Sunday, March 11, 2012

Bipolar disorder and hypomania - irritability and depression

hypomania-irritability-depression

Chronic unstable mood with irritability and superimposed bouts of depression is a common form of bipolar II disorder or hypomania. Persons with this pattern of illness tend to have an unstable course and stormy interpersonal relationships. They also have more irritable and hostile hypomanic episodes. The classical Bipolar II disorder or hypomania of mild elevation of mood, sharpened and positive thinking, and increased energy and activity levels is less disruptive.

Persons with this irritable type of hypomania and bipolar illness have unrealistically high expectactions of those with whom they interact; whether at the workplace, at home, or other casual day-to-day interactions. When these expectations are not met they pass on their irritation and negative mood to unsuspecting others.

There is usually a grain of truth in their version of the incident, but the growing number of incidents with various people at all levels reduces their credibility. At the workplace they are frequently in search of a new job and personally they have problems sustaining meaningful relationships.

Anger management alone is usually not effective. It needs to be combined with specific treatment for the bipolar illness. At the clinic couples and individuals come in for anger and interpersonal issues that are not resolved with counselling.

"I never realised how much my moods controlled my actions"

Treatment for bipolar disorder including hypomania hinges on medication and psychotherapy. Treatment requires patience by all parties in the therapy. Relapses are frequent when medication is stopped.
"I can see the difference when he stops his medication;
help me get him back, doctor"
It takes time for the affected person to accept he or she has hypomania or bipolar illness. The degree of realisation fluctuates during the course of therapy. Regular psychiatric review is essential to prevent relapse in bipolar illness and hypomania

Tuesday, August 30, 2011

Treating Depression

wild grass and moths
Depressed mood or sadness lasting two weeks or more requires treatment. We all feel depressed, sad, or ‘blue’ occasionally. Moods and feelings change in response to events in our external environment. Usually depressive feelings or sadness last for a day or two; longer in case of loss or bereavement. However, if these feelings of sadness and hopelessness persist for more than 2 weeks and interfere with daily life, it indicates a clinical depression.
Depression is the fourth highest contributor to the global burden of disease. 
Clinical depression is a treatable illness. Many people never seek treatment due to lack of awareness, lack of access to mental health care, ignorance, or shame.

Signs and Symptoms

The hallmark of Clinical Depression is a pervasive depressed mood. This depressed mood is not responsive to positive events. There is associated slowness of thinking and movement; and there are thoughts related to guilt, self-blame, hopelessness and suicide . These features of constitute the classical triad of symptoms for the diagnosis of Clinical Depression. For a more formal diagnosis some or all of the symptoms below are used
  1. Persistent sadness. Frequent crying, irritability, ‘emotional outbursts’
  2. Slowing of movement and thoughts
  3. Feelings of guilt - ‘I shouldn’t have done that’, ‘it is all my fault’
  4. Worthlessness - ‘I haven’t achieved anything’, ‘I let my parents down’, ‘what I do has no value’
  5. Hopelessness - ‘What’s the point?’, ‘I don’t see things getting better’
  6. Thoughts of dying and suicide - ‘I would be better off dead’
  7. Loss of interest in activities and hobbies that were once pleasurable
  8. Difficulty concentrating, remembering details, making decisions
  9. Insomnia, early morning wakefulness, excessive sleeping.
  10. Change in appetite – appetite loss or overeating.
  11. Fatigue, lethargy, decreased energy
  12. Headache, cramps or digestive problems that are not relieved by treatment

How is depression treated?

The first step to treatment is to visit a psychiatrist. Your psychiatrist is the only mental health professional qualified to prescribe medication and provide psychotherapy. Your psychiatrist will take a detailed history of your symptoms, and will ask you to complete some questionnaires to assess their severity. He will also do a physical examination and may get some tests done (thyroid disorders and blood glucose related problems can cause similar symptoms).

