Try This Instead of CBT: Panic Focused Psychodynamic Psychotherapy

Taken from   Decoded Science   which is located    HERE.

Although research indicates that Cognitive Behavioral Therapy (CBT) is a highly effective treatment for panic disorder, with one researcher even calling it the, “Gold Standard,” of treatment, many patients and practitioners prefer not to use it.

Up to one half of all patients with panic disorder do not respond to CBT or anti-anxiety medications. Furthermore, although CBT tends to minimize the occurrence of panic attacks, it has not been clearly found to help patients improve in quality of life issues, such as relationship and work problems.

Some patients with panic disorder strongly object to the exposure aspect of CBT, which forces them to temporarily raise their anxiety levels. Mental health practitioners wishing to help their patients can offer an alternative treatment that has been backed by research: Panic-Focused Psychodynamic Psychotherapy (PFPP).

What is Panic Disorder?

People with panic disorder experience recurrent panic attacks that interfere with their functioning. Panic attacks are waves of anxiety that have no clear cause. The attacks consist of physical symptoms such as sweating, dizziness, and chest pains. During the panic attacks, sufferers often have feelings of depersonalization and derealization, as if the situation is unreal and they are observing themselves from outside their own bodies. The attacks come without warning, and make the victims feel helpless.

CBT vs. PFPP For Panic: Approaching From Behind

CBT treatment asks people to learn to recognize and change their thoughts in order to control their anxiety. Rather than assuming that panic disorder is a physiological response that people can learn to control, PFPP theorizes that panic has psychological causes at its roots.

CBT is present and future-based, but PFPP ask patients to examine their pasts. They have to explore their early relationships in order to understand why they have panic attacks. Based on psychoanalytic principles, PFPP aims to have patients acknowledge  feelings and ideas which they have previously considered unacceptable. Instead of quashing their thoughts and feelings, which leads to a sense of panic, patients can learn to calmly accept them, thereby diminishing their panic attacks.

An example is a successful professional tennis player who suddenly starts to suffer from panic attacks so severe that she has to stop performing. She then works with a PFPP-trained therapist to determine the source of her anxiety. When she recognizes that her relationship with her highly critical father is at the root of her anxiety, her newly discovered insight helps diminish her panic attacks.

Defense Mechanisms: The Core of PFPP

At its core, PFPP adheres to psychoanalytic concepts such as the unconscious and defense mechanisms. According to the psychodynamic perspective, panic symptoms are set off by a real or fantasized fear of loss or separation, or a greater need for autonomy. Unconscious feelings of anger and fantasies of revenge that people avoid expressing can also be a source of panic. The transference of past relationships to the relationship with the therapist helps patients understand their underlying conflicts, leading to greater control over their feelings.

Reducing Panic: Coming to Terms with Feelings in Three Phases

PFPP treatment involves 24 twice-weekly sessions. The treatment focuses on resolution of core conflicts about fears, recognition of anger, and ambivalence about autonomy. PFPP therapists use confrontation, clarification and interpretation, which are all classic psychodynamic treatment techniques.

There are three phases of treatment. During the first phase, the therapist helps patients relieve the acute pain of panic by reviewing the patient’s past to determine the source of the panic and the unconscious meaning of the symptoms. The second phase seeks to reduce the patient’s susceptibility to panic, through increased understanding about internal conflicts. Lastly, the final phase helps patients work through separation difficulties, as they prepare to separate from their therapists and learn to deal with autonomy issues without panicking.

PFPP – Backed by Research

PFPP is a viable alternative to CBT for treating panic disorder, according to research. One study found that the treatment caused the cessation of panic disorder, as well as noticeable improvements in daily functioning. Six months later, a follow-up check of the patients found that they had maintained their progress.

Another study, which used a scale to determine severity of panic symptoms, found a high rate of responsiveness to PFPP treatment. The patients’ symptoms weakened, and their psychosocial functioning increased significantly.

Relieve Panic Attacks with PFPP

Given its ability to provide symptom relief, improved functioning and greater autonomy, the American Psychiatric Association recommends PFPP as a treatment for panic disorder. Unlike CBT, Panic-Focused Psychodynamic Psychotherapy focuses on immediate relief of symptoms, rather than asking patients to re-experience their symptoms. Panic disorder sufferers can find relief by seeking mental health practitioners who offer PFPP.

Resources

Kurtz, A. The Manual of Panic Focused Psychodynamic Psychotherapy – Extended Range. (2012). Psychoanalytic Psychotherapy. Accessed on June 4, 2013.

Busch, F., and Milrod, B. Panic Focused Psychodynamic Psychotherapy. (2008).Psychiatric Times. Accessed on June 4, 2013.

Milrod, B., et.al. Open Trial of Psychodynamic Psychotherapy for Panic Disorder: A Pilot Study. (2000). American Journal of Psychiatry. Accessed on June 4, 2013.

American Psychiatric Association (APA). Practice guideline for the treatment of patients with panic disorder. 2nd ed. (2009). American Psychiatric Association (APA). Accessed on June 4, 2013.

 

Are Psychiatric Drugs Of The Devil? Part 2

Quality of Life

Jackie, a “Spirit-filled” women’s leader and Sunday-school teacher, had anxiety in the daytime and was often wakened in the middle of the night by panic attacks. These symptoms had plagued her since her early 20′s. She has had Christians pray for her and has faithfully applied the Scriptures to her life – including everything it teaches on anxiety. Eventually she sought psychotherapy, which helped somewhat. Then a few years ago I started her on medication that has eradicated the attacks. Since then she has tried to discontinue the medicine many times – only for her symptoms to return. In the process she tells me she has discovered two types of anxiety. One is caused by violating Scripture – and is remedied by proper application of the Scriptures. She has this anxiety on or off the medications. The other is not related to sin; it is at best partially helped by applying Scriptural principles – and is eradicated by medications.

Jackie, like Jake and many other patients, don’t have to have medications. They will never come after me with an axe and will probably never be seriously suicidal – but their quality of life and their productivity are markedly affected by the disorder they suffer.

If you were in my shoes, would you prescribe medications for the Jackies and Jakes in your practice? Would you want to take medications if you could be helped like Jackie and Jake? Would you tell your Christian friends you are taking medications – or, like this missionary and women’s leader, would you keep it to yourself for fear of being misunderstood?

Medications and Personal Responsibility

I hope that by now you can see that chemical changes – not wrong thinking or actions – are often the primary cause of emotional problems. However, one’s own personal responsibility still plays a role, and one’s choices sometimes make a very significant contribution to one’s condition.

If we could accurately determine when the problem is due primarily to personal choice, should we refuse to treat that person with medications? In my opinion, not necessarily. I think that withholding the help “meds” can offer is like refusing to throw a rope to a person who falls into a hole and saying, “You got yourself in there. Now get yourself out.”

Some individuals are trapped in such an emotional hole that it is next to impossible for them to think objectively in order to work through their problems. Yes, some have made choices that led to their falling in the hole, but without help they simply cannot get out – at least not for a very long time. In fact, actions often tend to dig the hole deeper or cause it to cave in on them.

For such people, medication can be a rope to help them climb out of the hole. I think of one dedicated Christian who was depressed and repeatedly struggled with the questions “Am I saved?” Despite the best efforts of ministers and my counselling, the question continued to haunt him, along with his ongoing depression. After an adequate dose of medication he could positively resolve the question. I continued to work with him for another year until we tapered off and eventually discontinued all his medications without a recurrence of his symptoms. I’m pleased to say he has remained assured of his salvation!

Another frequent objection to medication is that it will keep people from working on their problems or it will mask the real issue. But if a person is drowning you don’t stand on the shore and give swimming lessons – you throw out a life-ring. The lessons come later. Depression, panic and other forms of emotional turmoil are sucking many people under so they can’t think straight. They need a life-preserver.

When people are severely depressed, the proper dose and type of medication actually facilitates their working through their problems. Studies have shown that the thinking process of depressed patients, for example, are severely impaired. Treatment with appropriate medication enables them to reason more like a healthy individual.

I sometimes explain to patients that medications can serve the same purpose as a cast on a broken leg. the cast allows healing so that gradually more weight can be placed on the broken leg until it is strong enough for the cast to be removed. Likewise, when someone’s life has been shattered, medications can help stabilise him or her until sufficient healing and growth have taken place for the person to stand on his or her own “emotional two feet”. Then the medicines can be reduced. It is a great joy to see a patient improve enough to reduce the meds and even to discontinue them if there are no remissions.

What if the Patient Needs a Wheelchair?

Some make the accusation “You are going to get “hooked” if you take drugs.” But most of the medications used in the field of psychiatry don’t cause physical dependence. It is true that a small percentage of patients will need medications for the rest of their lives, and many struggle with this reality. For them, accepting their condition and need can be a giant hurdle – even as the paraplegic must accept his wheelchair or the diabetic her insulin and regimented diet.

Most of can’t imagine accusing the insulin-dependent diabetic with questions such as “Are you still taking that drug? When are you going to get off of it? Are you seeing a good doctor?” But families, friends and patients themselves commonly fire such questions at the one with emotional problems who need medication. They show either a lack of knowledge or an inability to accept the fact that some people need medications for long periods of time in order to correct the neurotransmitter imbalance in their brains.

Today Western countries are finally beginning to allow the physically challenged to integrate into society. We provide more handicapped parking, seating, restrooms, and access to public places and transportation. We see more wheelchairs in schools, workplaces and amusement parks, and even on TV. We are beginning to accept those dependent on wheelchairs as equally valuable people, not at fault for their disabilities. In the same way we must begin to accept persons who need medications if they are to get out and function in society, the workplace and the church.

How Do You Define Necessary?

