Run for your life

A few years ago, I came across a website apparently run by and for people with various illnesses. There were discussions, and also places where people could rate the different types of treatments for their illnesses. I went to the "depression" section to see if people gave higher ratings to medication or to psychotherapy. To my surprise, the most highly rated "treatment" for depression was exercise.

Perhaps it shouldn't be surprising. Exercise tends to make people feel better immediately, whereas medication can take weeks to work and psychotherapy may take months.

I have noticed that some of my most depressed patients don't exercise. Are they so depressed because they don't exercise, or are they not exercising because they are too depressed to be motivated to exercise? Clinicans have long noted that depression can cause vicious cycles in which the depressed person stops participating in activities that would be enjoyable and becomes more depressed as a result. Consequently, we encourage depressed patients to do the things they have enjoyed in the past, whether they feel like it or not.

 Depression can cause distorted cognitions including inaccurate memory. People with severe depression may "forget" pleasurable experiences. It's not uncommon for inaccurate memories to include memories of treatment experiences. Recently, for example, someone told me that she had taken numerous psychiatric medications in the past and none of them worked. But as she described her life and past experiences, it became clear that she had functioned much better when she had been taking anti-depressants.

There isn't a one-size-fits-all treatment for depression. Effective treatment might include a variety of modalities, some of which, such as exercise, are the sole responsibility of the patient. In my experience, most depressed people recover, if they give treatments a chance to work. 

Rules for Healthy Relationships

I agree with everything said in this blog post about relationships:

http://www.psychologytoday.com/blog/nation-wimps/201407/the-new-rules-relationships?tr=HomeEssentials

Can anti-depressants cause violence?

I've read some commentary on the internet that Elliot Rodger, the most recent mass murderer, killed people because he was taking SSRI anti-depressants. I strongly suspect these commenters are NRA activists trying to distract from the issue of the availability of firearms. However, it is worth discussing what role, if any, psychiatric medications could play in an act of violence.

SSRIs don't cause violent acts to be committed by people whose only disorder is depression. Unfortunately, many people who receive prescriptions for SSRIs have other disorders. People with bipolar disorders (manic-depressive illness) may present to a psychiatrist with depression, and upon taking an SSRI, become manic. Mania can include symptoms of grandiosity, aggression, hostility, impulsivity, and psychosis. Needless to say, these symptoms can trigger violent acts, even homicidal acts.

Many people who have depression also have personality disorders. Narcissistic Personality Disorder and Antisocial Personality Disorder (sociopathy) have as symptoms a lack of empathy for others. People with Antisocial Personality Disorder are known for frequently breaking the law. When these individuals receive SSRIs, their depression often clears up, and they have more energy. This energy can be manifested in impulsive, sexual, aggressive or criminal behavior. It isn't necessarily mania, but an elevated mood combined with a lack of regard for others.

I read parts of Rodger's "manifesto." His thinking seemed quite grandiose through much of it and at times crossed the border into delusional. I don't believe his revenge motive; rather, I think he decided he needed an excuse for his violence in order to justify it to himself.  Rejection and bullying seemed like good justifications to him. I think that he killed people for the thrill of power and perhaps to gain notoriety. (Note that he killed men as well as women and none of the people who rejected or bullied him during childhood). He then killed himself to avoid arrest, condemnation, and jail. He knew he would never fulfill his grandiose desires, and decided that without that fulfillment, his life wasn't worth living. He wasn't going to get a blonde girlfriend who looked like a fashion model, and he wasn't interested in looking for a girlfriend who was someone more like him. This type of thinking is common among people with narcissistic problems and is the reason so many people with Narcissistic Personality Disorder present with depression. They can't fulfill their fantasies, and when reality hits, they are crushed. Rodger probably assessed his available options for achieving fame and power and came to the conclusion that mass murder was his one option.

What we need to do is keep guns out of the hands of people who are seriously emotionally disturbed regardless of whether they have been hospitalized or ruled mentally incompetent. Many severely disturbed people who are capable of extreme violence are also capable of day-to-day functioning and capable of lying to cover up their plans.

