NeuroLove

PTSD treatment

Like so many other things, people have individual differences in how they respond to different treatments.  Some people respond best to psychotherapy, others to medications, and still others to both.

Cognitive behavioral therapy focuses on ways of thinking and reacting to triggers for the PTSD symptoms and can help the individual to control these symptoms.  I am going to copy three types that can be used from the NIMH site:

• “exposure therapy — uses mental imagery, writing, or visiting the scene of a trauma to help survivors face and gain control of overwhelming fear and distress
• cognitive restructuring — encourages survivors to talk about upsetting (often incorrect) thoughts about the trauma, question those thoughts, and replace them with more balanced and correct ones.
• stress inoculation training — teaches anxiety reduction techniques and coping skills to reduce PTSD symptoms, and helps correct inaccurate thoughts related to the trauma.”

There are also a few medications that can be used to treat PTSD.  Prazosin (chemical structure is the image above) is a somewhat common treatment that blocks the alpha receptor subtype for norepinephrine.  We know that norepinephrine can activate the sympathetic nervous system (fight or flight response) and so the alpha receptors, which are activated by norepinephrine, promote amygdalar activity and the fear response.  Prazosin, basically, can block this. A newer one of the medications that can be used is Propranolol or beta blockers which can be given soon after a traumatic event to hopefully prevent PTSD.  Beta blockers, which block the beta receptor type for norepinephrine, are showing some success at preventing or reducing PTSD.  Please note that these explanations are very simplified, but they can give you the general idea.

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Post-traumatic Stress Disorder (PTSD)

Someone asked me to give more information about PTSD, so I thought I would do a couple posts about it.  After depression and substance abuse, PTSD is one of the most prevalent mental disorders.  An estimate of 70% of people in the US are exposed to a traumatic event in their lifetime (car accident, combat, physical/sexual assault), but only about 14-24% of these people will develop PTSD.  It has slightly higher prevalence for women (10-14%) than men (5-6%), but is much higher in soldiers than civilians.  For instance, 30% of Vietnam veterans had PTSD and almost half of prisoners of war developed PTSD in their lifetimes.

It is important to note that PTSD cannot be diagnosed until 30 days after a traumatic event, since some of the symptoms are “normal” to be seen immediately following the event.  It is their persistence that creates a problem.

The criteria for diagnosis of PTSD are:

Criterion A - Exposure to a traumatic stressor.
Criterion B - Re-experiencing symptoms.
Criterion C - Avoidance and numbing symptoms.
Criterion D - Symptoms of increased arousal (i.e. hyper-vigilance).
Criterion E - Duration of at least one month.
Criterion F - Significant distress or impairment of functioning.

In the image above taken from the NIMH site, you can see the VMPFC and amygdala are highlighted.  That is because the amygdala creates a fear response and the VMPFC is able to extinct a fear response.  In PTSD, it is thought that this system is somehow hindered and the individual is unable to extinct the fear response.

Medical Student Syndrome

I’d like to introduce you all to “medical student syndrome,” which is the fact that when people start reading about diseases and disorders, they will sometimes self-diagnose with them or worry that they have them.  I bring this up because I have been posting about mental illnesses and even if they might sound a bit like you, you can not know if you have them unless you have been diagnosed by a medical professional.  If these descriptions really do strike a very personal and real note, please do get help.  Talk to your primary care physician or seek the help of a therapist.

As for medical student syndrome itself, it is a really interesting and pretty common phenomenon, and was described well by Baars (2001): “Suggestible states are very commonplace. Medical students who study frightening diseases for the first time routinely develop vivid delusions of having the “disease of the week”—whatever they are currently studying. This temporary kind of hypochondria is so common that it has acquired a name, “medical student syndrome.””

It happens to a lot of students studying psychology and medicine- if this is happening to you, you are not alone!  But please do seek the help of a professional if you think you might have a mental illness described on this blog or elsewhere!

[Internet comic source]

How is bipolar disorder treated?