Sid Macaulay wrote about using “excessive amounts of medication…when it is unnecessary, harmful, or disturbing to the patient.” All psychiatrists would agree that medications should not be used when they are unnecessary. But “necessary” is a judgement call. If a patient with agoraphobia hasn’t left her house for three or four years because of panic attacks, is it necessary or unnecessary to give her relief with medications, some of which are addicting? She can live without the medication – but it’s not much of a life.

A few years ago I cared for a patient, an extremely dedicated Christian, who had agoraphobia and panic attacks. Not only did her condition keep her completely housebound, but she literally would not flush a toilet or turn off a light switch for fear of triggering a panic attack. (She would leave the lights on all day and wait for a family member to flush the toilet.) If you were the doctor, what would you do? Would you let her suffer or give her an addictive medication restoring her to normal life?

Though she was reluctant to take any “drugs,” with my encouragement – after many. many months – she conceded. Eventually she went back to working full time and living a normal life. It is true that many of the medications we use do have side effects, and some of them trouble the patient mildly to moderately. For example, a psychotic patient may complain that being on the meds “feels like being in a mental straitjacket.” But one of my patients – who is able to live at home and hold down a part time job when on the medications – would be institutionalised and possibly become suicidal or violent towards others without them.

In all branches of medicine physicians have to use medications with side effects. That’s why they are obtainable by prescription only – to treat a problem that is more distressing or threatening than the possible risks. Often we must choose between mild side effects on the one hand versus the patient’s incapacitating emotional distress, inability to work, and possible suicide or homicide on the other hand.

Some medications – especially the major tranquilizers – can be harmful; but so can many widely prescribed medications such as penicillin, used to fight infections and digitalis, used for heart disease. Medications with the greater potential for dangerous side effects must not be given for trivial reasons. The patients for whom I prescribe medications have such serious problems that the help medications can offer far outweigh the possibility of harmful side effects.

With patients who desperately need medications, conscientious psychiatrists labour over these issues. We try to weigh all of the medical, social, legal and quality-of-life factors in our efforts to make only appropriate use of medications.

Addiction: Problems, Prejudice and Controversy

As stated earlier, most medications used for emotional illnesses do not cause physical dependency. But there is one group of medications that can. Addiction can and does take place with the use of benzodiazepines in high doses over long periods of time.

Controversy abounds both within and outside the medical profession regarding the appropriate use of these medications. During the 1960′s Valium became extremely popular and was used effectively to treat a number of disorders.: not only anxiety but also muscle spasms and convulsions. But after the Kennedy hearings (which were critical of the use of tranquilizers) and the tremendous media attention on the abuses of Valium, I, like many other physicians, limited my prescriptions of this class of medications. Subsequently, however, some patients who had been functioning fairly well experienced a marked decrease in the quality of their lives; many became unable to leave their homes or keep their jobs.

These observations, along with more recent research showing a chemical basis for some of the anxiety-related diseases, have caused me to re-evaluate. I now believe it’s legitimate to give minor tranquilizers to someone such as the woman I described earlier who was unable to leave her house without it.

Jonathan Davidson of Duke University has shown, as a matter of fact, that patients with panic disorder and agoraphobia (the ones most prone to need these medications) do not develop an increased tolerance to the medication. Thus the dose of these medications can actually be decreased over time. Other studies suggest that misuse is probably less than many believe. Yet the prejudice against benzodiazepines still keeps many people who need them from utilizing them.

Because of the controversy over the use or misuse of benzodiazepines, the American Psychiatric Association established a task force to evaluate this problem and establish some guidelines. Its members concluded that two groups legitimately warrant the use of minor tranquilizers: older patients suffering medical problems with significant anxiety, and patients with panic attacks or agoraphobia. They further concluded that the benefits clearly outweighed the risk of addiction and that it is appropriate to use these medications on a long-term basis. Controversy still surrounds their use for individuals with chronic anxiety, depression or sleep disorders.

I believe more major breakthroughs will be made and more effective and specific medications will become available to those who suffer with emotional symptoms. It is sad when the church heaps guilt trips on any of its members who need these medications, or when it tries to talk them out of taking them

God does send help – but sometimes the vehicle he uses isn’t what we expected.

Are Psychiatric Drugs Of The Devil? Part 1

I originally published this article in 2011.  I found it on a website in England that no longer exists.  The author has been writing since at least the 80′s and I’m not sure when this article was written.  This article is not intended as a sweeping endorsement for all of us to go on medication but instead to present an article where the author tries to bring some balance to a conversation that can quickly go south in some instances. I had a pastor at one time tell me what medications I could take for my anxiety who was in no way qualified to be speaking on the topic. I share this article to hopefully remove any shame a reader might be feeling because they are on medication and to let them know that psychiatric drugs are not of the devil.  Allan

Dwight L. Carson

One of the organizations I used to link to is located in Great Britain.  Their web site was filled with excellent information and I’d like to share the following article from their archives.  Their name was  “Christian Mental Health- United Kingdom.” The publishing of this article is not intended to sway you to go out and look  for psychiatric medication. It is intended  to provide information for you to consider. Allan

Many people seem to be caught up by a powerful undercurrent of fear regarding medications for emotional illnesses. Especially among Christians, people often fear psychiatrists because they have been stereotyped as “drug-happy” – ready to prescribe excessive amounts of medication that aren’t always needed. Whether drugs are helpful, whether they are necessary, and whether psychiatrists are “drug-happy” are all legitimate questions.

Are all Psychiatrists Drug-Happy?

Not long ago I read a letter in the Psychiatry Section Newsletter of a Christian Medical & Dental Society (CMDS). The writer had a ‘bone to pick’ on behalf of psychiatric patients on medications. He expressed a concern that many people feel. The letter writer referred to a presentation he made before a number of psychiatrists on the theme of “stigma.”

Letter:-

I made the generalisation that “all healing comes from God” whether it is through the instrument of a believing or atheistic surgeon or psychiatrist.

The I talked about believers who have a strong fear of drugs and resent being sustained on strong medication over a long period of time by a Christian Psychiatrist. I said that I thought doctors expelled those fears too much. the natural fears patients have of psychiatrists are directed toward medication, mystery, and manipulation…

The bone of contention I have is that I sensed no-one listened to what I said about excessive medication of patients….

Are doctors brainwashed today in terms of drugs? Is it good treatment procedure to use an excessive amount of medication on a patient who wants to exercise more self-control? Is it moral to prescribe a legal drug when it is unnecessary, harmful, or disturbing to the patient? Where are the lines drawn?

Over and over I’m hearing people relate that they seek out Christian psychiatrists because the unbelieving doctor they have been seeing is not helping them but keeps them on medications. They call CMDS for recommendation of a Christian psychiatrist who will not string them out on drugs. Occasionally they reject a name of a CMDS member because they have already found he/she force-feeds medication in the same way as anyone else.

This is not an ax I’m grinding….Am I naive to believe what patients tell me? Can it be that Christian psychiatrists only rarely err in this regard? Or is this something you practice without being aware of violating your patent’s native fear of being out of control or overly dependent on drug?….

No-one discussed this after my talk. I have a stigma against drug-happy psychiatrists. And if I am bothered by this, what about the hundreds of other Christian workers and patients out there who share my concern? The thing that bothers me today is my uneasiness that it doesn’t seem to bother you. Will you respond and let’s get this out on the table with some enlightening discussion?

I Invite responses for the Psychiatry Section Newsletter. I will be even more disturbed if no-one has anything to say.

I remember reading this letter and slouching down in my chair in resigned frustration, thinking, He has not walked in my shoes. He has never had a paranoid patient come after him with an ax or had a distraught family member call because a loved one is ready to take her life – and know that medications would have prevented these crises.

I thought of a certain patient whom a minister referred to me. At the beginning of his appointment, the patient laid out the ground rules: he would talk to me and let me pray with him, but under no circumstances would he take any medications. My initial evaluation clearly demonstrated that he was a very paranoid and psychotic individual. So after evaluation I prayed with him and told him that under his requirements I couldn’t help him any further. The next day he returned, demanding to exorcise the devil out of me. Two days later he stormed into my waiting room with a Bible in one hand and pounded on my office door with an ax in the other hand. He charged around, threatening my life and terrifying everyone in the office until police arrived to take him to hospital.

Why Do We React So Strongly Against Psychiatric Medications?

I seriously questioned whether  it would be of any use to write a reply to the letter. If he’s already made up his mind, nothing I could say would change it. So what’s the use? I thought, But the clincher for me was his statement “I will be even more disturbed if no-one has anything to say.” Since I had no idea whether one of my colleagues would write, I did reply. The ideas that I am writing now, grew out of the letter I sent in response. But again, I sometimes wonder if people can “hear” what I have to say when so many people have such strong emotional reactions to any mention of medications for emotional problems.

Part of the problem, I believe, is all the stigma associated with treatment of mental patients. Outdated methods and past abuses, real or exaggerated, have left an indelible impression on our society. Movies such as “One Flew Over The Cuckoo’s Nest” have stereotyped psychiatric staff as villains who inflict cruel “treatments” and they have depicted patients who resist as courageous heroes. In addition, medications like vallium received a lot of negative press in the seventies. Some of it was appropriate, some probably not – but we still live under its influence.

In response to my lengthy letter, the response in part:-

Thank you so much for your excellent letter….it is very helpful to me….I am growing confident that there are real misunderstandings about the nature of drugs and the way they are used….I certainly hope that the stigma can be turned around….There is a lack of effective education….with regard to the way psychiatrists treat and make use of effective medications.

I feel the general public, including believers in the Church, are unaware of the way….quality of life is [improved] by a willingness to be on medication for those who are disturbed.

When Do Drugs Make Sense?

