Rheumatoid Arthritis Questions: Part 2
Flare After Dentist Visit
Difference Between Rheumatism and RA
Biologics and Lymphoma Risk
Preventing RA Progression
Prednisone Withdrawal
Joint Damage Without Pain?
Experimenting with Enbrel
Arthritis Flares and Mouth Sores
Taking Methotrexate Safely
Before You Order Drugs Online...
Cancer History and Drug Use
CREST Syndrome Spelled Out
Does RA Affect the Head?
Will OJ Worsen RA?
Joint Damage Without Inflammation?
When Arthritis Affects Your Appearance
Q: I have RA and fibromyalgia. Every time I get my teeth cleaned, I have a flare of both conditions a few days later. Do you know why this might happen?
A: We know any type of stress – whether physical stress, such as an infection, or emotional stress, such as fear – can make fibromyalgia and perhaps RA worse, too. In the scenario you describe, I can think of at least three potential stressors that may contribute to your flares: the release of bacteria from the mouth into the bloodstream during cleaning, which stimulates the immune system just enough to increase the level of cytokines in the bloodstream and tissue; the discomfort associated with the procedure, and the anxiety caused by anticipating another flare. Once you know this has happened in the past, it would not be unreasonable to assume it might happen again.
Theoretically each of these three stressors could be dealt with to help reduce your risk of future dental-cleaning-related flares. Antibiotics could be used before and during the procedure to control the bacteria, and deep-breathing or relaxation techniques could be used to help reduce your anxiety, and therefore flares. Analgesics could be used after the procedure, if necessary, to relieve pain. Speak to your doctor or dentist about pre-cleaning medications and about specific techniques that might be helpful.
Daniel Clauw, MD, Rheumatologist
Difference Between Rheumatism and RA
Q: What are the differences or similarities between rheumatoid arthritis (RA) and rheumatism?
A: Years ago, you may have heard a grandparent or other older person say, “My rheumatism is acting up” – translated as “my joints are really hurting today.” Your grandparent may not have known which particular form of arthritis he or she had and may not have been aware there were many different forms. Today we have more clearly defined types of arthritis and doctors don’t use the term.
So your question is a good one because “rheumatism” and “rheumatoid arthritis” are often thought to be one and the same, but rheumatism is an obsolete, catch-all term – once used by both the medical field and general public – referring to all inflammatory conditions that affect the muscles, joints, ligaments, tendons, bones and bursae. These conditions cause pain, stiffness and possibly joint deformity or structural damage. Although RA falls under the old umbrella term rheumatism, not all rheumatism is RA.
RA is a form of arthritis that occurs when the body’s immune system attacks the synovium – the thick membrane that lines joints – causing pain and inflammation. If the inflammation is not controlled, it can cause damage to the joint cartilage, underlying bone and supporting connective tissues, and leads to joint deformity. In some cases, RA can cause nodules (painless, hard masses that appear under the skin) or damage the lining of the heart, lungs or blood vessels.
Osteoarthritis (OA), fibromyalgia, ankylosing spondylitis, reactive arthritis and dozens of other arthritis-related conditions also fit under the rheumatism umbrella.
Robert Shaw, MD
Q: I have RA and Sjögren’s syndrome. My doctor recommends a biologic, but I’ve heard having RA and taking biologics increases the risk of lymphoma. Should I avoid biologics?
A: The question of lymphoma risk for patients with rheumatic diseases, particularly rheumatoid arthritis (RA), remains an area of active study. Biologic agents, such as the tumor necrosis factor (TNF) inhibitors – adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade) – as well as other medications, such as methotrexate, are often highly effective in treating RA but may increase patients’ risk of lymphoma.
Studies of more than 3,000 people with RA, combined, published recently in both the Journal of the American Medical Association and Arthritis & Rheumatism support the concept that the TNF inhibitors adalimumab and infliximab increase the risk of malignancies and serious infections. The studies did not include etanercept. The magnitude of this risk may be increased by the use of other medications – particularly cyclophosphamide – along with TNF inhibitors. The added risk of complications was very small, in the study that included people with RA, and appeared as dosages of the medications increased.
The overall percentage of RA patients who develop lymphoma remains rather low (well under 5 percent) but distinguishing whether the risk of lymphoma is inherent to having RA or is elevated by medications used to treat it has been extremely difficult. It is likely that both the disease and its therapies increase one’s risk of lymphoma.