Mood stabilizers are the most common treatments.  The most common of these is Lithium, which was first approved in the 1970’s.  It is not known exactly how lithium works, but it seems to be very effective at both preventing mania and preventing depressive episodes.  It probably acts on neurons in the brain (since these symptoms are neuronal), but it’s not clear how or where exactly.  Other mood stabilizers include anticonvulsants (used to prevent seizures in epilepsy) that were also found to stabilize mood.  For instance, valproic acid may work better than lithium for some people.

Lithium also seems to change brain structure.  It increased gray matter volume in limbic and related areas in patients with bipolar disorder as compared to other treatments (see image; Germana et al., 2010).  These areas are involved in emotional regulation, and so it suggests that lithium may help cause structural changes in these areas that lead to the mood stabilizing effects.

Antipsychotics can also be used along with other medications to decrease some of the symptoms of bipolar disorder.  These include olanzapine (which helps with severe depressive episodes), risperidone, and clozapine, among others.

Antidepressants can also be added to decrease depressive symptoms (such as the SSRIs, or selective serotonin reuptake inhibitors).  However, these are never (or should never) be given alone to people with bipolar disorder as this can cause the person to swing from depressive episodes into mania.  Therefore, antidepressants are usually given in conjunction with mood stabilizers, such as lithium.  It’s not clear whether mood stabilizers + antidepressants is all that effective though, as a study conducted by NIMH found it no more effective at treating bipolar disorder than the mood stabilizer and placebo (sugar pill).  For more information on that study, see here.

The next post will talk about EH’s experiences with treatment.

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Case Study: EH’s bipolar development

Please check out the last post for how bipolar disorder may develop.  In EH’s own words, “The earliest symptoms I think are less symptoms and more a personality type since as far as I can remember (7yo)— whimsical, permanently happy and carefree, occasionally very existentialist like I understand the whole universe.  Disease onset was junior year of college.  During the summer before junior year, I had the best summer of my life: doing research at [a hospital], sleeping maybe 4 hours some nights and going back to work on the weekend, when usually I am a very heavy and regular sleeper.  I had all the energy in the world to walk 2 miles to the market and carry all my groceries home, then spend all day by the river at a festival, and every aspect of my day was the most fun exciting thing ever.  This was extended hypomania which I hadn’t experienced in this prolonged intensity.  In the fall I had my first [significant other], who fell into the ‘totally uninteresting category’ until I became totally obsessed to the point that I was skipping school and even failing the majority of my classes half way through the semester.  What made this notable for me in retrospect is the fact that I had never behaved this way and it was very unusual for me to obsess like that.  My therapist and I now identify it as ‘catatonic thinking,’ or raging thoughts. 

“My first clinical depression came in spring my junior year.  I cried for basically no reason 6-7 times per day plus I couldn’t sleep, and would skip class to nap or cry for 1.5 weeks.  I am close with my mother, so she came down to visit out of concern.  After two days trying everything she could to cheer me up, she had to leave because she was so sleep deprived and distressed at my relentless despair that she developed hives.  Shortly after this episode, I binged and threw up, both to relieve anxiety, which, in retrospect, was my second clinical symptom.  This lasted off and on until I started taking lithium (very weirdly THE DAY I started taking lithium thank goodness!).  The final and clinching diagnosable episode was the week I was manic, skipped work for a week, bought a car I couldn’t afford, slept approximately 5 hours each night with lots of energy to bake or go for a run (which is dangerous in my part of the city) in the wee hours. 

“None of these things that I have said meant anything to me before my friend from lindy hop dancing lessons convinced me to see a doctor.  He was diagnosed that summer with a sudden progression of his symptoms due to a concussion from a car crash the previous spring.  The two of us had joked with the same sense of humor, we shared the same intensity regarding dancing, and had similar relationship patterns in our lives.  I am lucky that he noticed the same traits in me which turned out to be symptoms because it is not often that bipolar is caught at the early stages that mine was.  Many of the terrible things that you hear are from people in their thirties- it’s rare that someone at my age, 26, actually has full blown destructive bipolar.  Mine barely stepped over the line into clinical bipolar before it was identified.”