PTSD

If one judged from stories in the media, one would think the main cause of Post-Traumatic Stress Disorder is wartime combat. In fact the most common cause of PTSD is sexual assault.

PTSD is common, and, I believe, underdiagnosed. That's because its symptoms include anxiety and what may look like depressive symptoms. Furthermore, for many years, and perhaps continuing into the present, PTSD was thought of as an illness relating to a specific trauma experienced in the recent or moderately recent past. Some psychiatrists don't look closely at the causes of symptoms and just prescribe a pill for what the symptoms look like. It may take time in therapy for a patient to reveal the complete history of the trauma(s).

Many combat veterans are apparently now receiving disability benefits for PTSD. The illness is treatable, and in my experience, most people recover. I've wondered what our society would look like if everyone who had PTSD received disability benefits and stopped working. Whole industries might grind to a halt, because childhood trauma and sexual violence throughout the life cycle, are common.  Perhaps our society doesn't take PTSD suffered by victims of childhood trauma or rape in adulthood as seriously as we take PTSD suffered by combat veterans. Of course, many combat veterans have other disorders on top of PTSD, including Traumatic Brain Injury (TBI). TBI can cause behavioral and mood disturbance and  may be misdiagnosed.

I've worked with many combat veterans as well as a large number of people who have experienced childhood trauma. In fact, the vast majority of my patients have experienced some sort of childhood trauma--it's the main reason people come to therapy. Not everyone who has experienced trauma develops PTSD, however.  Many factors can affect whether or not someone develops PTSD. I've noticed that many cases of long-term PTSD involve unresolved guilt feelings.

It can be important to distinguish acute stress symptoms from PTSD. It's normal for anyone to experience certain symptoms after experiencing a life-threatening event or witnessing a fatal or life-threatening event. These symptoms can include anxiety, flashbacks and fear of the situation or locale in which the event took place. In most cases the symptoms go away after a few weeks. If not, the individual can be diagnosed with PTSD and will need treatment.

An Introduction to Personality Disorders

The term "personality disorder" was developed decades ago to describe patients who had a superficially normal presentation without psychosis but who, under psychoanalysis, were revealed to have deep disturbances in their psychological functioning. Many of these patients had chronic problems in interpersonal relationships or social/occupational functioning. Some had symptoms of "neurosis" such as anxiety or depression, whereas others had none. To this day, personality disorders remain difficult to treat. Yet, a large percentage of any psychotherapist's caseload is composed of persons with such disorders, as they comprise approximately 10-20 percent of the general population.

Traditionally, psychotherapists believed that personality disorders were untreatable. This view has changed over time, but whether the view has changed because my profession has become better at treating personality disorders or the view has changed simply because no one wants to admit that a large percentage of  patients are only partially treatable at best is open to question. What I have found in my practice is that most people with personality disorders present with depression or anxiety that can be treated, but that their core personality problems are treatable some, but not all, of the time.

The theories of my profession have held that real psychological treatment occurs in the relationship between the patient and the therapist, and my 20 years of experience has shown me that this is true. The reason that personality disorders are difficult to treat is because the personality disorder has a tendency to destroy the patient-therapist relationship.  Persons with personality disorders have a tendency to hide important information from the therapist, because either consciously or unconsciously, they are unable to admit what they believe to be shameful information or feelings. This is because they either have an inflated ("grandiose") sense of self that does not allow weakness, or they have an inordinate fear of judgment that is a product of their projection.

What is a personality disorder? In short, it is a malformation of the ego, the part of the psyche that mediates between pleasure-seeking urges and reality. We all make emotional compromises to deal with the fact that reality doesn't always give us what we want. A person with a personality disorder, either because of genetic tendencies, a history of early childhood trauma or both that have disrupted normal processes of maturation,  distorts reality instead of compromising with it (people who are simply neurotic, in contrast, engage in "compromise formations" which often involve symptoms that are easily identifiable to both the patient and the therapist).  I have found that many of my patients with personality disorders live in a fantasy world. They are unable to see what people around them are really like because they only see what they have projected onto those people, which may be what they wish others to be like, or, a projection of a  part of themselves that they don't like. Consequently, others may be either idealized or devalued.

