Psychiatric Database for Writers: Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD) affects approximately one in every fifty persons. Individuals with this disorder have problems with certain kinds of thoughts (called obsessions) and behaviors (called compulsions).

What is an obsession? 

The term “obsession” refers to distressing thoughts or psychic images that are repetitive in nature and difficult to get rid of. The more the sufferer tries to avoid them, the worse they become. These thoughts are always unwanted. The patient recognizes his obsession as excessive but can’t stop the cycle.  You’ll find examples below.

Obsessions strike where one is most vulnerable.   

A priest experiences distressing, sacrilegious thoughts (for example, a repeated mantra like “I hate God”) and/or images (doing horrible things to a nun)

A mother can’t stop thinking, “I hope my son dies today.” She knows the thought isn’t true – she loves her son, would do anything for him — but can’t seem to turn it off.

Obsessions can be the “norm” taken to an extreme. 

A student thinks it’s a good idea to wash his hands before eating (normal).

Another student worries about contamination so much that he washes his hands every fifteen minutes, leaving them chapped and red.  He knows it’s a problem but can’t stop.

What are compulsions? 

If obsessions describe what a person thinks, compulsions describe what one does. A compulsion is a strong, usually irresistible impulse to perform an action or behavior, especially when that action is senseless or contrary to one’s will.  See below for examples.

Compulsions must be acted on to avoid anxiety 

A woman needs to drive around the block five times before parking in her garage.  She knows the compulsion is senseless, but she can’t go on with her day until she does it.

Every night, before going to bed, a man checks and rechecks all household windows and doors to make sure everything is locked – but finds he must check window and door FIFTEEN separate times before he feels comfortable enough to climbs into bed.

Compulsions can be experienced as a way to “undo” an obsession  

A child believes she needs to count to 100 every day after school, or else her mother will have an accident on the way to pick her up and never be seen again.

A man struggles with intense, persistent unwanted thoughts about killing his family, something he would never do.  The obsession is extremely distressing but is countered each day when he says the Our Father prayer twenty-five times in a row.

An aside…

An addict has a strong, irresistible impulse to use drugs.  Is that a compulsion?

It’s easy to confuse the two: both describe the irresistible impulse to perform a certain behavior, right?  Nope.  The difference lies in the type of impulse and type of end-point, or action.  An addict’s impulse to use is driven by a good feeling, anticipation, as they know there’s something pleasant up ahead if they give into the impulse.  Addicts use drugs because the action of using brings pleasure.  An individual with OCD isn’t driven by something pleasurable — the end-point has nothing to do with pleasure.  Quite the opposite: people with OCD perform compulsions to avoid suffering, and the end-point (the compulsion) is typically a senseless, time-consuming, embarrassing tasks that must be performed to avoid anxiety.  

What is the typical treatment for OCD?

Treatment typically includes medications and Cognitive Behavioral Therapy (CBT), usually a combination of both.  Brain surgery can be helpful for individuals with severe, treatment-refractory OCD. (There are also various self-help techniques available in bookstores and online, though I won’t go into this.)

Medications are key. 

Although we don’t understand the exact mechanism, some antidepressants  have been shown to be extremely helpful for individuals with OCD.  The most frequently prescribed medication for this particular disorder are Luvoxamine and Clomipramine.  Individuals usually require very high doses.  Sedatives like Klonopin or Xanax can be helpful with anxiety and panic, but are best used short-term.


Cognitive Behavioral Therapy (CBT) is the most popular type of talk-therapy, when it comes to OCD.   Rather than searching for some psychic reason for the condition, CBT is about the here-and-now. The cognitive aspect focuses on rewriting problem thoughts.  For example, fear of contamination might be challenged by reviewing the evidence: studies suggest that touching a doorknob in a public place is unlikely to trigger disease. The behavioral side of CBT is geared towards action.  Usually this involves delaying time between urge to complete a compulsion and actually doing it.

An aside…

The interesting thing here about therapy for OCD is that it focuses on pushing further INTO the pathology itself, especially obsessions. For example, an individual plagued with thoughts about killing his family should NOT avoid the thoughts.  Quite the opposite: he should pursue them purposefully, full-throttle, as often as possible – until the thoughts lose their power. Eventually one realizes that a thought is just a thought, no matter its content. 

Psycho-surgery.  Surgical options for OCD include placement of a Vagus Nerve or deep brain stimulator as well as psychosurgery that uses radio-frequency waves to disrupt the cortico-striatal circuit in the brain.  The cortico-striatal circuit has been implicated in OCD.  Long term outcome for these procedures appear to be somewhere between 25 and 70 percent in alleviating OCD symptoms.  

That’s a quick overview of OCD.  Thanks for reading.

Alex Natalian, Psychiatrist and Author

Alex Natalian is a penname for psychiatrist KRR.

Psychiatric Reference for writers: bipolar disorder.