[Image Source: Bipolar Self Portrait by stacibar98]

Early Stages of Bipolar Disorder

When bipolar disorder first appears, it is very difficult to diagnose.  People naturally cycle through moods and in the earliest stages, people with bipolar disorder will cycle lightly- barely mania and barely depression (compared to what they will later experience).  Particularly hypomania is difficult to diagnose or recognize as a problem, as it may just seem like the person is particularly happy, productive, and energetic.  At the very beginning, individuals are more likely to experience major depressive episodes, and if they seek help for it, they will be diagnosed with depression.  It is also important to note that depression is much more likely to be viewed as a problem than mania socially as it is a more negative emotion, even though both and their combination can be very difficult to live with and cause many problems.  Furthermore, it is not unlikely for a person with bipolar disorder to have received treatment for depression, especially when their first few major depressive episodes first appear in the teenage years.

Eventually, the individual will experience a manic episode that if reported and recognized can lead to the diagnosis of bipolar disorder.  If bipolar disorder continues untreated, the person will experience more cycles into depression and mania that will often increase in frequency and shorten in duration (they begin to go in and out of depression and mania more rapidly).  Please note that I am not saying all cases of bipolar disorder present this way, but this is a general overview of the disorder’s development.  I will give EH’s views on their early stages in the next post.

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Bipolar Disorder (Depression and Mania):

In the last post, I gave you an idea of how we define depression and mania in the DSM-IV.  These two present differently in different people- as I mentioned before, depression can turn into a bit of a catch-all diagnostically (sleep too much or too little, eat too much or too little, etc). I feel like EH describes depression and mania better than the DSM-IV or I could through their discussion of their own feelings.

In their own words, EH defines their depressive episodes: “Depression for me is an empty mindless relentless crying.  It feels like desperation for something that doesn’t exist, hence the emotional pain.  When I wasn’t medicated, a single crying episode my last 5 hours…nonstop.  Before I optimized my dosage and had slight bipolar depressions, I might cry for 2 minutes while I think about where I am and what my actual situation is before deciding I need to distract myself by watching a movie.  Then strangely for no reason as soon as the movie ended I’d start crying again until I could find another distraction to wait out the bad mood.  My [significant other] can now tell the difference between my real crying, my hormonal crying, and my bipolar crying.  While my bipolar depression is spontaneous and without reason, my real crying is predictable and with reason.  My hormonal crying is unpredictable in that I can find an issue with anything to cry over and it feels very urgent and valid, but the reason is not warranting such a response.”

As for mania, EH describes these feelings as: “Mania is exactly the opposite in that it’s excitement without reason, except there were noticeable triggers for me.  Music was a trigger—I could go from reality, to feeling like what you would think of a nightclub in japan, slightly intoxicated, performing for an audience that is only half watching, being the most wild and free and coordinated dancer the managers could imagine hiring.  Contradictory, I know.  I had some really amazing personal dance parties in my room in college, needless to say.  People were sometimes triggers— but it was never the kind of party person you’d expect.  One friend, let’s call him Joe, was somewhat of a weird dull guy who none of my friends liked.  He became my best friend in the whole world within a day, secret hand shake and everything.  For a short period of time we skipped work to do all kinds of crazy stuff, like go to the pool or the supermarket or the computer lounge…however mundane, doing anything with him was fantastically exhilarating.  What I was supposed to be doing or would benefit from doing never had any bearing on what I actually did— I just didn’t occur to me that it could possibly pose a problem that I couldn’t make up for later. I think sunlight was a kind of trigger too, as I was always much more prone to be hypomanic in the summer.  I remember some mornings I’d wake up early, ready to get a jump on the day.  The sun was amazing- so radiant, as though it was pure life and joy being instilled in my soul.  I would dance-exercise, then cook, clean, talk on the phone, and plan my daily activities all at once, and usually drop one of these activities in the very middle to be cleaned up later because something else popped up that was SO more important.  I didn’t have a car at the time of the specific morning I’m thinking of, so running all over the city became the plan, as it often was.  On another occasion I walked 3 miles home with a canvas taller than me.  I regretted the decision shortly after embarking when the wind nearly carried me across the street like a sail boat but not enough to get a cab. When I was hypomanic, this was hilarious and exciting.  If I tried to do this now, I’d be tired and frustrated. Mania is the ultimate pink looking glass.”