Primary Sjögren’s syndrome – that is, Sjögren’s syndrome occurring without any other rheumatic disease – also is associated with an increased risk of developing lymphoma. The percentage of patients with primary Sjögren’s who will develop lymphoma is estimated to be around 5 percent. This risk does not necessarily apply to patients who, like you, have secondary Sjögren’s syndrome, which is Sjögren’s associated with another condition, like RA. In such patients, the likelihood of developing lymphoma is substantially lower, although no one knows precisely how low.
In the end, the decision about whether to use biologic agents is an individual one, made with the best possible information. The potential for a slightly increased risk of lymphoma must be weighed against the frequently striking positive effects of the TNF inhibitors for patients with severe RA. If you choose to use them, talk to your doctor about what cancer screenings you should have and when; stay up to date on vaccinations, including flu shots; and be aware of signs of infections, such as fever higher than 100.5 degrees, chills or night sweats.
John H. Stone, MD, MPH. Rheumatologist
Q: I am 31 and have just been told by a rheumatologist that I have the beginning stages of RA. My doctor is recommending Plaquenil. Do I have other options to keep RA from progressing?
A: There are many ways to treat RA and keep it from progressing. Using hydroxychloroquine (Plaquenil) may be effective for you, as it is for some people, but often a combination of medications is necessary. These medications include:
NSAIDs, such as ibuprofen (Motrin) and naproxen (Naprosyn), which help ease pain and inflammation;
Corticosteroids, such as prednisone, which control joint- and organ-damaging inflammation;
Disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine, methotrexate and sulfasalazine (Azulfidine), which reduce the signs and symptoms of arthritis as well as slow progression seen on X-rays;
Biologic agents, such as abatacept (Orencia), adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), and rituximab (Rituxan), which modify the immune system by targeting chemical messengers called cytokines that play a role in the inflammation and damage of the disease.
Medication choice depends on the activity and severity of your disease, as well as your preference and concerns over side effects. For more information about these drugs, look for the “2007 Arthritis Today Drug Guide” in the January-February issue. It details the commonly used drugs to treat arthritis and related conditions. Currently, methotrexate is a popular choice for initial DMARD therapy, although combining it with a TNF blocker can produce greater benefits in some patients.
Whatever the choice of DMARD, its effectiveness needs to be assessed regularly in terms of the number of tender and swollen joints and progression of disease as assessed by X-ray. If disease is persistent, your doctor should consider switching you to a different DMARD, adding another DMARD or adding a biologic agent. Be sure you have the recommended liver tests while on these medications.
David Pisetsky, MD, PhD. Rheumatologist
Q: I take prednisone for rheumatoid arthritis (RA). Recently my rheumatologist decreased my dosage from 10 milligrams (mg) to 2.5 mg. I developed a migraine, and it has persisted for more than 30 days. Could decreasing prednisone have caused this?
A: Your question brings up the possibility of prednisone withdrawal symptoms. Prednisone is a corticosteroid hormone related to the cortisone that your body makes naturally. If you take the drug for more than a month, it can slow down your own production of cortisone. A fast drop in prednisone dose then can cause symptoms of cortisone deficiency, such as nausea, fatigue, weakness, muscle pain, poor memory and low blood sugar. Although migraine headaches are not a normal side effect of corticosteroid withdrawal, decreasing your prednisone could have aggravated a pre-existing migraine condition.
Whether cutting back your prednisone is the cause of your prolonged migraine is difficult to answer. A general rule of thumb is to taper prednisone throughout the same length of time that you have been taking it. For example, if you were taking 10 mg per day for three months, you should taper your dose – from 10 mg to 7.5 mg to 2.5 mg – throughout the course of the next three months.
One test of whether prednisone withdrawal caused your migraine is to increase your dose back to 10 mg per day for a few days (with your doctor’s permission, of course). If prednisone caused your migraine, restoring the dose should help you. Thirty days is quite a long time to have a migraine headache. Regardless of whether increasing prednisone helps your situation, an evaluation by your doctor may be in order.
Don Miller, PharmD, Pharmacist
I have rheumatoid arthritis and would prefer to hold off on medication. Diet, exercise and acupuncture have relieved most of my symptoms. Are my joints still degenerating even when there’s no pain?