It is extremely difficult, if not impossible, to treat the psychotic, depressed, suicidal, manic-depressive or extremely anxious patient without the assistance of medications. Patients with these kinds of difficulties often come to a doctor and insist, “Get me better without medications.” A diabetic would never go into an emergency room in a crises and request treatment but demand that insulin not be used. the man with his axe is an extreme example of one who refuses to take any medications yet needs them desperately. In a situation like this doctors are sued for malpractice if they don’t use medications.

Admittedly, most patients are not in the desperate condition of the patient with the axe. Who then does and does not need medications? I can divide the patients into four categories.

In the first group are those struggling with emotional / spiritual issues that would be inappropriate to treat with medications. I don’t prescribe any for these patients.

The second group consists of those whose issues cause enough distressing symptoms that medications might significantly help them. Medications are a serious possibility but not mandatory. With these individuals I discuss frankly my reasons for considering medications, the benefits and potential risks. Then together we decide whether or not to use medications.

The third group of individuals have significant problems functioning and may, for example, have persisting serious, suicidal thoughts. To such I firmly and strongly recommend medications. Most of them accept my recommendations – but for those who don’t, I use all other means at my disposal, without medications.

The last category of patients have such serious difficulty that to treat them without medications would put them and myself at an unacceptably high risk for some catastrophic consequence. I give these persons the choice of continuing under my care and taking the medication or discontinuing therapy with me and seeking it from someone else. The man who came after me with the axe and Bible fits into this category. In the last seventeen years that I have practised psychiatry, only about six persons have had to choose between seeing me and taking medication or discontinuing therapy with me.

Mary came to me with severe depression and she would fit somewhere between the second and third categories, so I initially tried to treat her without any medications. However, her feelings were so overwhelming and her thinking so muddles that it kept her from making any progress at all. So I recommended and antidepressant along with therapy while we worked on many of the factors contributing to her depression.

It took about a month for her to feel better. As she dealt with issues in her life, we were able to reduce her medications by about one-third. But the symptoms and issues remained, plus a strong family history that suggested a biological basis for her illness, made me reluctant to decrease her medications too quickly.

About this time, four months after she had initially come to see me, a friend said to hey, “Aren’t you over that yet? You’re still taking the drugs? You know, you’re going to get hooked on them!” Her husband also remained skeptical about her seeing a psychiatrist and ‘taking pills.’ So Mary called me to say she was doing so well that she wanted to stop therapy and medications. I agreed that she was doing much better, but cautioned her about abruptly stopping her therapy and medications – to no avail.

Six weeks later I received a call from the emergency room. Mary had taken a lethal dose of Aspirin. Fortunately, someone got to her in time. After three days in intensive care she was finally alert, but very depressed. After a month’s stay in the hospital, during which she resumed the antidepressants, she could return home, but she still functioned marginally. It took another six months or out-patient therapy for her to get back to the level where she had been before discontinuing her medications.

When people are in sever crises, it may take weeks to help them become emotionally stabilised with the help of medications. They often feel so well that they want to discontinue the medication immediately. We physicians may have a very good idea, based on experience and research, of the likelihood of their continuing to function well without the medication. When we believe there is a high probability of recurrence, we are reluctant to discontinue medication.

Mary’s story is typical. Too many times after patients discontinue medications – when we recommend they not – we get called at 3am by the patient, a relative or a friend complaining, “Why don’t you do something?” Often such repeat crises in some way jeopardise the lives of the patients and others around them. Also, it often takes weeks for the medications to become effective again.

I always allow my patients the freedom to refuse medications, and I agree that this freedom is important. But it’s also extremely important that Christian leaders develop a greater appreciation for the gravity of emotional illnesses. They need to appreciate the fact that up to 15% of our population at any one time has significant emotional problems. These are bona fide illnesses, many with a biological basis, and some victims desperately need medications.

Mary’s story illustrates the consequences for the Christian who resists not only therapy but also medications. I am reminded of the fact that it was Christians who opposed the use of ether for anaesthesia during childbirth or surgery when it first became available. They reasoned right out of genesis that if God didn’t want people to have pain he wouldn’t have given women pain in childbirth. Therefore such a drug shouldn’t be used – on a scriptural basis. Few would hold to such reasoning about anaesthesia today, but we hold a similar logic about medications for mental illness.

Recent Breakthroughs and New Lives

Distinct, measurable chemical changes appear with many types of emotional problems. The key to these widespread changes seems to be twenty or more different neurotransmitters that interconnect the brain cells (neurons) with each other. years ago we did not understand these changes, so our treatments were crude.

A century ago doctors treated all kinds of problems with a few general means – sort of shotgun approach. Blood-letting was the treatment of choice for a wide variety of ailments. Now blood is removed from a person for only one or two specific illnesses – conditions for which this treatment has proved to help.. We have learned how to treat other problems with other means. Likewise, half a century ago psychiatry was at a primitive “all-purpose-blood-letting-stage-of-knowledge” in our use of medications that affect the mind (psychotropic medications). Everyone got phenobarbital or chloral hydrate, with only marginal help.

Now our vast increase in knowledge about the brain is leading to new medications every year. These allow the physician to pinpoint the chemical problem more precisely and often to remedy it. We can now treat many symptoms more accurately than ever before.

Out of the Institution

The first major breakthrough with medications came in 1954, with the discovery of major tranquilizers. Patients with psychotic symptoms like hallucinations, delusions and paranoia seem to have an over-active dopamine neurotransmitter system; major tranquilizers interfere with the transmission of dopamine, restoring it to a more normal level. With this group of medications tens of thousands of patients were able to be discharged from mental institutions.

One of my patients, who has had severe emotional problems for over 25 years and who has spent more than 2 years altogether in psychiatric hospitals even with medications, said to me, “If it weren’t for these medications I probably would have spent most of my adult life in a mental institution and would have lost my husband and daughter.” Another patient with a severe emotional illness recently said, “If it weren’t for these medications, I’d be six feet under.”

In all probability, if you attend a church of more than a hundred, at least one person there functions as a normal member of society only because of these medications. Before 1954 this person would have resided in a mental institution.

Awake and Alive

While certain neurotransmitter chemicals are increased in psychotic individuals, they are decreased with depression.

We now possess a variety of antidepressant medications to restore these to normal levels. As with all medicine, sometimes we have to try several medications until we find the right one for a given person. But when we discover the right one, I see the individual – as I’ve seen numerous patients – improve dramatically.

Here I am reminded of Jake, a missionary who suffered his entire adult life from insomnia. He had trouble going to sleep and slept fitfully after 3am for years. Not infrequently his wife would see the light on in the wee hours of the morning, because Jake knew he was wasting his time staying in bed. His low energy level and mild depression greatly decreased his productivity. A very small dose of an antidepressant resolved these symptoms and markedly improved his entire outlook on life and his ability to function. His wife continues to be astounded at the change in him; she even sleeps better herself, since he no longer paces the floor at night. His fellow missionaries have commented that he no longer falls asleep during meetings and he says, “I don’t have to push myself all day long to get things done.”

The Problem With How We Treat Bipolar Disorder: Part 2

 

Taken from  the New York Times  which is located    HERE.  Part 1 can be found   HERE.

My medical records show that by the spring, I thought I was in a Canadian train station and that it was 1976. I lugged a suitcase stuffed with towels around the unit, looking for the departure platform. If my self had been assailed by depression, then psychosis was the final blow. My sense of boundedness — where I stopped and other people or the environment began — was sloppy, like a toddler scribbling outside the lines. I didn’t envision myself as human; I pictured myself as black vermicelli on an asphalt driveway. For a brief time, I could neither write nor speak. My journals show a perseverating pencil — a long string of Ts or entries in hypergraphic writing, alternating between conventional and unconventional language: “They will have a stronstrazzly negative reaction to them. I need held . . . In stortingitoat — plus, the idea of [X] a new set of residential pleomorph — exoskeleton weitropstite jejoined to be betters. blep.”

I hallucinated. The world was suddenly up for grabs; reality, an option. Rectangular rainbows streamed through the day-room windows. Nonexistent organ music pealed through the neighborhood on a Sunday morning. Peasants from a Jean-François Millet poster walked out of the frame and marched across the wall.

Some researchers say that in psychosis, the self persists, however tenuously. Sue Estroff, a professor of social medicine at the University of North Carolina, described it as “more of a foreground, background thing. During psychosis, the self recedes.” But, she told me, “you’re still in there.” I don’t think so. If I had been allowed outside, I would have doubted the reality of my shadow.

By early summer, the psychosis had run its course, and I returned to lucidity. The kids came to visit. They dragged me off the sofa and onto the carpet. We were laughing and crying simultaneously. I felt the surge of something primal.

Later that summer, after I became well enough to be discharged once again, we decided to move to the Chicago area so that I could continue working with my father’s doctor, whom I trusted, and be near our families. But seven months after moving into our new house, I was back in the hospital. I would be readmitted and discharged two more times over the next half-year. When I left the hospital for the last time in August 1991, I was 38, and while no longer intent on self-destruction, I was more accurately rescued, not restored.

Taking care of children and running a household seemed like a herculean task. My husband and I realized we needed a full-time housekeeper. We found a wonderful woman who knew just what needed to be done: cook, clean and be a surrogate mother. While appreciative of her help, I felt as if my role had been usurped.

I continued to see my doctor every week as an outpatient. But I was demoralized and failed to see much of a change. I asked him how he healed my father, maintaining him on only three lithium tablets a day, whereas I had experimented with about 100 different combinations and dosages of medications (including antidepressants like monoamine oxidase inhibitors, tricyclics and, later, S.S.R.I.’s). “Because,” he said, “your dad was a Ford. You are a Ferrari.” I didn’t know if this was a compliment or an insult.

