Richard G. Petty, MD

Women, Asthma and the Brain

There’s been a longstanding puzzle in medicine. Well actually there are lots of them, but here’s one that may be a puzzle no more.

For many years now, it’s been known that asthma is more common in women, and also that psychological stress can cause flare ups of asthma.

Many women experience “menstrual flaring:” a worsening of asthma around the time of their menstrual period. There is also a strange paradox: some women with asthma wheeze less if they take an oral contraceptive, while some non-asthmatic women begin to wheeze when they take it. In some women pregnancy makes asthma worse, and in others it affords months of relief of symptoms. Women who are obese are more likely to get asthma, presumably because their intra-abdominal fat stores are churning out inflammatory mediators.

Researchers from the University of Wisconsin have shed  some important light on this link between asthma and the brain. In research published in the Proceedings of the National Academy of Sciences. In the study, six patients with mild asthma were exposed to ragweed or dust-mite extracts. The subjects were shown three different categories of words: asthma-related (e.g., "wheeze"), non-asthma negative ("loneliness") or neutral ("curtains").

Using functional magnetic resonance imaging, they showed that activity in two regions, known as the anterior cingulate cortex and the insula showed increased activity when the asthma-related words were heard compared with the other types. What is more, this enhanced activity was specifically linked to physiologic signals from the ragweed and dust-mite extracts. So being exposed to asthma-relevant emotional stimuli is associated with markers of inflammation and airway obstruction in asthmatic people exposed to an asthma-producing antigen.

In people with asthma and other stress-related conditions, these brain regions may be hyper-responsive to disease-specific emotional and physiologic signals. Taken together, these could contribute to problems that worsen the asthma, such as inflammation.

And one of the ways of making these regions of the brain hyper-responsive? Bathe them in estrogen.

That still does not explain why pregnancy and the oral contraceptive makes some women’s asthma better, and does the opposite in others. But it may just have to do with the “set point” of the cells in these regions of the brain. In the same way that we might set the thermostat in out house. An already hyper-responsive brain might be normalized and an under-active one stimulated to be over-active.

We need to do some more experiments, but these are a great start.

If you ever wheeze, have a look to see if there are stressors or hormonal events that trigger you. Whether you are being treated with homeopathy, herbals or conventional therapy, knowing when to expect trouble gives you the power to adapt you treatment when you are entering a risky time in your life.

Gender and Relationships

I sometimes review interesting or important books at I’ve just done that with a book entitled This Changes Everything: The Relational Revolution in Psychology by Christina Robb that is important for us on several levels. The book reviews the work of three remarkable individuals – Carol Gilligan, Jean Baker Miller and Judith Lewis Herman – who between them changed the way in which we think about some important gender differences.

The philosopher Ken Wilber first alerted me to Carol Gilligan’s work several years ago. In the mid-1970s, she wrote an essay entitled "In a Different Voice," that was subsequently expanded into a book that I recommend highly. She described the marked discrepancies in moral development processes and self-expression between men and women.

According to Gilligan, the whole notion of a woman’s self tends to be inextricably bound up in a web of close relationships. Women tend to be more diligent about maintaining and nurturing these relationships, and inter-personal details tend to be far more important to most of them, than they are for most men. I remember someone sending me a little joke about gender differences, in that mothers know the names of all their children’s friends, their parents’ names, birthdays, favorite music, likes and dislikes in people, food and clothes. While fathers may or may not notice the small people in the house. That was, of course, a joke. But like all jokes it had within it a grain of truth. But notice that I keep using words like “tend to,” when describing gender differences, because there are plenty of men who are into all these interpersonal details and women who are not remotely interested.

At the time that Carol Gilligan started writing about this, much psychological thinking in the United States had not yet dragged itself out of the confines of the post-Freudian theorizing that had dominated American psychology for decades. Gilligan and her co-workers identified relationships as the foundation of psychological and physical states. At the time, the idea that men and women might tend to think and relate in different ways was anathema. I worked in Boston around that time, and it was clear what could and could not be thought about and discussed. Gilligan’s work was courageous, and taken together with the findings of psychiatrists Judith Lewis Herman and Jean Baker Miller, would ultimately lead to radical alterations in the way that we understand the psychology of women. Are these gender differences social, political or biological? The answer is, I think, yes: all of the above.