AI’m glad you’re asking about this now. Current practices call for aggressive treatment of rheumatoid arthritis (RA) – in some cases. With my patients, I take several factors into consideration before going that route. The fact that you no longer have any symptoms is good news and suggests you could have a milder form of RA. If that is confirmed by your rheumatologist through a physical examination, laboratory tests and X-rays, then you may be able to hold off on treatment.
The first thing to consider before doing so, however, is how rapidly your RA is likely to progress. RA can damage the cartilage and bones of affected joints, and this can happen early in the course of the illness. How quickly this damage occurs does vary among people, though.
Risk factors for early damage to the joints include (1) pain, stiffness and swelling in many joints; (2) increased measures of inflammation, such as the erythrocyte sedimentation rate (“sed rate”) or C-reactive protein, in the blood; (3) the presence of changes on X-rays; and (4) detection of rheumatoid factor or antibody to cyclic citrullinated peptide (CCP) in the blood. If you have several of these factors, the importance of early treatment increases.
Leslie Crofford, MD,Rheumatologist
Experimenting with Enbrel
Q. I have polymyalgia rheumatica (PMR) and my doctor recently started me on Enbrel twice weekly as an "experiment." However, I haven't noticed any improvement in my condition. Do you think this treatment is appropriate?
A. Enbrel (etanercept) is a new agent recently approved by the FDA for the treatment of RA and juvenile rheumatoid arthritis.
Your doctor refers to your treatment with this new drug as an "experiment," because there are no published data on its use in PMR for him to turn to.
For the same reason, I really can't say whether the treatment is appropriate. In general, Enbrel is safe, although there is some concern in the medical community that Enbrel's ability to influence the immune system could lead to infection or other problems.
There is sufficient reason to believe that Enbrel might be helpful for PMR, however. And rest easy: It is not uncommon for a doctor to prescribe a drug for a type of arthritis other than that for which it was originally tested and approved, if the current treatment is not working.
In this case, your doctor knows the agent works to block tumor necrosis factor (TNF), a powerful mediator of inflammation in RA. And because PMR is an inflammatory disease, he probably considers it to be possible that by blocking TNF, Enbrel may help your PMR as well.
For most people, however, taking low doses of prednisone along with NSAIDs can control your PMR effectively and is a lot less expensive than Enbrel.
Bernard Rubin, DO, Rheumatologist
Back to Top
Arthritis Flares and Mouth Sores
Q. I have noticed that whenever my RA flares, I get sores on my lip. Is this simply a coincidence or a normal symptom of RA?
A. I really don't know of any direct association between the development of mouth sores and flares of rheumatoid arthritis, but your question is a good one. There certainly are some possible connections between the two.
You don't mention whether the sores are occurring inside your lip or on the lip's outer surface. Sores on the outside of the lip are more likely to be fever blisters, which appear as a cluster of fluid-filled blisters that may burn or tingle. They are caused by the activation of a herpes virus that lies dormant in the body. If the virus is activated by such factors as sun exposure or fever, blisters can erupt.
Small, white sores with red edges that occur inside the mouth are called canker sores and occasionally they do develop as a side effect of drugs used to treat RA. (Methotrexate and gold are two drugs that can cause canker sores.) If your doctor determines these sores are caused by your medication, a dosage change may alleviate your problem.
Although no one knows the exact cause of canker sores, it is clear that the immune system is involved in some way and that immune cells gather at the bases of the sores. Thus, the development of these sores has some similarities to what happens within the joint lining of people with RA.
One could easily imagine a scenario in which the immune system gets "out of whack," leading to both the joints becoming inflamed and mouth sores forming. One possible, but unproven, connection may be stress, which might act by disrupting the immune system in some way.
Finally, if you have persistent mouth sores, you might want to speak with your doctor and make sure that RA is the correct diagnosis. You may instead have a less common arthritis-related disease such as lupus, inflammatory bowel disease, or perhaps a rare condition called Behçet's disease.
John Klippel, MD, Rheumatologist
Back to Top
Taking Methotrexate Safely
Q. I have been prescribed varying dosages, sometimes up to 20 milligrams of methotrexate per week, for the past two years. What should I be aware of concerning methotrexate use?