The kiss of euphoria, the agony of a blackened soul: bipolar disorder

Consider these two quotations.

“Bipolar robs you of that which is you. It can take from you the very core of your being and replace it with something that is completely opposite of who and what you truly are. Because my bipolar went untreated for so long, I spent many years looking in the mirror and seeing a person I did not recognize or understand. Not only did bipolar rob me of my sanity, but it robbed me of my ability to see beyond the space it dictated me to look. I no longer could tell reality from fantasy, and I walked in a world no longer my own.”

Alyssa Reyans, Letters from a Bipolar Mother

“Creativity is closely associated with bipolar disorder. This condition is unique . Many famous historical figures and artists have had this. Yet they have led a full life and contributed so much to the society and world at large. See, you have a gift. People with bipolar disorder are very very sensitive. Much more than ordinary people. They are able to experience emotions in a very deep and intense way. It gives them a very different perspective of the world. It is not that they lose touch with reality. But the feelings of extreme intensity are manifested in creative things. They pour their emotions into either writing or whatever field they have chosen” (pg 181)”

Preeti Shenoy, Life is What You Make It

As these excerpts suggest, bipolar disorder is a sickness of extremes.  People with this illness have intense cyclical mood swings.  What rages as an energetic, brightened soul this month sinks into a creature of agony the next.  It’s not surprising that many artists, writers, and musicians struggle with bipolar disorder — when the highs aren’t catastrophic, they act muse and guide and mentor.

Bipolar Disorder, a definition

The official definition of this disorder could be “a disturbance in mood severe enough to interfere with the sufferer’s life.” These emotions are unique to the individual and can actually include different types of “highs” and “lows” in the same person, but in general, mood states are defined as follows:

What isn’t bipolar? 

The question should read “what’s normal?” Most people have natural fluctuations in their mood; sometimes glum, sometimes overjoyed.  These mood states don’t last long – a few days at most – and they’re rarely severe enough to cause problems.  Often a change of environment, improved coping skills, time for reflection, or a good person to talk to is all that’s needed to make things better.  If you need a definition of normal, that’s about as close as you’re going to bet.

Bipolar depression is characterized by sadness, loss of hope and interest in life, helplessness, excessive feelings of guilt, eating/sleeping too much or too little, problems thinking, low energy, and self-esteem problems.  These symptoms last a minimum of two weeks.  Left untreated, the episode can last years.  Severe depression can lead to strange thoughts and hallucinations (usually distressing experiences, like derogatory voices or pathological guilt over something the sufferer didn’t do).

“Bipolar habitus.” Sufferers of bipolar depression tend to sleep and eat excessively, while depressed individuals without bipolar disorder tend to suffer from insomnia and diminished appetite.  Old psychiatric texts often describe the typical bipolar “body” as pair-shaped, a consequence of overeating when depressed.   Bipolar depression is also linked to interpersonal sensitivity than its non-bipolar counterpart.

Mania and hypomania both present with euphoria or agitation, talking non-stop, excessive energy and pleasure-seeking, multi-tasking poorly, hypersexuality, poor decisions and choices (like overspending money, hyper-sexuality), problems with concentration, and diminished need for sleep.  Mania lasts longer than hypomania and is more disruptive.  Severe mania can lead to abnormal thinking and hallucinations (for example, sufferers might believe they have special powers and/or hear God speaking to them).

Mixed episodes is a term used to describe mood states that have both depressive and manic symptoms.

Types of bipolar disorder.

Recent nomenclature divides bipolar into four classes, though some clinicians think of the third “type” (cyclothymia) as a separate illness.  The reason for categorizing bipolar types is related to different disease patterns, prognosis, and to a large degree treatment strategies.

Type 1: Individuals are described as Type 1 bipolar if they have experienced mania. That is, if the patient has never experienced frank mania, he or she cannot be diagnosed with Type 1 bipolar.

Type 2: Someone who has experienced hypomania and clinical depression (but not mania) is considered Type 2 bipolar.  This subset tend to experience more depressive episodes than Type 1.

Type 3: The third type, called cyclothymia, is marked by episodes of mild depression and hypomania (i.e. not serious enough to meet criteria for a “real” episode) that interfere with the sufferer’s quality of life.

Bipolar disorder, not otherwise specified (NOS): The final category includes those cyclic mood disorders or bipolar-like conditions that don’t fit into the first three categories.  An individual who experiences hypomania but never depression would be considered bipolar NOS.


When it comes to bipolar, a multi-pronged approach is best.  This almost always includes medication.  Other “prongs” include psychotherapy, stress management, stable environment, consistent sleep schedule, and psychosocial support.

Medications: Treatment of bipolar disorder almost always includes medications: antipsychotics, mood-stabilizers, and when necessary, antidepressants.  Most people with this illness require medications.   This is a particularly difficult disorder to treat, in that the individual’s metabolism seems to change according to the type of episode.  For example, higher doses of medication are needed in the treatment of mania than other mood states.