It is surprising how often discussions of gender differences are still omitted from much work on self-psychology. In an otherwise wonderful book – The Self in Neuroscience and Psychiatry, edited by Tilo Kircher and Anthony David – there is scarcely any mention of gender.

I am not much of a fan of trying neatly to cleave men and women’s thinking styles in two. There will always be a great deal of overlap, and the key is not so much biological gender, but the style normally associated with a gender. The research of these three pioneers and of another pioneer – Deborah Tannen – is teaching us that the roots of many problems in our lives may be a consequence of misunderstandings about what men and women consider to be the most important things in their lives. It is also important to recognize that the amount of “maleness” or “femaleness” that we bring to our relationships and to our sense of self will change and evolve over time. Have you ever watched a relationship between a dominant career oriented male and a passive female gradually change into one in which the male takes the more passive role? This is a good example of a shift in “maleness” and “femaleness.”

I have been impressed by some of the recent work of David Deida, who has done a lot to explore the interplay of male and female essences in our lives. I have already mentioned in some of my other postings the importance of moving from a dominator to a partnership model in all of our relationships.

Consider whether problems in any of your relationships may be a result of misunderstanding gender needs.

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Migraine and Hormones

Migraine (can be a frightfully difficult problem to treat. It is such an interesting puzzle, that the first book that I ever wrote was on migraine and other types of headache. Migraine is a great deal more than just a severe headache. It is can also be associated with neurological symptoms, and people often become exquisitely sensitive to light and sound. Additionally, at the beginning of the attack, the stomach stops working properly, which can make the absorption of medicines very difficult. Then comes the vomiting and sometimes diarrhea.

Although migraine is usually described as a “vascular” headache, there are strong reasons for thinking that it is more than that. People who suffer from the classic type of migraine often have spreading visual problems or partial visual loss, which goes on for between ten and sixty minutes. These visual problems are likely the result of a spreading wave of neurological depression spreading over the visual cortex at the back of the brain. The sensitivity to light and sound suggests that something is going wrong in the neurological systems that normally filter sensations, and the gastrointestinal problems indicate that something is going wrong in some of the control centers of the brain. There are some real oddities about migraine: it is exceptionally uncommon in people with diabetes; appears to be slightly more common in people who are left handed and is one of the only illnesses that tends to gets better as we get older.

There are a number of well-known triggers to migraine attacks. Though the scientific literature on triggers is not conclusive, here are some of the more common ones, that if avoided, have helped a great many people:

  • Stress (either during stress, or when the pressure comes off)
  • Cheese
  • Chocolate
  • Coffee
  • Citrus fruit
  • Red wine
  • Changes in the weather (especially when there are a lot of positive ions in the atmosphere)
  • Mono-sodium glutamate (MSG)

One of the best-known features of migraine is that it is considerably more common in women and that there is often a relationship between headaches and phases of the menstrual cycle, in particular during the pre-menstrual days. There have been many small studies that have indicated that oral contraceptives might increase the risk of suffering from migraine. A new study from Trondheim in Norway, has confirmed a link between oral contraceptive and migraine. The Nord-Trøndelag Health Study was done between 1995 and 1997. It included 14,353 pre-menopausal women, of whom 13,944 (97%) responded to questions regarding their use of contraceptives. There was a significant association between migrainous and non-migrainous headaches and the women’s reported use of estrogen-containing oral contraceptives. An important finding was that there was no relationship between the number of headaches and the amount of estrogen in the contraceptive pill.