The first few years after my last hospitalization, I spent a lot of time on the shore of Lake Michigan, near my home. I collected hundreds of beach stones and organized them by size, color, shape and heft. Soon I had dozens of shoe boxes full of them. Sometimes I talked to the Russian fishermen looking for smelt on the pier; other times I walked alongside older women and helped them look for sea glass. I took three-hour naps every afternoon, trying to remember to set the alarm clock, so I would be awake when the kids came home from school. Many times they met a closed bedroom door.

By 1995, I started to feel small changes. The medications were the same. I was still seeing my father’s doctor. I had the same support from my family and from my husband, who once, when I came home on a day pass, had pansies — my favorite flowers — planted along the path from the driveway to the house. The protective cocoon he made for me, along with time, allowed my self to regrow. I could feel my self filling in.

Gradually, I was able to fulfill more of my maternal role: helping with homework, driving to piano lessons, making the worst Rice Krispies Treats in the school. Our housekeeper, while still a tremendous support, was becoming more of a safety net than a primary caregiver. One of my favorite things was driving in the car with the kids, singing along to oldies, trying to answer their questions: “Is the sun going to fall on the earth?” “Where is the first car?” “Why are some books called a ‘turn-pager’?” I had lunch with family members and the occasional friend. With confidence easing its way back to my self, I volunteered at an anorexia foundation near my house. I lined the edges of my desk with stones. Writing was getting easier, words were unlocking. One day I was on the porch with the two younger kids, who were doodling with crayons, when I wrote down the word “pain.” Without thinking, I picked up a crayon and added the letter T to the end of the word. A half-hour later, we were at an art-supply store, buying brushes, tubes of paint and a canvas. We converted the unused third floor of our house into a cavernous studio. Passion had returned and, along with it, creativity.

One day, about eight years ago, it struck me that bipolar disorder was the hand I was dealt. I remembered what my father said to me when I moved from Boston: “Don’t look at what your disorder has taken away from you, try to find what it has given you.” I began speaking to family-education classes of the local chapter of a mental-health organization. I presented a paper at a conference. The more often I spoke, the less traumatic my experience seemed, the less sad, the less painful and, somehow, the less personal.

Over the years, I’ve talked to clinicians about why the self is rarely mentioned in treating patients who suffer from mental illnesses that damage their sense of who they are. If anything, it seems that psychiatry is moving away from a model in which the self could be discussed. For many psychiatrists, mental disorders are medical problems to be treated with medications, and a patient’s crisis of self is not very likely to come up in a 15-minute session with a psychopharmacologist.

Philip Yanos, an associate professor of psychology at John Jay College of Criminal Justice, in New York, studies the ways that a sense of self is affected by mental illness. He told me that when his work was under grant review, it was initially met with skepticism. Some thought that what he calls “illness identity,” which manifests in some patients as overidentifying with their mental disorder, was a topic of lesser importance in the face of other serious symptoms that patients experience, like cognitive impairment and thoughts of suicide.

Yanos told me that reshaping your identity from “patient” to “person” takes time. For me, going from patient to person wasn’t so arduous. Once I understood I was not vermicelli, part of my personhood was restored. But reconstructing my self took longer.

One reason that may have been the case, as Amy Barnhorst, a psychiatrist at the University of California, Davis, told me, is the unique set of challenges facing people who have experienced mania and hypomania. “The parts of the selves that may come out” in mania and hypomania, which can be horrifying, “are very real,” she said, making it difficult for patients “to reconcile those behaviors with their self as they have come to know it.” In mania and hypomania, the sick self has no accountability; the improved self has a lot of explaining, and often apologizing, to do.

For many people with mental disorders, the transformation of the self is one of the most disturbing things about being ill. And their despair is heightened when doctors don’t engage with the issue, don’t ask about what parts of the self have vanished and don’t help figure out strategies to deal with that loss.

Some in the mental-health field are beginning to recognize this need. Janina Fisher, a psychologist and the assistant director of the Sensorimotor Psychotherapy Institute in Broomfield, Colo., told me that there has been a “sea change” in the role the self plays in the therapeutic dialogue since the decades when I was sick. New therapies and treatment philosophies, founded mostly by clinical psychologists and other practitioners who are not medical doctors, recognize the role of the self in people with mental illness. Patients tell her, “I just want to be that person I used to be.” Fisher encourages her patients to recognize that their mental trauma is a part of their life, but shouldn’t dominate it.

In my own experience with Scheftner, whom I began seeing after my father’s doctor moved away, we talk about the self but only when I bring it up. That’s why I have enjoyed helping to run a support group for people with mental disorders, something I’ve been doing for the last three years. There are usually 8 of us, sometimes 12. We sit in the basement of a local library every Wednesday afternoon. Though we know one another’s innermost thoughts, we are intimate strangers, not friends. Like A.A. and other self-help groups, we’re peer-led: run by and for people with mental disorders. We talk one by one about the past week — small achievements, setbacks, doctor appointments, family conflicts. While the self is not always an explicit topic, the loss of self — or for those doing better, the reconstruction of the self — is a hovering presence in the group.

One day, not long ago, a middle-aged man came to our group. He told us that he spent the past year attending different grief groups, but none of them were right. “Why not?” someone asked. The man said: “Because everyone there was grieving over the loss of another person. I was grieving for myself. For who I used to be before I got sick and who I am now.”

During the 20-odd years since my hospitalizations, many parts of my old self have been straggling home. But not everything made the return trip. While I no longer jump from moving cars on the way to parties, I still find social events uncomfortable. And, although I don’t have to battle to stay awake during the day, I still don’t have full days — I’m only functional mornings to midafternoons. I haven’t been able to return to teaching. How many employers would welcome a request for a cot, a soft pillow and half the day off?

One morning, about five years ago, my husband and I were talking on the family-room sofa. I was still wearing my pajamas and had wool hiking socks on. As he rubbed my feet, he told me he was leaving. It was, at once, a scene of tenderness and savagery. A little later, he threw some clothes into a suitcase and moved out. But my self — devastated, grieving, angry — remained intact.

Today, my mind is nimble. Creative writing has crept back into my life. I’ve made a couple of close friends in Chicago. My greatest pleasure is still my children — they’re starting careers, marrying, on the brinks of their lives. I’m looking forward to grandchildren, to singing the 1950s favorite “Life Is but a Dream” while spinning those babies under the stars of a falling night on a Florida beach. This June, I’m turning 60. I’m having a small party to celebrate my ingathering of selves. My old self was first to R.S.V.P.

The Problem With How We Treat Bipolar Disorder: Part 1 Of 2.

 

Taken from the  New York Times Magazine   which is located   HERE.

The last time I saw my old self, I was 27 years old and living in Boston. I was doing well in graduate school, had a tight circle of friends and was a prolific creative writer. Married to my high-school sweetheart, I had just had my first child. Back then, my best times were twirling my baby girl under the gloaming sky on a Florida beach and flopping on the bed with my husband — feet propped against the wall — and talking. The future seemed wide open.

I don’t think there is a particular point at which I can say I became depressed. My illness was insidious, gradual and inexorable. I had a preview of depression in high school, when I spent a couple of years wearing all black, rimming my eyes in kohl and sliding against the walls in the hallways, hoping that no one would notice me. But back then I didn’t think it was a very serious problem.

The hormonal chaos of having three children in five years, the pressure of working on a Ph.D. dissertation and a genetic predisposition for a mood disorder took me to a place of darkness I hadn’t experienced before. Of course, I didn’t recognize that right away. Denial is a gauze; willful denial, an opiate. Everyone seemed in league with my delusion. I was just overwhelmed, my family would say. I should get more help with the kids, put off my Ph.D.

When I told other young mothers about my bone-wearying fatigue, they rolled their eyes knowingly and mumbled, “Right.” But what they didn’t realize was that I could scarcely push the stroller to the park, barely summon the breath to ask the store clerk, “Where are the Pampers?” I went from doctor to doctor, looking for the cause. Lab tests for anemia, low blood sugar and hypothyroidism were all negative.

Any joy I derived from my children was now conjoined with grief. I couldn’t breathe the perfume of their freshly shampooed hair without being seized by the realization that they would not always be under my roof. While stroking their backs, I would mentally fast-forward their lives — noses elongating, tongues sharpening — until I came to their leave-taking, until I reached my death and, ultimately, theirs.

I lost my sense of competence. If a colleague remarked on my intelligence, I mentally derided him as being too stupid to know how dumb I was. If someone asked what I did for a living, I would say, “Nothing” — a remarkably effective conversation stopper. I couldn’t bear the thought of socializing; one night I jumped out of the car as my husband and I were driving to a party.

Despite having these feelings in my mid-30s, when my kids were 8, 5 and 3, I was thriving professionally: I had recently completed my Ph.D. in geography, had just finished co-teaching a semester at M.I.T. as a lecturer and was revising my dissertation on spec for a respected university press. Yet several nights a week, I drove to the reservoir near my home, sat under a tree and, as joggers and their dogs ran past, thought about ending it all. There was a gun shop on the way to my poetry group; I knew exactly where to go when the time came.

My day, once broken by naps, gradually turned into lengthy stretches of sleep, punctuated by moments of wakefulness. My husband and I didn’t explain to the kids that I was depressed. “Mommy’s a little tired today,” we would say. A year or so earlier, a therapist told us to tell the children. “But they’re just kids,” we said. “What do they know?” “They know,” she said. When we eventually spoke to them, my oldest daughter came to me and asked: “Why did you keep it a secret? I thought all mothers were like you.”

After a few weeks of stopping at the reservoir, as suicide eclipsed all other thoughts, I finally told my husband about my worsening psychic pain. The next day I was hospitalized. It was June 1989. Even though we were living in Boston, we decided I should go to Chicago to work with the psychopharmacologist who, 15 years earlier, restored the health of my father, who had also been hospitalized for depression. As the cab pulled away from our house, I turned and saw three children’s hands pressed against the screen of an upstairs window. This is the way the world breaks.