The treatment of depression rests on two pillars
  1. Pharmacotherapy (medication)
  2. Psychotherapy (counselling, CBT)
Medication (pharmacotherapy) is required for moderate and severe depressions. Formal psychotherapy is started later once concentration and thinking improve. Your psychiatrist will prescribe an appropriate antidepressant. Antidepressants are not addicting. Side effects if any occur during the initial phase of treatment, they should not make you feel worse. Antidepressants must be taken for 4-6 weeks before they have a full effect. Later you should continue the medication even if you are feeling better to prevent a relapse. Suddenly stopping antidepressants can precipitate a relapse. Medication should be tapered gradually under your doctor’s supervision. If you follow your doctor's advice regarding follow up visits your treatment will be optimal.

Psychotherapy alone may be used in mild depression. Usually it is combined with medication for moderate and severe depressions. Psychotherapy is of two types:
  1. Cognitive Behaviour Therapy (CBT) identifies self-defeating, ‘negative thoughts’ and behaviours that perpetuate clinical depression in a vicious cycle. Your therapist then works with you to replace these thoughts and behaviours with ‘positive’ ones to help you recover from the illness.
  2. Interpersonal Therapy (IPT) helps people understand and work through troubled relationships that may be at the root of depression or making it worse.

How can I help a friend or family member who is depressed?

  1. Listen carefully.
  2. Offer support, understanding and encouragement.
  3. Never dismiss feelings, but point out realities and offer hope.
  4. Encourage them to go out for walks, outings and other simple activities. Don’t push too hard but keep trying.
  5. Make sure they keep appointments with the psychiatrist and stay in therapy.
  6. Never ignore suicide comments
    • Gently correct blatantly ‘negative’ thoughts. Help the person form an action plan to resolve the problem
    • DON'T LEAVE THEM ALONE until they OK the plan. 
    • Accompany them to a known responsible person or a doctor or mental health professional. You could save a life.

What can I do when I am depressed?

  1. Stay active. Exercise; go out for a movie, or any event you previously enjoyed.
  2. Eat regular meals. Don’t skip them even if you are not hungry.
  3. Go to bed at a regular time. Don’t wait until you are extremely tired so you can get sleep. Insomnia is the first symptom to respond to antidepressant medication
  4. Set realistic goals for yourself.
  5. Break up large tasks into smaller ones and do what you can.
  6. Spend time with others, confide in a trusted friend or relative.
  7. Postpone important decisions such as getting married/divorced, changing jobs until you are feeling better.
  8. Do not wait too long to get treatment.
  9. Expect your mood to improve gradually. Sleep and appetite will improve before your mood changes.
  10. Keep your appointments with your psychiatrist and do not stop your medication suddenly.
Reference


Thursday, March 31, 2011

Anger management can save your life

T-wave alternans
Anger induced electrical changes in the heart
Anger management can save your life. Anger can place you at high risk for developing  electrical abnormalities in the heart tissue. These electrical abnormalities are strongly associated with subsequent heart attacks. The chances of surviving an out-of-hospital heart attack are not good. Anger control can save your life by reducing the risk of an out-of-hospital heart attack (Rashba, Lampert 2009).

Why we need the emotion of anger

Charles Darwin was the first to note the universality of anger and other facial expressions of emotion. He viewed this as evidence that emotional signals like anger have been stamped by evolution into the central nervous system. Anger has an essential survival function. Anger needs to be controlled or managed for it to be effective.

Anger management strategies

These are strategies to change your attitude to the expression of anger, as also immediate and long term behaviours to control anger.