A. Methotrexate is an effective and usually well-tolerated medicine for RA. But, like any drug prescribed for any reason, it does have potential side effects.
To get the most benefits from the drug and reduce the likelihood of complications, it's important to heed the following advice:
- Take methotrexate exactly as directed by your physician.
- Ask your doctor if you are unclear about the medicine's dosing or possible side effects.
- Don't take other drugs - including over-the-counter ones – without first speaking to your doctor. Certain pain-relievers can act to increase the effects of methotrexate.
- If you notice any unusual bleeding or signs of infection, tell your doctor. Methotrexate can lower the number of blood platelets (which help the blood to clot) and white blood cells (which normally fight infection).
- Don't get any vaccinations without informing the health-care provider that you take methotrexate. Certain vaccinations can be dangerous in people whose immune systems are altered by drugs such as methotrexate.
- Don't drink alcohol while you are taking methotrexate. That's because one of the most serious long-term side effects of methotrexate is liver damage.
- You will decrease the chance of liver problems when you avoid alcohol.
- Call your doctor immediately if you have trouble breathing. In rare cases, methotrexate can cause inflammation of the lungs. Although there is no known way to prevent this side effect, prompt treatment is essential if it occurs.
Don Miller, PharmD, Pharmacist
Back to Top
Before You Order Drugs Online...
Q. With rheumatoid arthritis, fibromyalgia and several other health problems, I find getting to the drugstore to pick up my medications difficult. I have heard that ordering drugs on the Internet is easy and convenient, so I would like to give it a try. Before I do, is there anything I should know?
A. You can get just about anything over the Internet these days.
Certainly, drugs are no exception. While it is no doubt convenient to get drugs online — essentially all you have to do is point and click — I can think of at least five reasons the Internet isn't necessarily the best place to purchase your medications. Before you decide to place an order, consider these potential problems and consider some words of advice:
1) Questionable products. Online pharmacies may lure you with the opportunity to get drugs, such as narcotic pain relievers, that your own doctor refuses to prescribe. Foreign pharmacies may even offer drugs that aren't approved in this country. Resist the temptation to buy these drugs — there's a reason why they aren't approved in the United States or why your own doctor, who is aware of your medical history, won't prescribe them for you.
Even if you just order the same drugs you have used for years, there is no way to ensure that the products you get from non-U.S. Web sites are genuine, of the right strength and uncontaminated.
2) Faceless doctors and unethical prescribing practices. Although there are a number of reputable online drugstores that require a faxed prescription from your own physician, others ask only that you have a "consultation" with an anonymous online physician, who most likely is not licensed to practice in your state.
The consultation essentially amounts to a brief questionnaire, which can't take the place of a face-to-face meeting with your own doctor and a thorough physical exam. With your multiple health problems, you really need at least one doctor who knows you well and can coordinate your medical care and direct drug prescribing.
3) Excessive costs. When it comes to prescription drugs, online shopping may be convenient, but it isn't cheap. In a study published last December in the Annals of Internal Medicine, researchers at the University of Pennsylvania in Philadelphia searched the Internet extensively to identify sites that provided consultations by a doctor and sold prescription drugs.
Among other things, the researchers found that drugs purchased through those sites were more expensive (even when excluding the shipping costs of $8 to $25) than were the same medications in Philadelphia drugstores. Furthermore, online "consultations" with physicians cost, on average, $10 more than a physician visit in Philadelphia.
4) Inconsistency. If you buy all your medications from one pharmacy, there will be a central location for all your prescription records. It's common for a pharmacist to notice and alert a person to the fact that they are taking, or are about to take, two medications that have the potential to interact with one another. Switching some — but not all — prescriptions to an online pharmacy or ordering new prescriptions online can potentially lead to drug interactions, particularly if you take different medications for your various health problems.
5) Delivery Delays. If you need a medication for an acute problem or if you're down to your last day's supply of the medication you need for a chronic illness, the Internet isn't the place to shop – the soonest an Internet pharmacy can deliver is the next day. In those cases, you should always opt for a local pharmacy where you can get your medications the same day.
I understand your interest in the Internet. But remember that it's not your only option for convenience. Some local pharmacies still deliver. (Check the Yellow Pages for one near you.) If you have health insurance, your plan may have a contract with a mail order pharmacy. Some will deliver three months of medication to your home with a single co-payment. (As with Internet shopping, this isn't appropriate for an acute illness that requires medication immediately.)