Lithium.  There was little treatment for bipolar disorder until the emergence of Lithium, which even today has been shown to be extremely effective in stabilizing this disorder.  It is the only psychiatric medication show to reduce suicide rate in individuals with bipolar disorder.

Psychotherapy:  Interpersonal and Social rhythm therapy is a school of psychotherapy used specifically for bipolar disorder. Cognitive behavioral and supportive therapy can also be helpful, as well as group therapy and support groups.  While therapy is helpful, few individuals with bipolar disorder respond to talk therapy alone.

Lifestyle: The interesting thing is that bipolar disorder seems to be caused in part by a faulty internal clock.   The goal, then, is to establish an effective external clock.  This includes keeping a strict routine (scheduled socialization, exercise, etc) and taking medications to normalize sleep patterns as much as possible.  Individuals with this disorder must also avoid behaviors that destabilize the internal clock, like rotating shiftwork (anything that interferes with consistent sleep hours), frequent changes of environments, and substance abuse.

“The creative curse:” famous people with bipolar disorder

Mania and hypomania can awaken the muse and set life a-flying.  When it isn’t destructive it’s extremely productive.  No doubt there’s some link between mood disorders and creativity, especially a mood disorder like bipolar disorder.  It’s no surprise then that many prominent artists, musicians, and writers have this disorder.  Click on the link below for the Wikipedia article, “List of people with bipolar disorder,” and you’ll see what I mean.

That’s bipolar disorder in a nutshell.  Thanks for reading.

Alex Natalian, Psychiatrist and Author

Alex Natalian is a penname for psychiatrist KRR.


Psychiatric Database for Writers: Sleep and Parasomnias

Sleeping Man DrawingYou don’t have to look far to find parasomnias in the media.  Poltergeist: a woman floating in the air, fidgeting and making strange noises.  Nightmare on Elm Street: the wondrous Freddy Krueger who likes to scare teenagers where they’re most vulnerable… their dreams.  Media aside, abnormal experiences during sleep are rampant everywhere, even in straight-science clinical medicine.  We psychiatrists call these experiences parasomnias — though I’ll admit parasomniacs never float.  And they rarely get killed in their sleep either.  Let’s start with the basics.

What, why, how, and where… sleep? 

Contrary to popular belief, we don’t sleep to “rest” our brains.  In fact, studies using electroencephalograms (EEGs) demonstrate the mind is just as active when asleep as when awake.  EEGs reveal two types of brainwaves during sleep: dream and non-dream.  A typical night starts with non-dream, then oscillates between dream and non-dream repeatedly until the sleeper wakes up in the morning.

Non-dream sleep (also called non-REM sleep) is marked by four stages.  Stage one (also called alpha waves) occurs when the sleeper is just starting to drift off.  In stage two, waves on the EEG gets bigger and slower.  We spend about 50% of our total sleep in stage two.  By stages three and four, the waves have slowed even more, and fluctuations in energy are greater. It is difficult to wake someone during the third and fourth stage, thus the name “deep sleep” for these two stages.

The dream part of sleep is called REM, or “rapid eye movement,” due to the eyes’ tendency to move around while dreaming.  Some scientists refer to REM as stage five.  While EEG findings during REM and wakefulness are almost identical, REM sleep is accompanied by total paralysis; that is, the dreamer doesn’t move when he dreams he’s moving.  This paralysis disappears during non-dream sleep. We typically spends two hours a night (about 20%) dreaming.  Dreams get longer as the night progresses.

What are parasomnias?

Unlike insomnia, which is defined as difficulty initiating or staying asleep, parasomnias occur during sleep.  They are disturbances of sleep architecture or behavior that seep into the waking world, causing trouble for the sleeper when they aren’t sleeping.  Here’s a little info about the most common parasomnias.

Most of us have nightmares from time to time.  A person is said to have a nightmare disorder when his nightmares interfere with his waking life, usually the result of recurring intense, horrifying dreams that the sufferer remembers upon wakening.  Nightmares are common in people with a history of severe trauma. Treatment involves medications that inhibit REM, like benzodiazepines, tricyclic antidepressants, or Prazosin.

Unlike nightmares, sleep terror disorder occurs during non-dream sleep. This is a disorder of sleep stages three and four (deep sleep) and is limited to the first third of the night. Sufferers wake up in a screaming panic, confused, short of breath, and unaware of their surroundings. This confusion lasts until they fall back to sleep. The next morning nothing is remembered. . . These episodes are NOT linked to nightmares. Treatment includes medications that block non-REM sleep.

Like sleep terror disorder, sleepwalking occurs in the first third of the night, during non-REM sleep. While sleepwalking, the sleeper has a blank, staring look on his face. He doesn’t respond to communication and can be difficult to wake up. When he does wake up – either from sleepwalking or the next morning – the sleepwalker doesn’t remember anything of the event. Contrary to popular belief, it isn’t dangerous to wake someone when they are sleepwalking.