The moment the psych-unit doors locked behind me, I was stripped of my identity as wife, mother, teacher and writer and transformed into patient, room number and diagnosis. I couldn’t open a refrigerator without permission. If I were on suicide watch, I had to ask before going to the bathroom. I was told when to sleep and when to wake, when to eat and when to go to group. My routine, which at home had cleaved so closely to my children’s, now revolved around the clattering sounds of the food trays being brought three times each day from the service elevators into our unit. With my husband and children nearly 1,000 miles away, I was severed from my fixed stars. I missed my children’s smells, the way they used to wrap their bodies around my legs when I was on the phone. I brought my son’s comforter to the hospital for my bed. I remembered him with one leg thrown across the covers, a small foot peeking out from his pajamas.

When my children visited, I had to resuscitate my maternal self, if only for an hour. I dragged myself to the shower, pulled on a pair of clean sweat pants and a fresh T-shirt and ran a streak of lipstick across my lips, hoping to look like a reasonable facsimile of a mother.

My doctor used my first hospitalization as a so-called washout, a period during which he planned to take me off the medication I was on and introduce several drugs in several different combinations. The prospect of polypharmacy — taking many drugs at once — seemed foreboding. I read about Prozac’s giving some people entirely new personalities: happier, lighter, even buoyant. “Who are you going to turn me into?” I asked my doctor.

“I’m not turning you into anyone,” he said. “You’ll be yourself, only happier.”

“I don’t think I even have a self anymore.”

“We’ll find your self.”

I was wary. “Just don’t turn me into Sandy Duncan.”

How much insult to the self is done by the symptoms of the disorder and how much by the drugs used to treat it? Paradoxically, psychotropic drugs can induce anxiety, nervousness, impaired judgment, mania, hypomania, hallucinations, feelings of depersonalization, psychosis and suicidal thoughts, while being used to treat the same symptoms. Before getting to the hospital, my daily moods ranged from bad to worse, each state accompanied by a profound depth of feeling. The first drug I was given was amitriptyline (Elavil), which, in the process of reducing my despair, blunted all my other emotions. I no longer felt anything. It was like going from satellite TV to one lousy channel.

While some medications affected my mood, others — especially mood stabilizers — turned my formerly agile mind into mush, leaving me so stupefied that if my brain could have drooled, it would have. Word retrieval was difficult and slow. It was as if the door to whatever part of the brain that housed creativity had locked. Clarity of thought, memory and concentration had all left me. I was slowly fading away.

I would try to talk to my doctors about my vanishing self, but they didn’t have much to say on the subject. Instead they focused on whether I could make eye contact or how much expression I showed in my face. They monitored my lithium and cortisol levels; they took an M.R.I. of my head. I received an EKG, was exposed to full-spectrum lighting and kept awake all night for sleep-deprivation therapy. Nurses jotted down their observations; my scribbled lines in art therapy were inspected. Everything was scrutinized — except the transformation of my self and my experience of its loss.

My current psychiatrist, William Scheftner at Rush University Medical Center, says this is typical when treating patients with acute mental disorders. The primary goal at the height of a mental-health crisis is symptom reduction. That means monitoring patients’ sleep patterns, appetites and responses to medications — not worrying about philosophical questions like who they are and who they will become. “The issue of self just isn’t there,” he told me, “because you’re so preoccupied with whether someone is actually improving or not.”

By August 1989, I was back in Boston with my husband and kids, having been discharged from the hospital almost three months after I was admitted. My children, like many people, mistook “discharge” for “recovery.” “Why did they let you out if you’re not better?” my daughter asked. I didn’t know how to explain the welter of factors that go into discharge: poses no threat to self or others; is functioning at a high-enough level to participate — however minimally — in the tasks of daily living. Recovery was not an end, I told her, but a process.

The trees were starting to change colors. Acorns dropped and exploded like tiny bombs. My car was in the driveway; my clothes were in my closet. But things felt ill fitting and unfamiliar. “Whose kids are these?” I wondered. “And when is their mother coming to pick them up?” Nowhere was my otherness more keenly experienced than at the driveway at the grammar school. Everyone knew that I had been “away,” and why. I tried to imitate the other mothers, their relaxed camaraderie, their confidence, the way they threw their heads back when they laughed.

Around Halloween, as our neighbors made wild-eyed pumpkins with crooked teeth, my children noticed that there were frightening things in our house, too. I had my first hypomanic episode. This was how my doctors confirmed that my depression wasn’t just depression — I had bipolar II disorder, like my father. With bipolar II, unlike bipolar I, the upward swing from depression stops at hypomania, not mania. Mania is having five grand pianos delivered to your house; trying to buy the Sears company; sleeping with the local baseball team. Hypomania is mania with a tether, and, while it might avert some of the financial and interpersonal disasters that unchecked mania may engender, it can still feel like a runaway train.

By that point my vestigial self had grown used to my depressed self, with her somber mood and tenuous hold on life. Now a newcomer arrived. I seemed to have split into three: my shellshocked self, my depressed self and a brazen hypomanic self. We could practically hear the new girl sizing us up, cackling. Under her reign, we slept two hours a night. We ate half a sandwich and two potato chips a day. We packed the children’s lunchboxes at 3 a.m. We began to study for the MCATs (the fact that we had never taken a biology or chem class seemed irrelevant). We telephoned long-lost friends. The hypomanic self’s activities, from relentless lunch dates and impulsive spending sprees, left my tattered and depressed selves saying, “That’s not us” and “We don’t do that.”

I no longer went to bed with my husband. Instead I stayed awake, scribbling in my notebooks. My wakefulness worried my son. “I had a bad dream,” he said. “You were downstairs working in the middle of the night. And while everyone else in the house was sleeping, the whole house fell down on you.”

“Oh,” I said, pulling him close. “That is a bad dream. Did anybody get hurt?”

“No, but the cats almost died.”

Every few weeks, I needed to buy smaller clothes. “What’s happening to you, Mommy?” my daughter asked. “You’re shrinking.”

Hypomania was consuming me. My doctor, in an effort to quash the hypomania, upped my lithium dose and catapulted me back into depression, back to Chicago, back to a locked psych unit, after New Year’s Day in 1990. A few weeks later, my kids came to visit. I met them in the lobby. The chair I was sitting in felt insubstantial; the walls seemed to bend. My son was excited. “I made a scientific discovery!” he said. “There can’t be a shadow in the darkness.” He understood depression better than my doctors, I thought. “Mommy?” he said a few moments later. He sounded miles away. I leaned back and fell asleep. I didn’t see them again for four months.

Hope’s Story Of Experimental Treatment For PTSD: Ecstasy. Part 3 of 3.

Taken from   CNN Health   which is located    HERE.

When Rachel Hope picked up the phone in 2005 to call Dr. Michael Mithoefer, she didn’t have high hopes.

“I had very low expectations,” said Hope, who suffered from post-traumatic stress disorder for years before investigating whether the drug Ecstasy might be able to free her from her torment. Her PTSD was traced to a period of sexual abuse as a child and a life-threatening car accident.

In the initial 45-minute conversation, Mithoefer determined that Hope didn’t have other serious psychological problems. He agreed to fly her to South Carolina to take part in his study of the experimental therapy. There, she underwent more psychological testing and a physical exam. There were standard therapy sessions, so Mithoefer could understand Hope’s past and her symptoms. Finally, she was ready.

Light streamed through the skylight as Hope lay back on a futon in Mithoefer’s office, in the rear of a small bungalow.

On either side sat Mithoefer and his wife, Annie, a nurse.

Annie put in a CD and music started playing. As Hope placed a capsule on her tongue, they began to talk. Thirty minutes later, she began to feel deflated. Even though she had no experience with drugs, she knew: she’d been given a placebo.

True to their protocol, the Mithoefers continued the therapy, as if Hope were under the influence of MDMA. Said Hope, “We went through the process, but by the end, I’m like, ‘I’m not different.’”

A week later, Mithoefer called back. He had permission to conduct MDMA sessions with test subjects who’d previously received the placebo. Would Hope like to fly back to South Carolina?

Read the first installment of this three-part series

And so once again, Hope found herself on the futon, the light streaming, the music playing, the capsule on the tongue. This time, everything changed.

“It was like my whole brain was powered up like a Christmas tree, all at once,” recalled Hope.

Listening to audiotapes, it isn’t obvious what’s happening. The conversation is fractured. But something was going on inside Hope’s brain.

“Somehow, I became aware of the hardwiring decisions that my brain had made to explain why all these traumatic things happened to me, and what they meant to me about being a woman, a child living in the world, about sex, about violence,” she said. “What the medicine did, it brought everything up for question.”

Mithoefer said he lets patients drive the direction of the session. Typically, they alternate between talking and stretches of pure introspection. The trauma, he said, “always seems to come up.”

“It’s not that people just have a blissed-out experience and feel great about the world,” he cautioned. “A lot of the time it’s revisiting the trauma, and it’s a painful, difficult experience. But the MDMA seems to make it possible for them to do it effectively.”

Hope said it certainly worked for her. She estimates that 80% of her symptoms disappeared after that first MDMA-assisted session. “It allowed me to rewire my brain,” she said. Another 10% of her symptoms went away over the next few weeks, she said.

According to results published last month in the Journal of Psychopharmacology, the effect was typical. Of 19 subjects in the study, more than two-thirds still showed significant improvement more than three years later — what Mithoefer and colleagues describe as “meaningful sustained reductions” in their symptoms.

With PTSD, a common measure of severity is the so-called CAPS score, determined by answers on a detailed questionnaire. To be part of the study, patients needed a CAPS score above 50, which generally signifies moderate to severe symptoms. Hope rated a score of 86. At long-term followup, about three years after their final MDMA-aided session, only two people in the study had scores as high as 50. The CAPS score for Hope was 14.