EH also talks about triggers.  Many therapists will work with a patient to identify the things that act as “triggers” to send the person from their current state into a manic or depressive episode.  This sort of therapy helps to work at recognizing when they might encounter a trigger and helping to prevent the resulting swing into a manic or depressed state.

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Recently, I’ve been talking about unipolar depression (or just depression).  I am now going to introduce bipolar disorder and go into some information about that.  I mentioned in the last post that I have a friend who has bipolar disorder and is willing to share their experience alongside my discussion.  For privacy, I will refer to them as EH.  I am sure it will not be necessary to ask you all to be respectful, but I would like to reiterate that you should be respectful and polite in any replies or discussion of their experiences (which are in quotes).  I am sure it is not easy for them to be willing to share their experiences in such a public manner, and I think it is a testament to their character that they is willing to do so, in order to help educate the general populace about bipolar disorder.

Bipolar disorder is characterized by a cycling of moods between depression and mania.  Depressed mood, as I’ve touched on before, is characterized in the DSM-IV as [my explanations for words you may not know in italics and brackets]:

“(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day [not sleeping enough or sleeping too much]

(5) psychomotor agitation [moving too much] or retardation [moving too slowly] nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue [feeling exhausted] or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide”

These periods of depression will be mixed with periods of mania, which are defined by these characteristics:

“(1) inflated self-esteem or grandiosity

(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3) more talkative than usual or pressure to keep talking

(4) flight of ideas or subjective experience that thoughts are racing

(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(6) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)”

Whereas with unipolar depression, a person might cycle between depressed mood and euthymia (“normal” emotional patterns), with bipolar disorder, a person will cycle between depression and mania or hypomania (low to moderate mania).  They may have some periods between depression and mania of a euthymic state and the length of their depressed and manic states will vary from person to person and over time.

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Mental Illness and Societal Stigma

Despite all that we know now about mental illnesses, there is still a lot of stigma against the people who are diagnosed with them.  While people with cancers, for instance, are empathized with and often very supported, people who have been diagnosed with a mental illness are often rejected and have difficulty garnering empathy.  The fact is that mental illnesses are caused by dysfunctional brain activity, the same way that physical illnesses are caused by other dysfunctional body organs.  Society on the whole is more likely to blame an individual for their mental illness than recognize it as something outside of that individual’s control.

I acknowledge that this has been getting much better with time, but society as a whole still has large bounds to make in understanding and treating mental illnesses.  Perhaps part of the problem is that they are relatively poorly understood at this point in time, but I would argue that the reason for that is that they have been stigmatized against for so long that it is preventative to learning more about them.  I am hoping that this will continue to improve with time and that eventually, there will be no preferential treatment of physical over mental illnesses, as they are just as real, debilitating and difficult in the individuals who have to live with them.

To this end, I am planning to start a multiple post series about bipolar disorder in conjunction with information provided by a friend of mine who was diagnosed with bipolar disorder.  I am going to walk through the diagnosis, development, treatment, as well as a few of the known brain differences in bipolar disorder.  For privacy, I will refer to my friend as “EH.”  I feel that providing this information from both a more clinical (my) and personal (EH’s) perspective will help to elucidate the image of mental illness and give a fuller portrait of bipolar disorder.  It is also important to know that I was unaware of EH’s diagnosis entirely until they outright told me, partially because they have been lucky enough to have been diagnosed and treated well and also because mental illnesses are often less obvious than physical disorders, which does not make them any less real or pervasive.  EH is a fully functioning and productive member of society, and is just one case of bipolar disorder, but I think we can still learn a lot from their experiences.

To begin, when I asked EH about the stigma around their diagnosis, they replied, “I am very open about my bipolar, mostly because it explains my personality type.  I recognize that there is a lot of stigma, as my mother is still waiting for me to admit it’s a sham and come off the medication.  Bipolar has helped me define myself, because it has allowed me to recognize what parts of myself are chosen personality traits and what parts I can now control.  Everyone has biology things they need to struggle to understand and work to find mechanisms to overcome.  This has been a huge science project for me, essentially. I am proud to be who I am, part of which is my relationship to my disease.”

Please take care to be polite and respectful in response to any discussion of EH’s personal experiences and observations, which will always appear in quotes.

[Image Source: Amber Osterhout’s anti-stigma art]