Sleep paralysis happens during that twilight zone between wakefulness and sleep. It’s normal to be paralyzed during REM sleep, but occasionally paralysis slips into wakefulness: the sufferer wakes up to find he can’t move. The experience of being “stuck” can be terrifying. However, the paralysis goes away within minutes and typically doesn’t require treatment. Sleep paralysis can run in families. It’s common in people with narcolepsy.


I’d like to believe sleep is an existential happening, a gateway to an alternative version of reality, a world where questions are answered, where poetry waxes physical law… but there’s no proof to my hypothesis, not yet.  A shame, really.   But reality and sleep can be synonymous with fiction and sleep, if you look at everything with the right pair of glasses on your nose.  Consider the following:

“People say, ‘I’m going to sleep now,’ as if it were nothing. But it’s really a bizarre activity. ‘For the next several hours, while the sun is gone, I’m going to become unconscious, temporarily losing command over everything I know and understand. When the sun returns, I will resume my life.’

If you didn’t know what sleep was, and you had only seen it in a science fiction movie, you would think it was weird and tell all your friends about the movie you’d seen.

They had these people, you know? And they would walk around all day and be OK? And then, once a day, usually after dark, they would lie down on these special platforms and become unconscious. They would stop functioning almost completely, except deep in their minds they would have adventures and experiences that were completely impossible in real life. As they lay there, completely vulnerable to their enemies, their only movements were to occasionally shift from one position to another; or, if one of the ‘mind adventures’ got too real, they would sit up and scream and be glad they weren’t unconscious anymore. Then they would drink a lot of coffee.’

So, next time you see someone sleeping, make believe you’re in a science fiction movie. And whisper, ‘The creature is regenerating itself.”

–George Carlin, Brain Droppings

That said, pleasant parasomnias!Alex Natalian, Psychiatrist and Author
Alex Natalian is a penname for psychiatrist KRR.

Psychiatric Database for Writers: Multiple Personality and Dissociative Disorders

Dissociative Disorders

Remember that quiet, little lady in the movie, the one who bats shy eyelids and blushes every time a car drives by?  “Doctor, I keep losing time, waking up in strange places and no idea how I got there.  I think there’s something wrong with me.”

The psychiatrist records the session.  They always do in the movies. The next scene is just as predictable.  We hear the patient’s interview.  The psychiatrist is alone, of course, thinking about what he’s heard, a perplexed look on his face, and you see his finger jump from button to button on the recorder… PLAY, REWIND…PLAY, REWIND… This is where the cinematography gets cool.  Colors drift into black and white.  Shadows appear.  You don’t know what you’re looking at, but you hear everything. Quiet, little lady’s voice takes on a masculine edge.  Educated vocabulary slips into street-talk, lots of F- and B-words.  Then it happens.  A harsh cry, choking sound, maybe a whimper or two, then a calm voice, much too calm:  “So, Doctor, you’ve been looking for me?  The others say you have a few questions for us.”

So, Doctor, what’s your diagnosis?  If you guessed “multiple personality disorder” (dissociative identity disorder (DID), if you want to get technical), you got it.  DID is one of several psychiatric conditions that falls under the umbrella of dissociative disorders.

What is dissociation? The word “dissociation” is used to describe a disturbance in one’s experience of reality.  This might be as simple as the absence of pain while doing something that would usually hurt (seen in drugs like Ketamine or PCP).  Alternatively, it might be experienced more broadly, as a mismatch between the different, normally integrated functions of a person’s consciousness; i.e., problems with identity and perception of the world around them.  Except for substance-induced dissociation, these dissociation is almost always an after-effect of severe, repetitive trauma.

What are the types of dissociative disorders?  There are four types:

  • Dissociative amnesia (also called “psychogenic amnesia”) occurs when a person suddenly has difficulty recalling important personal information – like his name or date of birth.  Usually this is a result of personal stress or mental trauma.  An example might be a man’s sudden inability to remember the recent death of his child.  Often these types of memories come back in time.
  • Dissociative fugue (also called psychogenic fugue) occurs when a person suddenly and unexpectantly travels away from his life and, during the fugue state, doesn’t remember who they were prior to the episode.  Many times the patient “comes to” after the event; he wakes up in a new place and become aware that he’s “lost” time.  An example might be a college student who suddenly disappears for three days, only to show up in a city one hour away unaware of where he has been during that time.
  • Dissociative identity disorder (also called multiple personality disorder) is a very rare phenomena defined by the presence of two or more distinct personalities inside one person.  Often these personalities have different names, characteristics, accents, even gender.  Most individuals with this disorder have suffered severe and catastrophic abuse as a child.  Of interest, many experts argue this illness doesn’t exist.
  • Depersonalization disorder is described as persistent or recurrent experiences of feeling detached from one’s mind or body.  The person experiences reality as something foreign to himself.  This experience feels like a dream, but it is terrifying and interferes with the sufferer’s ability to live and function well.  Imagine feeling déjà-vu for hours or days at a time, as though your world is off-kilter.