Focus and mindset strategies

To control anger one needs to control the scripts that lead up to it
  • He's being stupid again. Recognise how easy it is for the best among us to be wrong and make mistakes. Don’t expect life to go on as planned
  • It's OK to blow my top once in a while. Talk things over before you reach the explosive stage. Think of how you will regret having been indiscrete and hurting someone. It could work to your disadvantage later. Don’t view an occasional outburst as good for letting off steam. Don’t bottle up your feelings - express them civilly.
  • I'll show him who's boss. Remember that your aggression is likely to spark a chain reaction of aggression in others. Losing your temper is not the mark of a strong character who knows his/her mind
  • That's my right. There is a difference between feeling indignation and losing your temper because you cannot have things your way. The former leaves room for negotiation, the latter only makes things worse

Strategies for immediate anger control

  • Monitoring your feelings  is one of the key skills for anger control. Be aware of your body sensations, such as flushing, muscle tensing, and heart beat as you are getting angry. Take those feelings as a cue to stop and consider what to do next instead of shouting or lashing out.
  • Force yourself to keep your voice down. Make a deliberate attempt to speak quietly and slowly
  • Take 'time out'. Remove yourself physically by walking away from the place of argument
  • Count to ten slowly so the impulse to retort will pass
  • Look at your face in the mirror. Now you know why the others are laughing

What to do in the long run

Study your anger. Keep a diary of trigger incidents. Look for the pattern. Avoid precipitating situations as far as possible. Two situations that commonly precipitate anger.
  1. Insecurity, which makes you unduly sensitive. Social cues interpreted as hostile may in fact be neutral or friendly
  2. Frustration. Learn to accept what can’t be altered. Do your best – do not frustrate yourself over what is not in your control.
Cultivate a sense of perspective. Often the things we lose our temper over seem trivial in hindsight. What really matters to you in life? See things against that background. If its friendship, is it worth losing your friend by losing your temper? Take the perspective of other people. Get a sense of how you are being seen and of what other people might be thinking and feeling in the encounters that make you so angry
Understand people who make you angry. Ask yourself: ‘why do I always get angry with him/her?’ Why do you find them irritating? Enter into their experience – what does it feel like to be them? Others may not accept your point of view all the time. Understand the other person’s point of view. Don't be judgemental.
Relax. Incorporate a relaxation period in your routine – meditation, yoga, music; whatever works for you.
Get direct training in anger control. Many individuals are unhappy that they lose their temper easily. They are receptive to learning how to control it. In the heat of the moment, cool-headed responses such as walking away or counting to ten so the impulse to hit will pass are not automatic. Practice such alternatives in role-playing scenes. Try out friendly responses that preserve dignity while giving an alternative to shouting, hitting, and sulking.

Anger may signal a treatable underlying mood disorder. Treat it. Protect your heart

References
  1. Eric J. Rashba . Anger Management May Save Your Life: New Insights Into Emotional Precipitants of Ventricular Arrhythmias. J. Am. Coll. Cardiol. 2009;53;779-781. doi:10.1016/j.jacc.2008.11.023
  2. Rachel Lampert, Vladimir Shusterman, Matthew Burg, Craig McPherson, William Batsford, Anna Goldberg,  and Robert Soufer. Anger-Induced T-Wave Alternans Predicts Future Ventricular Arrhythmias in Patients With Implantable Cardioverter-Defibrillators. J Am Coll Cardiol, 2009; 53:774-778, doi:10.1016/j.jacc.2008.10.053


Monday, March 7, 2011

Jealousy, rage and murder

jealousy, rage and murder
In a jealous rage a Pune immigrant murdered his family - wife and two daughters - with an axe. He then attempted suicide. He suspected his wife of infidelity.

Evolution of jealousy

As with socio-sexuality, jealousy has an evolutionary basis that arises out of natural selection (Harris, 2003). Sexual jealousy drives males to guard against cuckoldry thereby ensuring that a rivals genes are not passed on through their mate. Emotional jealousy drives females to ensure her mates continued investment in her own offspring.

Psychodynamics of jealousy, rage and murder

  • Freud showed morbid jealousy to be the deepest form of paranoia. His analysis indicated use of the defense mechansims of denial and projection to protect against threatening homosexual impulses - I do not love him—she (a wife, lover) loves him. Othello struggled with jealousy until he murdered Desdemona and then committed suicide.
  • Murder or homicide can be understood as rage directed externally while suicide is rage directed inwards. Suicide is thus an inverted homicide (Menninger 1938). This argument is supported by the similarity in characteristics of perpetrators of murder-suicide and those of persons who commit only suicide (Palermo 1997).