One patient, who chose to stay anonymous, described a sense of new freedom: “I was always too frightened to look below the sadness. The MDMA and the support allowed me to pull off the controls, and I … knew how and what and how fast or slow I needed, to see my pain.”

“The question is whether this was just a flash in the plan, where people just feel good from taking a drug,” said Mithoefer. “The answer to that turns out to be no, it really wasn’t just a flash in the pan for most people.”

For all the promise, however, 19 people is still a tiny study.

Read the second installment in this three-part series

‘Rebooting a computer’

Not surprisingly, there are skeptics. Dr. Edna Foa, who developed a widely used treatment for PTSD called prolonged exposure therapy, or PE, met with Mithoefer to review audiotapes of MDMA-assisted therapy. She walked away shaking her head.

“I was completely confused,” Foa said. “They were all over the place. They didn’t use evidence-based therapy, which would be CBT (cognitive behavioral therapy), PE or EMDR (eye movement desensitization and reprocessing). They were just kind of going with feeling. I don’t know the rationale.”

She was also jolted by the frequent hugs the Mithoefers gave patients at difficult points in the session. “It’s very unusual,” Foa chuckled. Foa said she never touches a patient “unless they ask for it. And then I hold their hand.”

Mithoefer said the key feature of his approach is that it’s “nondirective,” in that what happens during the session is determined primarily by the individual’s own process and needs. He said he often includes elements of other types of therapy — including PE and CBT — but that it depends on the patient’s response.

Even those who see promise in MDMA-assisted treatment aren’t sure how it works. “It’s not well understood by any means,” said Mithoefer. “We think it gives people this window of time in which they can process things without being overwhelmed by emotion, but also not being numbed up.”

He said brain imaging studies, while crude, support the theory that MDMA alters hard-wired connections between conscious thought and emotional reactions — or overreactions.

“We do know that MDMA decreases activity in the left amygdala, and increases it in the prefrontal cortex” — brain areas associated with emotion and higher thinking, respectively, he said.

David Nichols, a professor of pharmacology at Purdue University, said no one really knows why MDMA, as well as drugs like LSD and psilocybin, have such a profound effect on the brain.

“I liken it to rebooting a computer,” he said. “But when it comes to things that change the fundamental structure of personality and consciousness, and changes who you are, we don’t really understand that.”

Nichols warned against a simple explanation. “You could talk about neurotransmitters, but that’s really superficial. (MDMA) releases serotonin, dopamine, norepinephrine. It activates other hormones. But what does that all mean?”

‘Why do we need this MDMA?’

Uncertainty is easier to take if you think there’s no other option, and Foa argued it’s a misperception that existing treatments are ineffective.

A recent study by psychiatrists at the National Center for PTSD tracked 171 patients who received either PE or CBT therapy. After 10 years, fully 80% still enjoyed milder symptoms. However, about one in four of those treated could not be found for followup.

“With PE, you get about 40-50% (cured) of PTSD, and you get about 80% getting improvement,” said Foa. “So we have good treatments, that have no side effects. The question is, why? Why do we need this MDMA?”

Foa also cites concerns about neurotoxicity, although a 2011 study by Harvard psychiatrist Dr. John Halpern found that occasional MDMA use produced no cognitive damage.

Dr. Julie Holland, a psychiatrist who is overseeing the safety of an MDMA study Mithoefer is now conducting on veterans, said most risk is eliminated by the controlled nature of the experience.

For casual Ecstasy users, said Holland, “The biggest risk is not knowing what they’re taking.” Apart from being illegal, the street drug is often contaminated with other substances. Holland added that, “The next big one (risk) is heatstroke, if you get out and dance for six hours.”

“The third biggest risk is overhydration,” she explained. People are taught to stay hydrated, but MDMA causes the body to retain water. Combined with the drug’s disorienting effects, this can lead users to overdrink, to a condition known as hyponatremia, a dangerously low concentration of sodium in the blood. “This is the main reason MDMA users die,” said Holland, “from drinking too much water.”

In a controlled setting, said Holland, “You get an incrementally higher heart rate, higher blood pressure and body temperature, but there isn’t real danger as long as you’re moderately healthy.”

‘Real people are paying the price’

Additional studies using MDMA against PTSD either have been completed, are planned or are under way in Colorado, Canada, Spain, Switzerland, Israel, Australia and Great Britain. Meanwhile, Mithoefer is conducting a study treating military veterans and firefighters; so far 11 people have enrolled and more than 280 have called to see if they might take part.

While the military and Department of Veterans Affairs have expanded services in recent years, they struggle to keep pace with the inflow of new patients. The number of active-duty military personnel seeking treatment for PTSD rose from 10,408 in 2002 to 281,468 last year, according to Cynthia Smith, a Department of Defense spokeswoman.

One reason MDMA seems tempting is the sense that existing treatments are not enough. “It’s not like we don’t have effective treatments for PTSD,” said Dr. Boadie Dunlop, director of the Mood and Anxiety Disorders Program at Emory University. “But there are many people for whom these therapies don’t work.”

Retired Brig. Gen. Loree Sutton, who headed the DOD’s Centers of Excellence for Psychological Health and Traumatic Brain Injury from 2007 to 2010, said she left the Army in part because she felt existing treatments often do more harm than good.

“We invested in conventional approaches towards research, but I also knew we had to go beyond that,” said Sutton. “Real people are paying the price for our failure to harness knowledge.”

The National Center for PTSD, a branch of the VA, says approved treatments include a type of antidepressant known as SSRIs (selective serotonin reuptake inhibitors), along with EMDR, CBT and PE, developed by Foa. In some studies, more than three-quarters of those who complete PE therapy are “cured.” But success can be hard to evaluate, in part because treatment is too emotionally painful for many patients to complete.

The DOD and VA also support a variety of research, much of it to try to fine-tune existing approaches. For example, Foa is leading a study offering more sessions in a shorter amount of time — twice weekly — to soldiers at Fort Hood, Texas. About 360 people are expected to enroll.

Neither the VA nor the military is part of clinical MDMA research, but Sutton said that before leaving the Army, she did call Rick Doblin to encourage his work. Doblin is the founder of MAPS, the Multidisciplinary Association for Psychedelic Studies, which wants to turn mind-altering drugs like Ecstasy into prescription medicine.

“With MDMA — Ecstasy — if rigorously designed studies show there’s a benefit, better than existing therapies, then we should use it,” Sutton said.

Doblin said he’s working with the Defense Department to develop a protocol involving active-duty troops, and said he would gladly give up his status as the prime backer of MDMA research: “If there are other people who have a better idea, or want to try it with cognitive behavioral therapy, or whatever — if there are other people trying to fund MDMA research, we think that would be great.” With a laugh, he added, “We could even provide them with free MDMA. We have a lot more than we need.”

Encouraging signs

Hope no longer has flashbacks or night terrors, and she no longer jumps when the phone rings. After finishing with Mithoefer, she decided to abandon her quiet life on Maui and moved to Los Angeles.

In 2008 she felt strong enough to have a second child. “That’s another part of the gift of MDMA,” she said recently. “Before those sessions, I just couldn’t get it together, to expand my family the way I wanted to.”

Crowds no longer faze her. In fact, she spent two months this fall as a full-time climate-change protester, doing street theater in a polar bear hat in front of hostile crowds at presidential debates and similar events.

“It gets pretty intense,” she said. “It’s something I couldn’t have done, before the treatment.”

Grateful as she is for Mithoefer’s study, she feels as strongly as ever about avoiding recreational drug use. “I have a very, very serious respect for that medicine. You really don’t want anybody to do this without professional supervision. It could open portals, in a way that could really damage you.”

Chatting in his office, where books about shamanism sit side by side with standard psychology texts, Mithoefer remained cautious.

“I think at this point, what we know is that MDMA can be administered safely to people with PTSD, to the right people in the right setting with the right screening. It shows very encouraging signs of being effective, you know, but the numbers are too small to say we can definitively prove that.”

Hope’s Story Of Experimental Treatment For PTSD: Ecstasy. Part 2 of 3.

Taken from   CNN  Health  which is located    HERE.

Post-traumatic stress disorder begins as a natural response to danger, according to psychiatrists.

Rachel Hope says her life had been the stuff of nightmares. She reached out to South Carolina psychiatrist Dr. Michael Mithoefer in 2005 after suffering the effects of PTSD for years and trying various treatments, to no avail.

“My mom was 19 when she had me, and she was very ill-equipped,” Hope said.

But the worst arrived when Hope was 4 years old and her mother went on vacation, leaving her with a male friend who’d agreed to babysit.

As it turned out, says Hope, he was a pedophile who raped her repeatedly over the six-week stretch that her mother was gone. When they finally reunited, her mother noticed a change.

“She told me, ‘I just wondered why you were kind of withdrawn and weren’t the happy child you used to be,’ ” Hope said. But the angry, bewildered child didn’t tell tell her mother what had happened, and no one put the pieces together.

Not long after, Hope went to live with her grandmother in San Diego, where she did well in school and became accustomed to a “normal” life.

Read the first installment of this three-part series

But five years later, another catastrophe struck — literally. She was hit by a delivery truck as she was riding her bike to a dance lesson. Hope nearly died. As it was, she needed two reconstructive surgeries on her face and was partially paralyzed for four months.

Yet, she survived. The 11-year-old found strength in stoicism.

‘”That was good and bad. I mean, it was heartbreaking to be a kid like that,” she said. “To realize, there’s not gonna be a magical fairy that shows up. ‘Bad news, kid, no one’s saving you.’ And that was a big turning point.”

Seemingly against all odds, she pulled her body and mind back together. She became fascinated by notions of human potential, the way the mind works.