Dissociation in other syndromes.  Many patients experience dissociation as part of other syndromes.  One example would be post-traumatic stress disorder (PTSD), as flashbacks.  Flashbacks are to wakefulness as nightmares are to sleep.  Like nightmares, the flashbacks are extremely distressing to the sufferer.  They’re experienced as though the sufferer is living through the trauma again. Flashbacks may last minutes to hours.

Alex Natalian, Psychiatrist and Author

Alex Natalian is a penname for psychiatrist KRR.

The Benefits of Nicotine

014What your doctor doesn’t want you to know about nicotine.

So I’m writing a blog about the benefits of nicotine.  I mean, I’m supposed to tell people not to smoke. That’s what doctors do, right? Already I worry about the consequences: e-cigarette companies will declare me a hero, yes, but my colleagues will ostracize me, and the anti-tobacco mafia will flatten me dead before I can upload this article. Strange thing is there are benefits to nicotine.  Don’t get me wrong.  Tobacco is BAD for you.

The scene unfolds.  Let me warn you: I’ve got a good imagination.  I’m walking through one of those top-secret government buildings, the ones with whitewashed walls and doors that require a hose-down before allowing passage – where there’s a big sign reading, “Beware of Carcinogenic Chemicals: Hazmat Suits Required.”  Alternatively, I’ve been blind-folded and flown to a secret warehouse in Colombia, where I now stand amidst a gaggle of Big Tobacco engineers – and a vial of clear fluid in my hand.  In this version of the story, I’ve been paid a million dollars to write this blog.  Whatever the case, money or not, someone utters three important words: “This is nicotine.”

Here it is: an anticlimactic, boring vial of clear liquid.  What, the fountain of tainted youth?  The essence of venomous glory?  Shouldn’t it fizz through the testtube and melt my hand away?  Shouldn’t I die on the spot?  Oh, the horror.

Okay, you’ve got the image.  This stuff’s led millions of people to their deaths — and I’m about to sing its praises.  (That’s my second disclaimer: I promise it’s the last.)

So what are the benefits of nicotine?  If you want articles cited and literature that supports everything I’m about to tell you, please see the end of this article.  Keep in mind it’s a biased batch of information: I’ve only included the ones that support what I’m about to say.  For those who want everything in a nutshell, start here and keep reading.

021There are at least five diseases or disorders with evidence supporting the effectiveness of nicotine in either minimizing symptoms or preventing the illness altogether.  See bibliography at the end of this article for more information.

Parkinson’s disease is a neurodegenerative disorder which leads to progressive loss of control over movement.  Symptoms include tremor, stiffness, slowness, impaired balance, a shuffling gait, problems eating, and eventually dementia.  Studies suggest that smokers are less likely to get Parkinson’s disease than non-smokers.  The benefits of tobacco for avoiding Parkinson’s seems to be linked to the amount of tobacco a person uses. That is, the more tobacco consumed, the more beneficial it is to the patient.  Of note, ex-smokers seem to have a lower risk of contracting the disease compared to nonsmokers.

Ulcerative Colitis (UC) is a digestive tract disorder caused by inflammation of the colon’s inner lining and the rectal wall, which become red, swollen, and ulcerated.  This causes bouts of severe abdominal pain, rectal bleeding, and diarrhea; serious complications include intestinal blockage, liver disease, cancer, and death.  Studies suggest UC is an illness of non and ex-smokers.  Even passive smoking seems to reduce the risk.  Among people with UC, those who smoke typically have later onset, fewer exacerbations, need less medication, and require fewer surgeries.

Alzheimer’s Disease is marked by memory problems that affect an individual’s abilities to take care of himself.  The mechanism behind this disease is related to the neurotransmitter acetylcholine, the substance found at the nicotinic receptors in the brain.  Studies suggest that nicotine improves attention, memory, thinking, and performance in people with Alzheimer’s.  As an aside, nicotine has even been found helpful in memory and attention in people who don’t have dementia. In one study, scientists tested pilots by giving them (1) nicotine gum, (2) Aricept (a medication used for Alzheimer’s Disease), (3) a bit of alcohol eight hours before their flight, or (4) nothing they wouldn’t usually take. I’m not sure about the ethics of giving alcohol to pilots, but the results were fascinating: those that took Aricept or nicotine demonstrated superior attention, learning, and visual memory than those who drank or took nothing.

Tourette’s Syndrome is marked the presence of tics, both physical and vocal.  Studies suggest nicotine gum or patch can diminish tic behaviors by 50% — and that improvement lasts days or weeks after the nicotine is withdrawn.