There is one more thing to factor into the equation. Over the last two decades, there have been many reports of an association between certain types of migraine and cerebrovascular accidents (“strokes”). In the largest analysis of the data, that was published in the British Medical Journal, there was indeed a higher rate of strokes in women who had migraine and who were taking oral contraceptives. These studies included some of the older ones done in the days when the doses of hormones were higher than they are today, but when making decisions, it is important to be aware of this rare association.

An editorial in the British Medical Journal made these recommendations, with which I agree:

1. In an otherwise healthy young person, there is little cause for concern because the absolute risk of stroke is very low.

2. People with migraine who are on oral contraceptives have another reason for not smoking

3. Use low dose estrogen or progesterone only contraceptives in young women with migraine.

4. Although there isn’t much good evidence, many neurologists suggest stopping oral contraceptive pills if the migraine becomes more frequent or changes in character.

5. The risk of stroke gradually increases over age, particularly in smokers, so a slightly older smoking woman with migraine, should probably not be taking an oral contraceptive, unless it is the only option for her.

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Coffee and Sex

These two may seem strange bed fellows(!)

But a study published in November 2005, was picked up by a lot of the news media, and probably lead a lot of people to encourage their wives and girlfriends to have an extra cup of coffee. The reason? Because this study, from Southwestern University had the title “Coffee, Tea and Me: Moderate doses of caffeine affect sexual behavior in female rats.” The research showed that at least in rats, coffee stimulated regions of the brain regulating arousal. It was immediately reported around the world that coffee drinking would raise a woman’s libido.

I don’t know what the report did for sales of coffee, but sadly, once again, the devil is in the details. Not only is human sexuality a lot more complex than it is in rats, but there is also this. In order for an adult woman to get the same amount of caffeine, she would have to drink at least ten large cups of coffee at once.

And coffee is a pretty good diuretic…..

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Some Suggestions for Dealing with Insomnia

I have received an interesting question from a 50-year-old professional woman, who has had sleep problems that are especially severe during times of stress. As she says:
“I seem not to have the shut down switch in my brain.” She is worried about taking medications, and wonders if there is anything else that she can do to help herself.

It is always unwise to make specific recommendations about someone without seeing them face-to-face, and the evaluation of a problem like this will normally take several hours. But the points that she raises have a great deal of relevance for so many people that I thought that a few comments would be helpful and equip everyone reading this with some information to discuss with their healthcare providers.

As usual, I think that it is a good idea to look at the question from the multiple dimensions of physical, psychological, social, subtle and spiritual. They are all inter-related, so dividing them up is simply a convenient way to help us think through the problem.

Before we do anything, we have to try and find out why someone has problems with sleep, and that may need investigations up to and including a sleep study.

The first thing is that my correspondent is female and likely either menopausal or perimenopausal. That is important, because as most women know, hormones have potent effects on sleep. It is not just that uncomfortable hot flashes can wake a person; it is also a direct effect of estrogen and probably of some of the releasing hormones in the hypothalamus. Hormone replacement therapy alone, does help some women but by no means all. Even at the physical level we see the general principle that there is rarely one cause for one problem. Typical menopausal sleep disturbances include a difficulty in falling asleep, and around 20% of menopausal women report that they sleep less than six hours a night. There is also some degradation in what we call sleep efficacy and an increase in deep slow wave sleep. Estrogen has effects on nasal mucosa, and when estrogen levels fall obstructive sleep apnea is more likely to occur. A major physical and psychological issue is that insomnia may become a learned habit that can persist even in the face of the best treatments.

This leads me to the second dimension, and that is psychological. The writer of the letter mentioned that she couldn’t turn off her thoughts. You would be amazed at how frequently I have been asked to consult on someone with a sleep problem and the individual has never been asked the question, “What is it that stops you falling asleep?” I have seen countless people prescribed sleeping tablets, when the real problem was anxiety or some other nasty problem that needed to be tackled first. In a moment I am going to make some suggestions that will try and help with both sleep and the ruminations and anxieties that may be contributing to its disturbance. Similarly, I have known a great many people whose sleep problems were the result of relationship difficulties or of something as simple as one person being a night owl and the other an early morning riser.