And she asked herself the big questions. “I wanted to make sense of it all.”

It took years, however, to reach out to Mithoefer. Her plan: to see whether she could free herself from torment by taking a drug called MDMA, commonly known as Ecstasy.

Party drug and forbidden substance

The compound known as 3,4-methylenedioxymethamphetamine, or MDMA, was first synthesized in Germany in 1912. No one quite knew what to do with it. It was studied by the military in the 1950s and eventually emerged from the lab in the late 1970s.

The first report on its effect in humans was published in 1978 by independent chemist Alexander Shulgin and David Nichols, a professor of pharmacology at Purdue University.

At the same time, Shulgin was churning out the drug in his lab and sharing it with a handful of psychiatrists and therapists who saw MDMA as a lever for human growth.

Dr. George Greer helped Shulgin make an early batch and offered it to interested couples and individuals. “MDMA reduced the fear response, so people could talk about the things that made them afraid or upset,” he recalled.

At the same time, “people were able to have normal cognitive function, and the insights they had were able to translate to everyday life.” A few people had mild panic attacks, says Greer, “but in general, it was well-tolerated.” He described his experiments in a paper, detailing the experiences of 29 people.

Not everyone was so careful. By the mid-’80s, Ecstasy was also in use as a party drug. In the spring of 1985, the alarm was sounding, and Ecstasy was making headlines.

Congress held hearings, and the Drug Enforcement Administration put MDMA on the list of forbidden substances alongside heroin and LSD.

The uproar left the small community of MDMA therapists shaken. Greer submitted testimony asserting the drug’s safety to the DEA, but to little avail.

Rick Doblin, a soon-to-be Harvard graduate student who would later found the Multidisciplinary Association for Psychedelic Studies — a group wanting to turn mind-altering drugs like Ecstasy into prescription medicine — saw the writing on the wall. Shortly before MDMA was banned, he persuaded Nichols to synthesize two kilograms for researchers, for the cost of materials.

“Doing science that gets reported, that’s an idea we can sort of leverage,” Doblin said. To win broader acceptance for MDMA — and for cousins like LSD and psilocybin, the mind-altering compound in so-called magic mushrooms — “the medical route was the only route. Everything else was blocked.”

That meant a formal plan for drug development: study protocols, institutional review boards and the rest. Mithoefer, a University of Virginia-trained clinician who specializes in trauma and had a long-running interest in MDMA, was the perfect partner.

Before taking Hope’s call, Mithoefer had spent nearly three years navigating the federal bureaucracy to win approval for his small experiment, designed to test a simple question: Is MDMA, used in a clinical setting, safe?

‘I got to survive. But for what?’

As a teenager, Hope marched with a precocious sense of purpose. At age 13, she moved across the country to live with family friends in New Jersey.

A year later, she was back in California, where she found a full-time secretarial job while completing her high school coursework. She built a strong relationship with her father, who had separated from her mother when she was an infant.

By the time she was 17, she was back with her mom but supporting herself financially.

She was wary of relationships but wanted a family, and at 19 she found a like-minded colleague who agreed to co-parent a son. They moved to Hawaii, because she had fond memories of a childhood vacation.

“I think there was a part of me that thought I could run away from all that crazy horrible stuff,” she said. “I was trying to find ways to be okay.”

But the peace was fragile. When her father died in 1991, Hope became so depressed, she fell into a stupor. She was hospitalized, and for the first time, a psychiatrist listened as she talked about her childhood abuse. It was eye-opening, but therapy offered limited relief. She grew well enough to leave the hospital but found little joy outside.

In 1998, she suffered another breakdown after learning from a friend that the man who’d sexually abused her was under investigation for molesting another girl.

Under the weight of stress and emotion, Hope’s carefully constructed shell began to crack.

“I started having these outrageous flashbacks, and body memories,” she recalled. “The first time, I thought someone slipped me a drug. Because it would be these unstoppable, full-body blackout memories, and people would tell me later, ‘You were just screaming for an hour.’ “

She stopped sleeping. Her stomach problems worsened; she vomited every time she ate.

Once again, she checked herself into the hospital. Once again, it was all the doctors could do just to tape the pieces back together.

“I became like a survival machine. And I’m kind of blessed, because I didn’t become violent or hostile or self-destructive,” she said.

At the same time, a “normal” life felt out of reach. “It was kind of like, ‘OK, I got to survive. But for what?’ “

 

Hope’s Story Of Experimental Treatment For PTSD: Ecstasy. Part 1 of 3.

I rarely have done three part articles.  I had seen articles of  Ecstacy being mentioned in conjunction with helping PTSD victims and I figured I’d avoid them because of the harm Ecstacy has done to so many people.  As I admire Sanjay Gupta greatly and because of the content of the articles I have chosen to share the story of Rachel Hope. I highly encouage you to view the video below as an introduction.  Allan

Taken from   CNN  Health   which is located    HERE.

Rachel Hope was 33 years old when she received a painful reminder: She couldn’t outrun the past.

Hope was trying to help a new assistant at her Maui rental property business, but it wasn’t going smoothly. Part of it was Hope herself.

“I had this startle reflex,” she explained. “The phone would ring, and I’m literally three feet off the floor, screaming.

“My new assistant said, ‘You’re driving me crazy!’ And I would say, ‘I’m really sorry, just please try to ignore it. It’s embarrassing, but let’s keep working.’ “

But the young man, a teacher on break, wasn’t pushed off easily. Soon after, Hope said, “he walked over to my desk and dropped a stack of papers two inches thick. It was every single PTSD study that was online, and he just said, ‘pick one.’ “

A few days later, Hope was dialing the number of South Carolina psychiatrist Dr. Michael Mithoefer. Her plan: to see whether she could free herself of a lifetime of torment by taking a drug he was testing — a drug most people know as Ecstasy.

A teetotaler, Hope wasn’t looking for a thrill. She’d been born to a young hippie mother who couldn’t stand the thought of parking their VW bus in one spot. After seeing psychedelic casualties all along the road, to Hope, drugs signified a lack of control. That was the last thing she needed. It was hard enough to hold things together stone sober.

Truth be told, Hope didn’t need her new assistant to tell her what the problem was. She just didn’t know how to fix it. She’d been diagnosed with post-traumatic stress disorder, traced to a period of sexual abuse as a child and a life-threatening car accident.

She’d been hospitalized four times for the debilitating symptoms, and stress had caused bleeding ulcers bad enough to send her to the emergency room twice more.

Along the way, she tried cognitive behavioral therapy, hypnosis and acupuncture. She tried an established therapy called eye movement desensitization and reprocessing, where a therapist used physical stimuli — light tapping and guided eye movements — to try to retrain her brain. It made her eyeballs feel like they would burst out of her head. She tried gestalt therapy, screaming out her rage.

“Nothing worked,” she says. “I got to the point where I just said, ‘I’m handicapped. I’m just going to have to live my life like this.’ It was pretty horrible.”

A formal plan

More than 7 million Americans suffer from PTSD, and by most estimates, only half of them — at best — are ever cured. A decade ago, the widely acknowledged need for better treatments opened the door to Mithoefer and his unconventional approach.

By the time he took Hope’s call in February 2005, the soft-spoken, ponytailed Mithoefer had managed to convince the Drug Enforcement Administration to green-light a study of Ecstasy as an adjunct to psychotherapy.

Of course, he wasn’t calling it Ecstasy. Neither were the scientists from the Food and Drug Administration and certainly not the DEA agents who had picked over Mithoefer’s bungalow in Charleston, South Carolina, making sure it was “secure” in case drug-hunting criminals tried to break in and grab the stash.

He’d gotten the 3,4-methylenedioxy-methylamphetamine (MDMA) — the chemical name for pure Ecstasy — from Rick Doblin, the founder of a MAPS, the Multidisciplinary Association for Psychedelic Studies. The group’s stated purpose is to develop “medical, legal and cultural contexts for people to benefit from the careful uses of psychedelics and marijuana.” It wants to turn mind-altering drugs like Ecstasy into prescription medicine.

The advocacy unsettles some people, but this was no Timothy Leary operation. Doblin says he was determined to do things the right way.

“Doing science that gets reported, that’s an idea we can sort of leverage,” Doblin said. To win broader acceptance for MDMA — and for cousins like LSD and psilocybin, the mind-altering compound in so-called magic mushrooms — “the medical route was the only route. Everything else was blocked.”

That meant a formal plan for drug development: study protocols, institutional review boards and the rest. Mithoefer, a University of Virginia-trained clinician who specializes in trauma and had a long-running interest in MDMA, was the perfect partner.

When Mithoefer enrolled the first patient in the new study in 2004, U.S. troops were in Iraq fighting the longest-running war in American history. They just didn’t know it yet. Even then, there were men and women jumping out of their shoes at the sound of a car horn and waking up in the middle of the night drenched in sweat from another nightmare. But most troops hadn’t come home yet. America wasn’t ready.

A sense of crisis was years away, but Mithoefer — and other specialists in psychological trauma — were bracing for a wave of tortured souls. Before taking Hope’s call, the doctor had spent nearly three years navigating the federal bureaucracy to win approval for his small experiment, designed to test a simple question: Is MDMA, used in a clinical setting, safe?

The point is sometimes lost, but even today, civilians make up the vast majority of people struggling with PTSD.

As Mithoefer launched his research, he wouldn’t be working with veterans. He’d be working with civilians, mostly female survivors of sexual assault. All had tried conventional treatments — either therapy or medication — without success. On average, they had suffered their debilitating symptoms for 19 years. Hope was patient No. 7.

‘It just wouldn’t stop’

Hope was used to putting on a front. To a casual visitor, she seemed fine. Her rental property business in Hawaii earned a steady living, and she and a close friend were happily raising a 13-year-old son through an unconventional co-parenting arrangement. She was restless on Maui, but after a bumpy childhood, it seemed she’d found a kind of peace.