People with Schizophrenia suffer from hallucinations, delusions, confused thinking, and personality changes that interfere with their ability to live independently.  They tend to be smokers, and they smoke a lot: three packs/day isn’t unusual.  The theory is they’re self-medicating.  Research shows that Schizophrenics who smoke do better on cognitive tests than when they abstain from smoking for a prolonged period of time; that is, when smoking, they demonstrated superior test results in attention, visuospatial and working memory, sensory gating (ability to ignore unimportant stimuli), and ability to juggle multiple ideas at once).  Of interest, some studies suggest smoking is a protective factor against developing Schizophrenia.

Potential benefits of nicotine aren’t limited to the above-mentioned conditions.  Research suggests the chemical might be helpful for Hyperactivity Disorder and Hypersomnulance (excessive daytime sleepiness), as well as diminish the risk of obesity.

Alex Natalian, Psychiatrist and Author     Alex Natalian is a pseudonym for psychiatrist KRR.




Bibliography/More reading

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Psychiatric reference for writers: Medications used to help antidepressants work better

Sometimes an antidepressant alone aren’t enough to get depression under control.  Psychiatrists see this often: the patient has had a partial response to the medication (at an adequate dose over an adequate amount of time), but there’s definite room for improvement in the individual’s mood.  Treatment options at that point include switching the antidepressant to something else, adding a second antidepressant, or adding an augmenting agent to help jumpstart the first antidepressant.  Here is a partial list of augmenting medications. 

Thyroid hormone.  People who have too little thyroid hormone in their body have a tendency to feel depressed.  They are mentally and physically slowed.  It turns out that thyroid medication at low doses can help relieve these same symptoms in people without thyroid problems.  Thyroid hormone is also effective in treating bad mood swings.  Side effects can include anxiety, loss of appetite, dizziness, and sensitivity to heat.  Chest pain and osteoporosis are rare.

Stimulants.  Stimulants include amphetamines as well as wakefulness-promoting medications like Modafinil (Provigil).  Stimulantss are especially helpful in patients who sleep too much, have little energy, and exhibit slowed thinking/concentration problems.  They should be avoided in people with anxiety issues, as well as heart problems. Side effects can include high blood pressure, fast heart rate, weight loss, anxiety, fidgetiness, jerking movements, and poor sleep.  Some stimulants are addicting.  These medications are usually avoided in patients with substance abuse issues.

Lithium.  Typically used in bipolar disorder, Lithium exhibits an anti-depressant effect even in people who don’t have bipolar disorder.  The dose is typically much lower than one would use in people with bipolar disorder.  Side effects can include weight gain, shakes, problems during pregnancy, acne, diarrhea, thirst, excessive urination, and rarely thyroid and kidney problems.

Lamotrigine, or Lamictal.  Lamictal is often used in patients with bipolar depression.  It has been shown to be very helpful for depressed people without bipolar disorder, especially for those with mood swings.  The most concerning side effect is rare: a life-threatening rash.  It is important to start this medication at a low dose and increase it very slowly.

Atypical antipsychotics (AAP).  AAP’s can be helpful for depression, and some are FDA indicated for depression in people with only partial response to an antidepressant.  Examples include Quetiapine (Seroquel) and Aripiprazole (Abilify).  Some atypical antipsychotics exhibit antidepressant effects on their own, but they’re especially helpful when depression is accompanied by agitation, confused thinking, racing thoughts, insomnia, or hallucinations.  Side effects can include sleepiness or insomnia, weight gain, sugar or cholesterol problems, movement problems, and very seizures, heart problems, or coma.  Atypical antipsychotics should be used with care in patients with dementia.

Benzodiazepines (BZ).  BZ’s are helpful when depression presents with anxiety or insomnia.  Examples include Lorazepam (Ativan) and Clonazepam (Klonopin).  Side effects include sedation, loss of impulse control, and at high doses, breathing problems and coma.  These medications can be very addictive, so doctors try to avoid using them in people with substance abuse problems.  Usually BZ’s are used on a short-term basis.

Over-the-counter (OTC) augmentation strategies.  The major concern with OTC treatments include medication interactions and potential to worsen physical problems, especially if treatment isn’t discussed with the physician.  Some work directly on mood (SAM-E, 5-HTP, Omega-3 Fatty Acids).  Others target sleep or pain.

Alex Natalian is a pseudonym for psychiatrist KRR.

Psychiatric Database for Writers: Antidepressants

Antidepressants are used for the treatment of depression and other disorders, like anxiety, pain, and difficulty with attention.  The following is a very general overview of antidepressant groups.