I always start with some simple sleep hygiene:

    1. Stress management
    2. Exercise a couple of hours before retiring
    3. Keeping mentally stimulated until it is time for bed
    4. Don’t go to bed until you are tired
    5. No caffeine, alcohol or nicotine after 6pm. (Preferably, of course, no nicotine ever!!) {Remember that many over the counter painkillers contain caffeine, as does chocolate}
    6. There are some specific dietary recommendations for helping with sleep, and I shall write about those on a future occasion
    7. Try to keep the bedroom atmosphere relaxing, and establish a sleep ritual
    8. If you cannot sleep, get up and do something relaxing: struggling to go to sleep is virtually impossible.
    9. Always get up at the same time in the morning, to try and re-set your brain, and as soon as you get up, be exposed to as much bright light as possible.
Now let me give you a few tricks that work on the five dimensions.
  1. Start by lying on your left side for 5-10 minutes and then roll onto your right side. This appears to work by exploiting the so-called nasal cycle, which I shall write more about on a future occasion.
  2. Still on the subject of the nose, one of the reasons that aromatherapy can be helpful, is because smell is unique amongst our senses, in that it is the only one that is not filtered by the thalamus. The regions of the brain that respond to smells are also directly related to some of the memory centers. The result is that smells can evoke memories extremely rapidly. You will probably have had the experience of smelling a perfume or cologne and instantly remembering someone who wore it in the past. This close linkage of smell and memory has enormous survival advantages: the smell of a predator can cause us to respond extremely rapidly. We can also use this knowledge to our advantage. Lavender has been used as a sleep aid for centuries. You can try putting a few drops of lavender oil on a cloth on your night-stand. Or you can use an electric diffuser or aromatherapy lamp. When I was growing up, we grew lavender and would put sprigs of it in the bed linens. It certainly seemed to help.
  3. Some people have found that melatonin can be very helpful, and it is readily available. Discuss it with your health care provider.
  4. Here is an old trick from traditional Chinese medicine. If you cannot sleep, soak a washcloth in cold water, lie down and put it on your abdomen for about ten minutes. I was taught that this works by pulling excess energy out of your head and neck down into the abdomen. There’s not a shred of scientific evidence that the technique works, but it does surprisingly often.
  5. If people who are good at visualization, some have reported great success by creating a picture of a warm, calm and relaxing place. And not just a picture, but also a five senses experience. It has to be personal, and perhaps even a place to go back to on a regular basis. When I first learned to do hypnotherapy I was put into a light trance by one of my teachers. To this day, more than 25 years later I can still vividly recall the experience of being told that I was drowsing on a grassy knoll on a warm summer’s day on the Downs of Southern England, and actually feeling that I was there. I can still evoke the memory at will and I’ve made it more detailed over time. If you are a visualizer, try that.
  6. Another technique that I learned from an early teacher, is to review the day backwards. Remembering what you did immediately before going to bed, and before that and so on. A simpler and often effective technique is just to start slowly counting backwards from 100.
  7. Herbs: There are three that are widely used, and for which there is some research base. There is good evidence that the herb Valerian can induce drowsiness, and it is widely used – even by doctors – in France and Germany. An important point about valerian is that it is poorly absorbed and chemically and thermally unstable. So it needs to be kept cool, and used fairly soon after it is prepared. As with all herbs, Valerian has side effects and can interact with prescription medications and alcohol, so it really is essential to discuss its use with your health care provider. The same goes for the other two widely used herbs: Hops and Passionflower.
  8. There is some evidence, though it’s not that strong, that taking a combined calcium/magnesium supplement (500mg calcium and 250-500mg magnesium) an hour before bed helps some people.
  9. I recommend massaging your facial muscles before lying down to sleep. Not only does this reduce muscle tension, but also the face is covered in acupuncture points, and so that may be another reason why it can help.
  10. Do not read or watch television in bed, but listen to a little calming music before retiring.