Finally, if you do decide to order drugs online, please keep the following in mind: Use only a prescription from your own doctor, choose a U.S. Web site that requires a prescription from your physician, then compare prices — and be prepared to pay more for the convenience.
Doyt Conn, MD, Rheumatologist
Back to Top
Cancer History and Drug Use
Q. I have heard that malignancies can occur in people taking the drug Arava. Because I have a history of Hodgkin's disease (a cancer of the lymph nodes), as well as RA, do you think I should avoid this drug?
A. Leflunomide (Arava) is a relatively new drug for the treatment of rheumatoid arthritis (RA). The drug reduces joint pain and swelling and, in addition, can slow damage to cartilage and bone, as shown by X-ray. There are no studies showing leflunomide increases cancer risk; however, published studies on leflunomide have involved limited numbers of patients and, because the drug is relatively new, it is really too early to know whether the drug puts people at serious risk of malignancy somewhere down the line.
This potential to cause malignancies has been raised for a number of other RA drugs. Further epidemiological studies are needed to determine if, in fact, drugs do significantly increase cancer risk. Complicating this issue is the fact that RA itself may be associated with an increased occurrence of certain malignancies. In that case treating RA aggressively with medications may actually decrease cancer risk.
I have no easy answer to your question. The best path is to consult both a rheumatologist (arthritis specialist) and oncologist (cancer specialist) and decide which arthritis drugs will likely work best and have the fewest side effects and risks.
Interestingly, some drugs used to treat malignancy, such as methotrexate, are also effective in treating RA.
David S. Pisetsky, MD, PhD, Rheumatologist
Back to Top
CREST Syndrome Spelled Out
Q. I have had rheumatoid arthritis for eight years. I have now been diagnosed with CREST syndrome. Can you tell me what that is?
A. CREST is an acronym for calcinosis (calcium deposits in the skin); Raynaud's phenomenon (blanching of the fingers in response to stress or cold temperatures); esophageal dysmotility (difficulty swallowing); sclerodactyly (tightening of the skin of the fingers); and telangectasias (red vascular skin lesions), frequently on the face and hands.
CREST syndrome is a variant of a more serious and diffuse disease known as scleroderma. Many people with CREST also have joint pain and swelling (arthritis) and may not have all the characteristic symptoms I mentioned above. There is no cure for the syndrome; however, treatment can help alleviate the symptoms. For example, swallowing problems may be treated by drugs called H2 blockers -- including cimetidine (Tagamet), ranitidine hydrochloride (Zantac) -- or proton pump inhibitors, including omeprazole (Prilosec) and lansoprazole (Prevacid). Raynaud's syndrome may be treated with drugs that open the blood vessels including calcium channel blockers, such as bepridil (Vascor), diltiazem (Cardizem) and felodipine (Plendil).
Leonard H. Calabrese, DO, Rheumatologist
Back to Top
Does RA Affect the Head?
Q. Rheumatoid arthritis has severely affected several of my joints, but my more troublesome problem is this: Periodically, for no apparent reason, the left side of my head seems to fall asleep – the left side of my face tingles, my left ear hums, the tissue under my left eye turns red and swells, and I lose my balance. MRIs of my spine and brain appear normal, but the problem continues. Do you know what to make of this?
A. The symptoms you describe are complex. The possible diagnoses would depend on your age and other problems you have, such as cardiovascular (having to do with the blood’s circulation around the body) or cerebrovascular (having to do with the blood vessels in the brain and its surrounding membrane) disease.
Rheumatoid arthritis can cause neurologic problems, although these are typically caused by joint problems in the spine that affect the nerves. Since your MRI was negative, I suspect that arthritis of the spine is probably not the cause of your symptoms.
I think that the best course for you is to have a complete evaluation by a neurologist.
This evaluation may include assessment of the blood vessels to your head, looking for the possibility of any blockages that could temporarily cause insufficient blood flow and cause the symptoms of numbness.
David S. Pisetsky, MD, PhD, Rheumatologist
Back to Top
Will OJ Worsen RA?