There are many other aspects of personality disorders-- this is a complex subject that cannot be adequately explained in a blog post. If you suspect that you have a personality disorder, the path to recovery is to be completely honest with your therapist, even if it feels uncomfortable. Ultimately this honesty breaks down the pathological defenses that comprise a personality disorder, leading to the formation of an acceptance of reality, a realistic self-image, and perceptions of others that aren't so distorted. 

The Patient's Responsibility Part II

Once in awhile, a patient will preface what they are going to say by saying "I hope this isn't TMI [too much information]." There is no such thing as TMI for your therapist.

It used to be common knowledge that patients in therapy were supposed to discuss all of their thoughts, feelings and experiences. Dreams and sexual fantasies were common topics in therapy sessions. Of course, most people are not comfortable immediately discussing their most personal thoughts, which is fine. Most people begin by talking about what is going wrong in their life. It's important for the therapist to know more than the superficial details, however. Patients who hide details of what they consider embarrassing material may be leaving out important information.

Sometimes people hide information out of fear. A drug addict who doesn't really want to give up drug use may hide the extent of his/her use in order to avoid confrontation and a referral to an inpatient facility. It's important to trust that the advice a therapist gives is based on clinicial evaluation, not judgment.

I've had some patients who apologized for cursing in sessions.  If you feel like cursing to express yourself, go ahead (if you feel like cursing at me, however, I suggest we discuss what is making you angry instead).

The basic rules of social interaction mostly don't apply in therapy sessions, the exceptions being that you are supposed to be on time, pay any bill that you owe, and participate. Cursing, talking about sexual behaviors or fantasies and admitting to drug and alcohol use fall into the realm of expression. Without your honest expressions, therapy cannot be effective.

My Thoughts on Psychiatric Medications

Usually about 20-50 percent of my patients are taking psychiatric medication. Psychiatric medication can be extremely useful, even crucial; however, it is often misprescribed.

About one out of every five times I see a new patient who is already on psychiatric medication, the person has been prescribed the wrong medication. Someone might ask how I know, as I am not a medical doctor. First of all, if a medication isn't working, then someone should not be taking it. Secondly, my consulting work in psychiatric facilities involves reading the entire medical records of  patients. I've read the records of severely ill patients who are taking three, four, or even five medications. I spend time discussing clinical care with the prescribers in the hospitals (along with a multidisciplinary team including our team psychiatrist). What this means is that I've become extremely familiar with both the intended effects, side effects and possible adverse reactions of most psychiatric medications.

Some common errors I have seen are: Prescribing dangerous anti-psychotic medications instead of anti-depressants to depressed patients, failing to properly diagnose conditions such as Attention Deficit Hyperactivity Disorder in adults, failing to prescribe mood stabilizers when warranted, prescribing anti-anxiety medications for what is actually depression, failing to consider the consequences of prescribing addictive medications to persons who already have addictions, and more.

Several years ago I had two patients who were being prescribed Zyprexa, an anti-psychotic with potentially serious side effects. I knew this was not the right medication for these two depressed patients. In one case, I called the patient's psychiatrist and suggested changing the medication to something else. The doctor decided to try something different and the patient improved markedly. In the second case, the doctor (a different doctor) ignored my suggestion and the patient tried to kill herself. Fortunately, she did not die, and I made sure she was admitted to a hospital where her medication regimen was changed.

In other cases I have just spoken directly with the patient and suggested they talk to their prescriber about their medication. Sometimes this is effective. In one case, the patient had been taking a medication for panic disorder even though she did not have panic disorder. She had been dutifully taking this medication every day (a highly addictive medication) and had begun to wonder if it was making her sleepy. Her doctor agreed she could reduce the medication and she quickly became less sleepy without developing any more anxiety.

I have often thought in recent years that the practice of medicine in this country leaves much to be desired. The explanation of one of my colleagues is "today doctors treat symptoms instead of illnesses." He's probably right. Without figuring out what the underlying illness is, the medication can be wrong and even dangerously wrong.

If you need psychiatric medication, or a new prescriber, I can refer you to someone whom I believe to be competent.