Tricyclics Antidepressants (TCA) were the first group of medications to emerge on the market for depression.  They are used for depression, anxiety, obsessive compulsive disorder, chronic pain, sleep, bedwetting, and other problems.  Examples include Imipramine (Tofranil) and Amitriptyline (Elavil). These medications are often quite sedating.  They’re often used in depressed patients with insomnia.  Side effects can include dry mouth, blurred vision, constipation, urinary retention, forgetfulness, and less common, confusion, low blood pressure, heart problems, seizures.  They are very dangerous in overdose.

Like TCA’s, Monoamine Oxidase Inhibitors (MAOI) have been on the market for many years.  They are very effective medications for depression and anxiety but are rarely prescribed due to potential interactions with food and other medications.  Examples include Tranylcypromine (Parnate) and Phenelzine (Nardil).  Side effects include weight gain or loss, sleepiness, low blood pressure, high blood pressure, and rarely coma.  Most newer psychiatrists don’t have experience prescribing these antidepressants.

With the discovery of Prozac in the 1990’s, Selective Serotonin Reuptake Inhibitors (SSRIs) are perhaps the most-used antidepressant group on the market.  They are used for depression & anxiety/panic attacks, as well as obsessive-compulsive disorder, mood disorder related to menstruation, and many other conditions.  This group includes Celexa, Lexapro, Luvox, Paxil, Prozac, and Zoloft. These medications are well-tolerated and are typically safe in overdose.Side effects can include slight tremor, stomach upset, diarrhea or nausea, problems sleeping, sleeping too much, and sexual problems. Individually, Prozac is perhaps the most activating.  Most cause weight loss except Luvox.  Paxil is particularly effective for panic attacks.  Celexa, Lexapro, and Zoloft are good choices for medically complicated or older patients, due to fewer medication interactions.

Serotonin Norepinephrine Reuptake Inhibitors (SNRI’s) are similar to SSRI’s, except they influence both Serotonin and Norephinephrine, which means they’re a little more likely to cause high blood pressure than SSRI’s and are typically more effective for treatment of pain than medications like Prozac.  Examples include Venlafaxine (Effexor) and Duloxetine (Cymbalta).  They are used for depression, anxiety, and sometimes for pain conditions, like fibromyalgia.  Side effects are similar to SSRI’s, apart from blood pressure changes.  They are very rarely fatal in overdose.  Cymbalta is considered better for pain management than Effexor.

Buproprion (Wellbutrin) is a “novel” antidepressant, in that it’s very unusual.  While most antidepressants work on Serotonin and Norepinephrine, Bupropion affects a chemical called dopamine.  It is used for depression and concentration, as well as smoking cessation, but isn’t good for anxiety.  Major side effects include shakiness/anxiety, problems sleeping. It is rarely associated with visual hallucinations and (especially at high doses) seizures.

When it comes to depression in people with insomnia, doctors often turn to sedating antidepressants. Mirtazapine (Remeron) is moderately sedating and can promote appetite, which can be helpful in underweight patients.  Trazodone is a very sedating antidepressant, so sedating in fact that most people can’t take a high enough dose for the antidepressant effect to kick in.  Trazodone is used mostly for sleep.  Side effects can include daytime sleepiness or slowing, painful erection of the penis (rare), and dizziness; it doesn’t usually cause weight gain.  Nefazodone, also called Serzone, is a sedating antidepressant that can cause mild weight gain, sleepiness, and rarely liver disease.  It isn’t used all that often due to risk of liver problems.

Alex Natalian, Psychiatrist and Author     Alex Natalian is a pseudonym for psychiatrist KRR.

Psychiatric Database for Writers: Asperger’s Syndrome

Asperger’s Syndrome is marked by unusual behaviors and difficulty with social interactions. Some professionals equate this disorder to high-functioning autism, whereas others see autism and Asperger’s as distinct diagnoses. Symptoms frequently include:

Unusual behaviors

  • Narrow, intense interests or “obsessions.”
  • Intense fascination for unusual things, like doorknobs or alarm clocks.
  • Rigid about sticking to routines and rituals.
  • A tendency to experience odd physical habits, like unusual ways of walking or talking.
  • Fascination with parts of objects; for example, taking apart TV’s.

Difficulty with social interactions

  • Problems understanding nonverbal communication. Problems understanding facial expressions and gestures.
  • Difficulty understanding social “rules” and cues
  • Difficulty finding close friends
  • Lack of interest in sharing time with others.
  • Difficulty expressing interest in another person’s welfare.
  • Often prefer to be with animals or inanimate objects than with other people.

Other characteristics that aren’t always present

  • Very formal and complex language, as if reading from an encyclopedia.
  • Tendency to interpret things literally.
  • Extremely sensitive to touch, smells, sounds, tastes, and sights (for example, they might prefer soft clothing, low stimulus environments, or mild-tasting food).
  • Tendency to be physically awkward
  • Exhibits messy handwriting
  • Dislike of being touched.

