicine in California. “The 5 most common are getting headaches, feeling nauseous or even throwing up, feeling edgy or agitated, feeling excessively sleepy or low on energy, and experiencing reduced sexual desire or satisfaction.”

The older types of these medications, including tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), are typically associated with more severe side effects. As a result, they are not prescribed as much anymore. Some of examples of the TCAs include amitriptyline, amoxapine, desipramine and doxepin, while some of the MAOIs are isocarboxazid, phenelzine, selegiline and tranylcypromine.

Antidepressants are serious medicines that can significantly improve some people’s lives. However, the newer types such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) have also been linked with problems. A study published in 2008 in the journal Dialogues in Clinical Neuroscience, for example, found that 55% of people taking an SSRI reported that they had experienced at least one troublesome side effect as a result.

The sexual side effects are a top concern for both men and women taking antidepressants. In addition to issues with sexual interest and arousal, SSRIs can impede erection or ejaculation in men, and they may interfere with lubrication, genital blood flow or orgasm in women.

According to the results of a large survey conducted by Consumer Reports published in 2010, between 23 and 36% of people taking antidepressants reported having had related sexual problems, and some research findings suggest that rates of such side effects could actually be as high as 60%.

Trial and Error

“The side effects vary across the different types of antidepressants, and the precise mechanisms are not always understood, but in general, antidepressant medications alter the levels of chemicals in the brain that regulate many different functions,” explained Humphreys. “When they are effective, the result is reduced depressive symptoms and greater quality of life, but because medicine can’t perfectly adjust such a complex organ as the brain, unwanted effects also often occur.”

In addition, though the reasons are unclear, some individuals have a better response to some antidepressants over others, and one drug may work well for one person and poorly for another. Settling on the right one can sometimes take a bit of trial and error.

Your doctor should initially start you on the lowest effective dose of medication and then keep tabs on your response. Keep in mind that it can take up to 6 weeks before you notice any change as a result of the medication, and it is important to stay on it for about that long — unless you have severe side effects — in order to give it a chance to take effect.

Still, researchers have found that 30 to 40% of people do not improve with the first medication prescribed, in which case the doctor may need to increase the dosage or switch the medication to another one. “It’s not uncommon to try as many as 3 or even 4 antidepressants before you find one that works,” according to Consumer Reports.

Note that means it could be 3 to 4 months before you find an antidepressant that works for you. During this time period, you’ll need to take other steps to cope with your depression. Your doctor might suggest cognitive behavioral therapy (it’s the industry standard to partner antidepressants with therapy in any case). And many people find exercise, change of diet or other non-medical interventions to be helpful.

If you do experience bothersome side effects, other options should generally be considered if they do not fade after weeks or months, advises Humphreys. He points out that many side effects are often temporary, and those that linger should be checked out.

“The best advice is to talk to the prescribing doctor about alternative antidepressant medications,” he said. “Many patients who have unpleasant side effects with one medication will have a better experience on a different medication.” You may ultimately decide that the benefits of a particular medication outweigh any negative effects it may cause.

Know What to Expect

When people experience side effects — or in some cases, when they start feeling better — they may decide to suddenly quit taking their antidepressant. But don’t do it. You should not stop taking the medication without the guidance of your healthcare provider, who will help you taper off of it at a safe pace that will allow your body adequate time to adjust.

“People don’t get addicted (or “hooked”) on these medications, but stopping them abruptly may also cause withdrawal symptoms,” according to theNational Institute of Mental Health. Suddenly quitting these meds may also increase your risk of depression relapse.

Certain symptoms, however, could signal an emergency and require immediate action. You should call your doctor right away if any of the following occur while you are taking antidepressants, particularly if the symptoms are new, getting worse or causing you significant worry:

  • Suicidal thoughts or attempts
  • New or worsening depression or anxiety
  •  Feeling very agitated, irritable or restless
  • Panic attacks
  • Sleep problems such as insomnia
  • Acting aggressively, dangerously, impulsively and/or violently
  • A significant increase in activity and talking–symptoms of mania
  • Other unusual behavior or mood changes

According to researchers at Boston University and Massachusetts General Hospital/Harvard Medical School in Massachusetts, the “successful management of side effects begins with adequate communication and patient education prior to and throughout treatment with antidepressants.” Physicians should also help you sort out whether symptoms are truly side effects of treatment or symptoms of depression or other medical problems. Diminished sex drive, for instance, can be caused by antidepressant medication, but it can also be a symptom of the depression itself.

Ideally, your doctor will consider a wide range of options such as changes in the dosage or timing of medication, behavioral approaches, possibly a different medication altogether or additional pharmacological strategies. “Sound and resourceful management of side effects is an important component in achieving depressive remission and enhancing patient safety and quality of life,” they concluded.

Does Medical Marijuana Cut Down on Prescription Drug Use?