I do hope that will help you in your discussions with your health care provider. And I am always interested in hearing other suggestions, particularly if there is some research to back them up.

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Women’s Health

“There is no female mind. The brain is not an organ of sex. As well speak of a female liver.” Charlotte Perkins Gilman (American Feminist Writer and Editor, 1860-1935)

It is easy to understand the sentiments behind this well-known statement by a pioneer feminist, but the fact is that it is dead wrong. In recent years there have been a host of new discoveries into the very marked gender differences not just in the brain, but also in the liver and for that matter throughout the body. Differences that have important implications for your health and well-being. For some years I worked with a husband and wife team who had made important discoveries about gender differences in the brain. In fact some of this work made the front page of Newsweek magazine. The female member of the team once told me how, after giving a lecture at a prestigious University, she had been scolded by some people who told her that her research was undermining the movement toward gender equality, and that she should stop what she was doing. I leave it to you to make up you own mind about that.

Yes, there are demonstrable differences in the brains of men and women, but ONLY when looked at statistically. There is as much variation in brain structure as there is in height or skin color. There are also gender differences in cognitive ability, but again there are huge variations. As a male I should have a good sense of direction. In fact my sense of direction is so bad that I once joked that we should put up signs inside my house directing me toward the kitchen and the den! An over-emphasis on gender differences can have some undesirable consequences: couples therapists tell me that if clients have become overly dependent on the Mars/Venus concept, they will often have to schedule an extra 3-4 sessions to “deprogram” them.

Are gender differences in the brain and in cognition culturally determined? Probably not: experiments conducted since the 1960s have found that gender differences in cognition, emotion and perception appear to be trans-cultural, and what is more some of the same differences are found in animals. Higher rates of depression are found in women around the world, while autism is more common in boys. Estrogen and testosterone have profound effects on the developing brain. More than 20 years ago Norman Geschwind, one of my early mentors, published some challenging speculations about the interactions of sex hormones with the brain, and handedness, migraine and autoimmune disease. Some cognitive skills change during the menstrual cycle, a fact that has allegedly been used by some professional female chess players, who regulate their cycles with the oral contraceptive to ensure that they hit the big tournaments at times in their cycles when their reasoning and visuospatial abilities are at their best. The Scottish Grandmaster Jonathan Rowson discusses some of these issues in this month’s issue of the magazine New in Chess.

If we leave aside the brain, there are also enormous gender differences in other parts of the body that have significant implications for health. Apart form obvious differences in size, women tend to have more subcutaneous fat than men, so medicines that go into and are stored in fat have to be dosed differently in men and women. There are big differences in one of the key enzymes in the liver that is involved in dealing with toxins or in metabolizing drugs: important to know if you are being prescribed medicines. Women’s stomachs also tend to empty more slowly than men’s: yet another reason for being careful to take gender into account when prescribing medicines.

Amidst all of these physical differences, that I am going to explore in future entries, it is important not to lose sight of the different cultural demands on men and women. In the United States and Europe more women than ever are being expected to fulfill multiple roles: worker, wife, mother, cook, chauffeur, nurse and planner, to name only a few. It is no surprise that so many women are facing a condition that I call, for obvious reasons, “Overload.”

In my book Healing, Meaning and Purpose, I discuss some of the drawbacks of conventional methods of helping people cope and some novel solutions. As an example, I have known many people who have gone to stress management classes, that have meant them rushing across town, missing dinner, doing the class and then rushing home to put the children to bed and check their email. That kind of thing is not very likely to be helpful. When I taught T’ai Chi and Qigong classes, I would usually spend the first 45 minutes helping people wind down before we could get to work.

In response to this chronic overload, I have spent many years devising extremely brief things that people can do to help themselves in the course of a day. I have a principle that has guided me for years: for most people, if it takes more than one minute, it’s going to be very difficult to fit it in. But once they have found that one minute, other minutes often begin to follow. I shall shortly be going into the studio to record some more of my one-minute miracles, and early in the spring, we shall begin to attach some podcasts to this blog.

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