Family murder-suicide by males

The jealous male resorts to spouse abuse. The resulting screams are usually ignored by society. If the woman has some independence repeated incidents may result in splitting from her partner. Here again her children may be used as hostages to keep her compliant. It is rare for the morbidly jealous male to be brought for psychiatric evaluation without some external coercion. The tragedy of a family murder-suicide is that its indicators are ignored by the family's society.
  • Wife murders are commonly based on jealousy and suspicion of infidelity. Dr O Somasundaram (1970) showed that 30% of ‘The men who kill their wives’ were cases of sexual jealousy and 10% had delusional jealousy.  
  • When the children are suspected to be those of the paramour, paternity testing through DNA samples is sought at Hyderabad. Or the children could also be put to death along with their mother. 
  • Family murder followed by suicide of the assailant is significantly associated with morbid jealousy in upto a quarter of cases (Goldney 1977, Adinkrah 2008).

How does morbid jealousy manifest in women?

  • The newly wed woman who turns jealous is tormented by her suspicions. At this stage the delusion is not yet fixed. The process of paranoia is not entrenched. The woman is aghast at her own attraction towards other males. She struggles to conceal her thoughts and impulses. Freud’s analysis of the process of morbid jealousy is rendered explicit. When she musters the courage to confront him the caring spouse will seek psychiatric consultation if it is available.
  • The slightly less caring husband will seek psychiatric consultation for his delusional spouse when it affects his work. She has tried private investigators and other sources to identify the paramour and to check his mobile phone records. At this stage she may also consult with a psychiatrist to recruit his help against her husband. Her husband is alarmed only when his boss or a female colleague is entreated to join cause in the search for his paramour.
  • The least caring spouse will try to beat the suspicions out of her. However, by their very nature the delusions are strengthened with each blow. She may then herself seek psychiatric help for her emotional problems or may be referred for the same after treatment for physical abuse. The morbidly jealous woman may also beat her partner.(Stuart, Moore et al., 2006).

Underlying mental illness is apparent before the family murder-suicide

References
  1. Adinkrah M. Husbands who kill their wives: an analysis of uxoricides in contemporary Ghana. Int J Offender Ther Comp Criminol. 2008 Jun;52(3):296-310. Epub 2007 Oct 8.
  2. Freud S. Psychoanalytic notes upon an autobiographical account of a case of paranoia (dementia paranoides). In Standard Edition of the Complete Work of Sigmund Freud, vol 12. Hogarth Press, London, 1966.
  3. Goldney RD. Family murder followed by suicide. Forensic Sci. 1977 May-Jun;9(3):219-28.
  4. Harris CR. A review of sex differences in sexual jealousy, including self-report data, psychophysiological responses, interpersonal violence, and morbid jealousy. Pers Soc Psychol Rev. 2003;7(2):102-28. Erratum in: Pers Soc Psychol Rev. 2003;7(4):400. Comment in:Pers Soc Psychol Rev. 2005;9(1):62-75; discussion 76-86.
  5. Menninger K. 1938. Man Against Himself. New York: Harcourt, Brace.
  6. Palermo GB, Smith MB, Jenzten JM, Henry TE, Konicek PJ, Peterson GF, Singh RP, Witeck MJ. Murder-suicide of the jealous paranoia type: a multicenter statistical pilot study. Am J Forensic Med Pathol. 1997 Dec;18(4):374-83.
  7. Somasundaram O. The men who kill their wives. Indian J Psychiatry 1970;12:125.
  8. Stuart GL, Moore TM, Gordon KC, Hellmuth JC, Ramsey SE, Kahler CW. Reasons for intimate partner violence perpetration among arrested women. Violence Against Women. 2006 Jul;12(7):609-21.