The rise in the number of states allowing marijuana for medical use seems to be having an unexpected benefit: It has led to fewer drug prescriptions being filled, especially meds used to treat pain.

W. David Bradford, PhD, of the Department of Public Administration and Policy at the University of Georgia and his daughter, Ashley C. Bradford, a graduate student in the department, made their conclusion based on prescriptions filled under the Medicare Prescription Drug Plan (Part D) between 2010 to 2013.

In 2013, 17 states and the District of Columbia allowed cannabis to be prescribed for medicinal purposes. Now, it’s 25 states.

The pair focused on scripts written in these states that could potentially be substituted for medical marijuana instead, to treat conditions such as glaucoma, nausea, pain, seizures, depression and anxiety.

Fewer prescriptions were written for most of the conditions: A drop of 1,826 daily doses in the pain category and 265 in the depression category, for example, the researchers reported in Health Affairs.

However, the number of daily doses for glaucoma medication increased by 35. The researchers explained that even though marijuana can produce a reduction in eye pressure, the effect only lasts about an hour, and expecting patients to take marijuana throughout the day is considered “unrealistic.”

The Part D program also saw a financial benefit from states with medical marijuana laws since fewer prescriptions were filled. The Bradfords estimated those savings to be $165.2 million in 2013. In addition, the results suggest that if all 50 states had medical marijuana laws on the books, the overall savings to Medicare would have been about $468 million.

While medical marijuana may appear to be a panacea for many conditions, it is important to note that there is a potential for abuse. Many states now require medical marijuana patients to have an established relationship with their doctor and a physical exam in order to receive cannabis, an effort to curb the use of so-called “pot doctors.”

However, compared to traditional prescription medications, marijuana’s side effects appear to be more mild, one factor in why people turn to cannabis for relief.

Synthetic Marijuana Overdoses Rising Across the Country

Just a matter of days after more than 30 people in a Brooklyn neighborhood simultaneously overdosed on synthetic marijuana in a scene witnesses described as “zombie” like, a federal report has found that overdoses attributed to the street drug are rising across the country.

Also known as K2 or Spice, synthetic marijuana is really a mix of man-made chemicals designed to mimic the effects of marijuana, but is usually cheaper and more potent than natural cannabis. And the side effects of K2 are downright scary: anxiety, paranoia and hallucinations, vomiting, seizures, fainting, increased heart rate and uncontrollable body movements. When used long-term, Spice can lead to kidney failure and heart damage.

In addition, synthetic marijuana is said to be highly addictive.

The Centers for Disease Control and Prevention report, published in the Morbidity and Mortality Weekly Report, included data from 50 medical centers that took part in the Toxicology Investigators Consortium (ToxIC) Case Registry. Between 2010 and 2015, these sites treated 456 patients for effects related to synthetic marijuana.

Compared to other types of poisonings, those from synthetic marijuana rose in every part of the country between 2010 and 2015, with synthetic marijuana incidents rising more than 14 times just in the Northeast.

The results also showed that K2 users are overwhelmingly men and a startling number are teens. Among the 456 synthetic cannabinoid intoxication cases, 125 (27.4%) occurred in people between the ages of 13 and 18, and 379 (83.1%) of the patients were male.

“Educating the public on the potentially life-threatening consequences of synthetic cannabinoid use is important for countering the observed upward trend in synthetic cannabinoid poisonings,” the report concludes.

3 Situations Where a Child May Be Overdiagnosed with ADHD

The number of children diagnosed with ADHD has skyrocketed since the early 2000s, and with it, so have prescriptions for powerful stimulant medications — with a long list of side effects — that many doctors are too often eager to dole out.

So, what’s going on here? Why are so many more children being exposed to medications like Adderall and Ritalin, with side effects including poor appetite, stomach aches, irritability, sleep problems, and slowed growth. There are even some indications that ADHD meds are linked to hallucinations and psychosis.

Have so many of our children always had ADHD and we just missed it? Has some cataclysmic genetic or epigenetic shift taken place, causing ADHD to be the most prevalent childhood disease second only to obesity? I don’t think so.

I believe the increase is due to 2 factors: Overdiagnosis due to poor evaluation and pressure by society for treatment, and increasing pressure being put on children and families.

With this in mind, what’s a parent to do? As a pediatrician who has studied ADHD for decades, there may be situations where your child might be misdiagnosed with ADHD. Here are 3 such examples to look out for to make sure your child isn’t needlessly given medication and other possible issues are not overlooked.

1. If you do not see symptoms of ADHD both at home and at school

Your daughter, Sarah, is in the middle of 3rd grade and the teacher says that she is not able to focus on academic tasks and tends to be disruptive in class. You are puzzled because Sarah is quite well behaved at home and does not seem to have trouble focusing, getting work done, or have any other of the symptoms of ADHD that you have read about.