Q. A friend told me I should avoid citrus fruits and juices because of my rheumatoid arthritis (RA). I love orange juice – and the calcium-fortified juices are good for my bones – so I hate to give it up. Is it true that something in orange juice will worsen my RA?
A. No, orange juice should not worsen your RA. There is far more benefit to you from getting the folate and calcium in the orange juice than any possible harm. Because RA is an up-and-down disease, it often happens that people notice a worsening of their arthritis after eating or drinking something, and then blame that food for the worsening of their disease. But the fact is, a connection between particular foods (orange juice included) and arthritis has been very hard to prove in most people.
A large study by Richard Panush, MD, and his colleagues showed that very few people with RA got demonstrably worse after eating a food they suspected of exacerbating their arthritis, when that food was hidden in a capsule and given in a “double blind” fashion. Unless you yourself have noticed worsening of your arthritis repeatedly after drinking orange juice, I would recommend you continue drinking it. The benefits of orange juice are clear, while any risks are small.
Ronenn Roubenoff, MD, Rheumatologist
Back to Top
Joint Damage Without Inflammation?
Q: I take DMARDs, an anti-inflammatory and a biologic for rheumatoid arthritis (RA). Lab tests show a very low sedimentation rate, yet I have deformities in both hands that are getting worse. Why?
A: The treatment of RA involves agents like disease-modifying antirheumatic drugs (DMARDs) to reduce the signs and symptoms of disease. These drugs can slow joint damage as measured by X-rays. In general, it appears that the better the disease is controlled, the slower it progresses and the less the joints are damaged.
The sedimentation rate measures inflammation. A high sedimentation rate typically indicates joint inflammation, which usually is considered the cause of the damage and deformity. However, it is possible that other mechanisms are involved in damage and deformity and that laboratory studies, such as sedimentation rate, do not tell the entire story. Some deformities may be caused by an event from the past -- such as damage related to trauma, poor alignment, awkward positioning or overuse of the joint -- rather than an underlying inflammatory disease process.
Assuming your disease is well controlled, as reflected by a low number of tender and swollen joints and a low sedimentation rate, prevention of further damage might involve splints to help support and align affected joints. For joints of the hand, surgery is also possible if function is limited or if there is concern about damage to the ligaments and tendons that keep the joint in proper alignment.
David Pisetsky, MD, PhD, Rheumatologist
Back to Top
When Arthritis Affects Your Appearance
Q: I've had rheumatoid arthritis (RA) for 10 years. Lately, I've become so self-conscious about the way the disease and the drugs I take have changed my appearance that I don't even want to leave the house. Can you offer suggestions for improving my self-esteem and appearance?
A. You bring up an important issue. Sometimes we are so focused on controlling arthritis and its symptoms that we downplay the effects the disease and its treatment can have on physical appearance.
Such changes include joint deformity or skin rash caused by the disease itself, or problems such as moon face, weight gain or hair loss caused by the drugs used to treat arthritis. These can be devastating to your body image and self-esteem – particularly in a culture like ours that places such emphasis on outward appearance.
It may be helpful for you to address both self-esteem and appearance problems. In many cases, appearance problems can be minimized or camouflaged with the right clothing, accessories or make-up. To learn how, ask your doctor if he or she can recommend a cosmetologist who works with people with chronic diseases.
To improve your self-esteem you may need to rethink what defines who you are. In other words, what is more important – what you look like on the outside or who you are inside?
Sometimes our self-esteem suffers because of what we fear others think of us. Talk to your family and friends and get their feedback. You'll see they value you for who you are, not what you look like.
Self-esteem also suffers because of what we say to ourselves. What do you say to yourself in the morning when you look in the mirror? "I look terrible," or "I'm doing pretty well given all I've been through." How we talk to ourselves helps determine how we feel each day.
You may find it useful to join an arthritis support group. You can learn from others how they maintain their self-esteem and seek tips they may have for improving their appearance.
You may find it helpful to join an aquatic exercise program for people with arthritis. While your outward appearance may not change dramatically, becoming more physically fit may help you feel better about your body and yourself.
I'm concerned that you avoid leaving your house because of your appearance. If you continue to avoid going out, you may become depressed. I would recommend that you speak to your doctor about the signs and symptoms of depression, and learn if you might benefit from antidepressant medication and/or counseling.
Stephen Wegener, PHD, Psychologist