But you didn’t have to look hard to see a dark side. “I was argumentative and defensive, and I was very angry,” she recalled. “I was having panic attacks and anxiety attacks and all the physical problems that come with it. I had irritable bowel syndrome, and I couldn’t sleep.”

To survive, she pushed people away. “It makes intimate relationships very difficult,” she said. “Some part of me was on guard, and it just wouldn’t stop.”

Click    HERE    for part 2

A Call For Caution On Antipsychotic Drugs

 

 

Taken from the  New York Times  which is located    HERE.

You will never guess what the fifth and sixth best-selling prescription drugs are in the United States, so I’ll just tell you: Abilify and Seroquel, two powerful antipsychotics. In 2011 alone, they and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion, a 13 percent increase over the previous year, according to the market research firm IMS Health.

Those drugs are used to treat such serious psychiatric disorders as schizophrenia, bipolar disorder and severe major depression. But the rates of these disorders have been stable in the adult population for years. So how did these and other antipsychotics get to be so popular?

Antipsychotic drugs have been around for a long time, but until recently they were not widely used. Thorazine, the first real antipsychotic, was synthesized in the 1950s; not just sedating, it also targeted the core symptoms of schizophrenia, like hallucinations and delusions. Later, it was discovered that antipsychotic drugs also had powerful mood-stabilizing effects, so they were used to treat bipolar disorder, too.

Then, starting in 1993, came the so-called atypical antipsychotic drugs like Risperdal, Zyprexa, Seroquel, Geodon and Abilify. Today there are 10 of these drugs on the market, and they have generally fewer neurological side effects than the first-generation drugs.

Originally experts believed the new drugs were more effective than the older antipsychotics against such symptoms of schizophrenia as apathy, social withdrawal and cognitive deficits. But several recent large randomized studies, like the landmark Catie trial, failed to show that the new antipsychotics were any more effective or better tolerated than the older drugs.

This news was surprising to many psychiatrists — and obviously very disappointing to the drug companies.

It was also soon discovered that the second-generation antipsychotic drugs had serious side effects of their own, namely a risk of increased blood sugar, elevated lipids and cholesterol, and weight gain. They can also cause a potentially irreversible movement disorder called tardive dyskinesia, though the risk is thought to be significantly lower than with the older antipsychotic drugs.

Nonetheless, there has been a vast expansion in the use of these second-generation antipsychotic drugs in patients of all ages, particularly young people. Until recently, these drugs were used to treat a few serious psychiatric disorders. But now, unbelievably, these powerful medications are prescribed for conditions as varied as very mild mood disorders, everyday anxiety, insomnia and even mild emotional discomfort.

The number of annual prescriptions for atypical antipsychotics rose to 54 million in 2011 from 28 million in 2001, an 93 percent increase, according to IMS Health. One study found that the use of these drugs for indications without federal approval more than doubled from 1995 to 2008.

The original target population for these drugs, patients with schizophrenia and bipolar disorder, is actually quite small: The lifetime prevalence of schizophrenia is 1 percent, and that of bipolar disorder is around 1.5 percent. Drug companies have had a powerful economic incentive to explore other psychiatric uses and target populations for the newer antipsychotic drugs.

The companies initiated dozens of clinical trials to test these drugs against depression and, more recently, anxiety disorders. Starting in 2003, the makers of several second-generation antipsychotics (also known as atypical neuroleptics) have received F.D.A. approval for the use of these drugs in combination with antidepressants to treat severe depression, which they trumpeted in aggressive direct-to-consumer advertising campaigns.

The combined spending on print and digital media advertising for these new antipsychotic drugs increased to $2.4 billion in 2010, up from $1.3 billion in 2007, according to Kantar Media. Between 2007 and 2011, more than 98 percent of all advertising on atypical antipsychotics was spent on just two drugs: Abilify and Seroquel, the current best sellers.

There is little in these alluring advertisements to indicate that these are not simple antidepressants but powerful antipsychotics. A depressed female cartoon character says that before she starting taking Abilify, she was taking an antidepressant but still feeling down. Then, she says, her doctor suggested adding Abilify to her antidepressant, and, voilà, the gloom lifted.

The ad omits critical facts about depression that consumers would surely want to know. If a patient has not gotten better on an antidepressant, for instance, just taking it for a longer time or taking a higher dose could be very effective. There is also very strong evidence that adding a second antidepressant from a different chemical class is an effective and cheaper strategy — without having to resort to antipsychotic medication.

A more recent and worrisome trend is the use of atypical antipsychotic drugs — many of which are acutely sedating and calming — to treat various forms of anxiety, like generalized anxiety disorder and even situational anxiety. A study last year found that 21.3 percent of visits to a psychiatrist for treatment of an anxiety disorder in 2007 resulted in a prescription for an antipsychotic, up from 10.6 percent in 1996. This is a disturbing finding in light of the fact that the data for the safety and efficacy of antipsychotic drugs in treating anxiety disorders is weak, to say nothing of the mountain of evidence that generalized anxiety disorder can be effectively treated with safer — and cheaper — drugs like S.S.R.I. antidepressants.

There are a small number of controlled clinical trials of antipsychotic drugs in generalized anxiety or social anxiety that have shown either no effect or inconsistent results. As a consequence, there is no F.D.A.-approved use of an atypical antipsychotic for any anxiety disorder.

Yet I and many of my colleagues have seen dozens of patients with nothing more than everyday anxiety or insomnia who were given prescriptions for antipsychotic medications. Few of these patients were aware of the potential long-term risks of these drugs.

The increasing use of atypical antipsychotics by physicians to treat anxiety suggests that doctors view these medications as safer alternatives to the potentially habit-forming anti-anxiety benzodiazepines like Valium and Klonopin. And since antipsychotics have rapid effects, clinicians may prefer them to first-line treatments like S.S.R.I. antidepressants, which can take several weeks to work.

Of course, physicians frequently use medications off label, and there is sometimes solid empirical evidence to support this practice. But presently there is little evidence that atypical antipsychotic drugs are effective outside of a small number of serious psychiatric disorders, namely schizophrenia, bipolar disorder and treatment-resistant depression.

Let’s be clear: The new atypical antipsychotic drugs are effective and safe. But even if these drugs prove effective for a variety of new psychiatric illnesses, there is still good reason for caution. Because they have potentially serious adverse effects, atypical antipsychotic drugs should be used when currently available treatments — with typically fewer side effects and lower costs — have failed.

Atypical antipsychotics can be lifesaving for people who have schizophrenia, bipolar disorder or severe depression. But patients should think twice — and then some — before using these drugs to deal with the low-grade unhappiness, anxiety and insomnia that comes with modern life.

Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College in Manhattan.

The Unreal World: ‘Homeland’ And Bipolar Disorder

 

Taken from the Los Angeles Times which is located   HERE.

The premise

Sgt. Nicholas Brody (Damian Lewis) returns as a hero to the U.S. after spending eight years as a prisoner of war in Afghanistan. Carrie Mathison (Claire Danes) is a mentally unstable CIA officer who is convinced that Brody is an agent of Al Qaeda. She gets antipsychotic medication and lithium from her sister, psychiatrist Maggie Mathison (Amy Hargreaves), but she fears she’ll lose her job if she gets medical treatment through normal channels. In this episode, Carrie is hospitalized after being burned and bruised in a briefcase bomb explosion. She hasn’t taken her medication in several days and is becoming increasingly manic. Saul Berenson (Mandy Patinkin), her mentor at the CIA, is alarmed by her behavior, and Carrie admits that she is bipolar. Her sister arrives and gives her a ramped-up dosage of lithium as well as clonazepam to “level her out.” When she is discharged from the hospital, Carrie tries to run away and is nearly hit by a car.

The medical questions

What is bipolar disorder? Is it possible to hide the symptoms from one’s co-workers, especially in a high-stress job such as Carrie’s? Can the condition be exacerbated after a traumatic event, such as a bombing? Is it proper for a doctor to treat a close relative, even if the patient won’t get medical care any other way?

The reality

Bipolar disorder is a serious mental illness involving extreme mood swings, in which people go back and forth between periods of elevated or irritable mood (mania) and depression, explains Carrie E. Bearden, associate professor of psychiatry, biobehavioral sciences and psychology at UCLA. Other characteristics, all exhibited by Carrie Mathison, include grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility and obsessive goal-directed behavior. In addition, 60% of people with bipolar disorder experience psychotic symptoms.

“People with bipolar disorder can function extremely well and continue in their jobs when their symptoms are effectively treated,” Bearden says. Lithium, a mood stabilizer, is one of the first-line treatments. Stopping it precipitously can provoke a manic episode (50% of patients will develop such an episode within three months after coming off the medicine). Clonazepam, an anti-anxiety medication, is often used for short-term relief of anxiety or agitation.

Bipolar disorder can be difficult to treat, and a high-stress job such as Carrie’s makes it harder. The situation is even more challenging when a second condition is present, such as psychological trauma. An acute stress such as a bombing could definitely trigger a relapse or the onset of a manic or psychotic episode, Bearden says.

Should a doctor treat a relative? This is at best controversial and probably the answer is close to never, especially in psychiatry, says Dr. Stephen M. Stahl, adjunct professor of psychiatry at UC San Diego and author of the book “Depression and Bipolar Disorder.” One cannot be objective, records are often not kept and the person inadvertently receives substandard care.

Bearden agrees that it would not be appropriate or advisable for a patient’s relative or close friend to prescribe medications and/or provide ongoing psychiatric treatment.

Siegel is an associate professor of medicine at New York University Langone Medical Center. His latest book is “The Inner Pulse: Unlocking the Secret Code of Sickness and Health.”