But you see your pediatrician, who speaks to you for a few minutes and then gives you ADHD questionnaires for yourself and her teacher. Two weeks later, you see the pediatrician again, and he says the teacher’s questionnaire is positive for ADHD and yours is not. The pediatrician suggests a trial of a stimulant medication like Ritalin, to see if Sarah really has ADHD. You wonder if perhaps you should give the medication a try.

This is a situation in which the possibility of overdiagnosis is very high. First, the accepted definition of ADHD is that the symptoms “have an impact in 2 areas of life.” In children, this is home and school. Clearly this is not the case. When the problem is only in one of these areas, one must look very carefully to see if there is some other issue that is causing problems that may be interpreted as ADHD.

Second, just using questionnaires is an inaccurate way to make the diagnosis. In one study, children had a complete ADHD evaluation and this was compared to the results of just using the questionnaires. Two-thirds of the children diagnosed as having ADHD only using the questionnaires were misdiagnosed; that is, they did not have ADHD based on a more complete evaluation. These questionnaires were never meant to be a “stand-alone” diagnostic tool. They are highly subjective, with scoring easily influenced by the intentions and prejudices of those filling them out.

Finally, a trial of a stimulant drug is not a good way to confirm a diagnosis of ADHD. Most kids will focus better with these medications whether they have ADHD or not, much like most adults focus better if they drink coffee. Therefore, this method should never be used to determine if a child or adult has ADHD.

So what would constitute a good ADHD evaluation and who would do it? There are a number of types of professionals who would be qualified to make the diagnosis of ADHD. These would include pediatric psychiatrists, pediatric neurologists and developmental pediatricians. Some general pediatricians and family doctors or nurse practitioners would be qualified if they had the time and expertise to devote to the evaluation, which is not true for most generalists. Child psychologists can make the diagnosis,  but a medically trained provider should be included in that case.

The evaluation should consist of interviews with both the parents and the child, separately when the child is old enough. Teacher feedback is crucial, at least with the questionnaires but ideally with telephone interviews or email feedback. Information from counselors, tutors or others directly involved with the child can be very helpful. In many cases, psychoeducational or neuropsychological testing to rule out learning disabilities, anxiety disorder, or other issues is very important, although not required for all children.

School observation can also be very helpful. In my opinion, blood tests for levels of iron and zinc are necessary, although this is not an opinion shared by most mainstream providers. Overall, if the initial evaluation and treatment plan are scheduled for less than 2 hours, I do not believe there will be time for an adequate evaluation.

2. When a child is having attention problems with only one subject area

Johnny is in 2nd grade. During any reading or writing assignment, he has trouble staying focused and finishing his work. He is falling behind academically. He may even be disruptive; talking to other students, getting out of his seat, becoming uncharacteristically defiant. At home, the reading and writing homework takes forever. Johnny does not want to sit down and do it. He needs frequent breaks, and anger and tears are common. As was the case with Sarah, ADHD questionnaires are positive, this time with both parents and teachers, and medication is recommended.

However, more in-depth questioning reveals that the opposite is true of math or any other assignment that that does not involve reading. He breezes through math homework both at home and at school. He has no trouble focusing on art projects, and is a well-organized boy who rarely loses things or forgets his assignments. Mom remembers that even early reading was very difficult for Johnny.

In this situation, dyslexia, or a reading disability, is a very strong possibility. Children with reading disabilities have a difficult time picking up the basics of learning. It can become frustrating and aversive to them. They may begin to act out or stop paying attention when any reading or writing work is required. This may also result in behavioral problems. The crucial issue here is the dyslexia, though, not the ability to pay attention.

The major clue here is the ability to focus and complete math assignments so easily. This would not be true if the only issue was ADHD. Johnny needs psychoeducational testing to evaluate for learning disabilities. This problem can be tricky because many children have both learning disabilities and ADHD. This is where a team approach, including testing by a psychologist, is crucial.

3. A child with emotional problems

These could include anxiety, depression, or PTSD. Children with these issues may find it very difficult to concentrate on academic subjects. Anxiety, especially, is often confused with ADHD. It is well known that a mild level of anxiety, as most of us feel when taking a test or meeting a deadline, can improve performance. However, higher levels of anxiety can severely impair performance. This can result in a destructive feedback cycle, as these children begin to do poorly and then become understandably more anxious about their poor performance. A similar pattern may occur with depression or PTSD.

As with learning disabilities, this can be difficult to sort out, as a child can have both emotional issues like anxiety or depression and ADHD. Again, this requires careful evaluation, often with the help of a mental health professional.

One thing to watch for especially is when a child who previously had no symptoms suggestive of ADHD suddenly develops these symptoms. This may indicate that some event has caused symptoms of anxiety, depression, or PTSD. Careful history may uncover a source of these feelings, including bullying, family issues, or even sexual or physical abuse.

These are just a few of many situations where ADHD may be overdiagnosed. I hope it is clear that the solution to these and other diagnostic problems rests with a careful and complete evaluation by a provider who is knowledgeable, skilled, and willing to take the time to do it properly.