Extra notes on personality, character, and history:

  • It is speculated that Albert Einstein and Isaac Newton might have had Asperger’s Syndrome.
  • Children with Asperger’s disorder sometimes display advanced abilities in language, reading, mathematics, spatial skills, and/or music compared to their age group, often reaching into the “genius” range.
  • Adults with this disorder tend to be talented in logic and spatial imagery, a characteristic that often leads to professional success, especially in careers where they can work alone.
  • Individuals with Asperger’s are known for their witty sense of humor, usually involving intelligent wordplay and satire

Alex Natalian, Psychiatrist and Author     Alex Natalian is a pseudonym for psychiatrist KRR.

Did you say “Happiness Training?”

What is the secret to happiness?  Seems I’m not the only one asking.  Ranging from Socrates to Shakespeare, politicians to tribal chiefs, and splendidly splashed across banners at every college campus in the world, the question of happiness transcends geography and time.  The second question, “What can I do NOW to promote happiness when I get old?” follows quickly behind.  The third question: “I’m old already, what can I do to be happy now?”

Google the words “happiness in old age,” and you get a list of great ideas, including “Happiness Training Program.”  Turns out this training course is geared at old people in nursing homes and, as the name suggests, it trains people to be happy.

Hang in there a moment.  Don’t give up on me.  The course, “Happiness Training Program” was developed by psychologist Michael W. Fordyce. What I found delightful about his training program was his list of “Strategies for Increasing Happiness.” The list was worth including in a blog, so here it is.  I write this with hopes that we can all find happiness in old age – and hopefully a little sooner.

Strategies for Increasing Happiness:

  1. Strengthen your closest relationships. Remember that your personal relationships have the greatest impact on your level of personal happiness.
  2. Be more social and outgoing. People who are outgoing and sociable are happier than people who are not (Pavot & others, 1990).
  3. Keep busy doing things you enjoy. Generate a list of activities you enjoy, then incorporate at least one of them into each day.
  4. Engage in pursuits that you find personally important and meaningful. Choose a career or a line of work that you think is important and meaningful.
  5. Develop positive, optimistic thinking patterns. Make a list of the positive things in your life and, at least once a day, review that list.
  6. Worrying about the future and dwelling on negative past events are significant causes of unhappiness. But rather than simply worrying about your problems, focus your thoughts on concrete actions that will help you deal more effectively with the problem.

Simplistic?  Yes.  Inspiring?  Maybe.  It’s enough to raise lots of questions, anyway.  Dr. Fordyce’s message was simple enough: he believed happiness was a choice.  Act happy, make happiness a priority, and you become happy. But do you really believe happiness is a choice?  Can changing your behavior leave you content for the rest of your life?

Want to know what I think?  As a psychiatrist, I believe happiness is a choice, most of the time, but not always.  Some people are so struck by biological misfortune that the only way to avoid or overcome depression (or any mood disturbance) is by drugs or electroconvulsive therapy.  Does that mean they don’t choose to be happy?  No, not at all: most have chosen happiness at each turn and found it beyond their reach.  No, happiness isn’t always a choice.

But here’s the catch-22: looking for happiness is a choice, and an effective one.  The willingness to fight depression is a choice.  The willingness to “not give up” is a choice.  And that single choice, the one that offers hope and miracles and potential future, it’s that decision that can very well bring the happiness we’re after.

Can we train people to be happy?  Michael W. Fordyce thought so.  As a psychiatrist, I’m supposed to agree.  The idea is delightful.  I just wish it were that simple.

Alex Natalian, Psychiatrist and Author     Alex Natalian is a pseudonym for psychiatrist KRR.

Are fencing and riding bicycles the secret to enjoying old age?

Google “oldest person who ever lived” and you’ll find Jeanne Louise Calment.  She passed away in 1997 at the age of 122 years.   According to Wikipedia,

[Jeanne Louise Calment] led an extremely active life, taking up fencing at 85-years-old and still riding a bicycle at 100. Jean played herself at the age of 114 in the film Vincent and Me (Can 1990) – becoming the oldest actress to appear in a film. Her keys to long life were olive oil, port, chocolate and although she enjoyed smoking, she gave up in 1995…

What does that mean about happiness in old age?  Are fencing and riding bicycles the secret to enjoying our final years?

Let me put this in context.  Most of my patients are over 80 years of age.  Few of them fence, and none of them ride bicycles.  In fact, all of my patients are homebound.  Amidst the wheelchairs, Attend briefs, patronizing kids, and growing caddy of medications, where is there room for happiness?  Yet many are happy.  Funny thing is my happy patients are just as disabled and medically ill as my unhappy patients.

So what is the secret to happiness?  Truth is I have no idea.  But I do have a captive audience of happy patients, as well as unhappy ones, and I ask them lots of questions.  The answer: they have more questions than I do.  And many of them are happy without answers.

Alex Natalian, Psychiatrist and Author     Alex Natalian is a penname for psychiatrist KRR.