Why Psychiatric Medication is Confusing

“Hey Doc, why are you using me as a guinea pig? I am not taking these meds!”

Anybody who has been around people who need psychotropic medications (drugs for mental illness) has heard this complaint. Psychiatrists can never be sure if the prescription they write will do the “magic” that is sought. It is normal practice for a physician to give a trail of one medicine for a few weeks (or months) and if it is not working, try something very different. Or even begin a “cocktail” of medicines that might just do the trick.

It seems unusually cruel that people who have issues trusting people are given medicine that is so unreliable.  In American culture physicians are the most trusted of people. But when some of us feel so bad that we can’t even think straight, and we can’t trust anybody, we often go to a doctor who will write something on that special pad that might help, but might even harm! Why is the system so cruel?

To understand this, we need to understand a little bit about psychiatric diagnosis, and then a little bit about the medicines themselves.

Psychiatric diagnoses or the types and categories of mental illness is defined in a book called DSM (Diagnostic and Statistical Manual) published by the American Psychiatric Association (APA). This book is periodically updated and is currently in the fourth edition. The APA is an association for physicians who specialize in psychiatry. So they are interested in having their particular specialty be as similar to other medical specialties as possible. But there is a major, essential difference. Mental illness is not like most other medical illnesses. Most illnesses are defined by what causes them. Mental illness is defined by symptoms.

In most fields of medicine a disease is defined by the pathogen (the “bug”- virus, bacteria, etc.) that causes it. You have a sore throat so you go to the doctor to find out what you have. She takes a culture and tells you that you have strep throat. And she writes out a prescription for a medicine that will kill the strep.

The sore throat is a symptom. Before you went to the doctor you knew you had a sore throat. You did not know if it was strep throat or post nasal drip. Any symptom can have multiple or various causes. It is the doctor’s job to figure out the cause in order to prescribe a cure. Otherwise, you could just go and but some Cepacol.

But the DSM does not define mental illness according to cause. That because we generally do not have much of a clue about the causes of mental illness. (Except for one case, I will mention later.) So all of the categories in the DSM are defined by symptoms. A person has bipolar disorder because he or she acts like a person with bipolar disorder. A person is labeled schizophrenic because he or she has two or more of one set of symptoms and a certain amount of other symptoms. But nowhere is there a diagnostic test that is similar to a blood test, MRI, or throat culture. (This is also why people with major mental disorders usually have multiple diagnoses or the diagnoses change over time.)

All of the symptoms are behavioral. That means, we can look at the way a person is acting and apply the label that fits best. Of a seven year old has six or more features of inattention for at least six months, then he has ADHD. But do we know (or care) if it is caused by a malfunction of the brain or because the home is so unorganized that the kid rarely gets enough sleep? (Try staying focused on 4 hours a night of sleep.) Or some other reason?

Since psychiatric illness is defined by symptoms and not causes, the medicines are also given to address the symptoms and not the causes. That can be very good. If you need to control the symptom of hallucinations, it is fine to give anything that will work. If you need some immediate relief for your sore throat there is nothing wrong with a Cepacol. But it might not work, if the cause remains and can overpower the symptom. So if it doesn’t work, we can’t be sure why not. So the next best thing is to try the next best thing. Try a different medicine that might attack the symptom a bit more efficiently.

There is one category of psychiatric illness where we do know the cause. That is Post Traumatic Stress Disorder, and the related diagnoses. We know that there is a clear environmental cause. But that just makes the problem of prescribing medication even more complex. You cannot prescribe a retroactive anti-trauma medicine. (It would be wonderful, wouldn’t it?) Which is why there is no medical intervention for ex-abused people or people who have survived trauma. And when medicine is helpful, it is very difficult to apply that helpful experience from one person to another.

So if symptom relief is the best we can get, go for it. It can be much better than being with the symptoms. Without a cure, I’ll go get a Cepacol.

Anger Management is stupid. Better to Avoid Anger

Anger and Stress. Most of us suffer from these two maladies, especially if we are blessed with families that struggle with special challenges like mental illness of a member that is an ex-abused person. Last week I attended a family support group. One member shared a list of 100 ways of coping with stress and anger.  I looked over it and it was quite impressive. Many of the items we would think of without the list, and many were very clever. It included things like taking a bath, deep breathing, taking a walk, singing a song, dancing in the living room, etc. I’ve used some of those strategies, and some work really well for me. Bubble baths don’t help me at all, but dancing like a teenager (as long as nobody it there to laugh at me) works really well.

But when you get these suggestions you realize that they are all useful only after you are stressed out or angry. They can help you manage the stress or anger, but do little to help you prevent losing it in the first place. If your spouse had a hard day and complained about you for no good reason, you might just flip. If he or she was really bent out of shape and insulted you or worse, it is possible that the stress and anger can become unmanageable. After you are ready to strangle somebody it can you really turn on the music and just dance?

What we need is some antidote to reduce the stress and anger before it gets too much. Some way that we can feel that it really is not so bad to begin with.

Impossible, you say. I would think the same way. But my eldest daughter is in this matter almost opposite from me. She never seems stressed out. She takes everything easy. I have not seen her act angry since she was a teenager. If she were not my own daughter I would be terribly jealous. But instead I realize that I need to learn from her.

But I am not like her. So I researched and learned from others also. I found that there is actually ways to reduce the anger before it happens.  No guarantees. Not always. But ways to make a significant change in your life and the lives of the people around you.

First let’s understand what anger is. Anger occurs when somebody or something either harms us, threatens to harm us, or prevent us from getting something we need or want. When the car in front of us keeps cutting us off many of us get angry. On the other hand, if we’ve had a hard day and come home to the 7 year old’s shoes in the living room, and we trip on them, we can get angry. Why? Because we feel like that behavior almost hurt us. Or if we are a bit more sensitive, we feel like we are losing control of our seven year old, or of the way we want our home to be. No matter how you cut it, though, we feel somehow threatened by the other person, either physically or psychologically.

The next step (which happens all too fast) is that we think something negative about the person who is threatening us. “That no- good SOB, why does he always DO THAT” “Jimmy, how many times do I have to tell you to put away your shoes? Can’t you learn that simple thing?” These thoughts are what solidifies and crystallizes the emotion into real anger. It takes about 1/3 of a second to move from the feeling to the thought. If we can hijack this process in less than 1/3 of a second, we can avoid the anger.

In order to do that we need to identify an emotion that can replace the anger. What is the opposite of anger? It is not calmness. That is just the disappearance of anger. The one emotion that is absolutely incompatible with anger is compassion. If a person feels compassion for another then it is impossible to feel anger.

Compassion and anger are not really so different. When you are angry at somebody you focus on that person’s faults. “She is so stupid, I can’t stand her! If she comes here again I will tell her to leave.” With compassion we also focus on the person’s faults. “She is so stupid, I feel sorry for her. If she comes here again I will make sure she feels better.”

What about other situations? That ridiculous driver? “That guy really has a problem. I can’t get involved in his problems, so I’ll steer clear of him.” “Jimmy is just a seven year old.  He can’t remember to put his shoes away. I can’t hurt him by yelling at him, poor kid.”

Training yourself is conceptually easy, but it takes a lot of practice. You need to practice coming up with compassionate explanations for other people’s bad behavior on a regular basis. Keep a compassion journal. Set ten minutes every day to think of those stupid things that bothered you during the day and write down how you can feel sorry for the person who displayed the stupidity or bad behavior. It may not be easy at first, but it is the practice that will reap the rewards.

If you keep it up for about two weeks (or less) you will begin to try to think compassionately about people as soon as they do things that are hurtful. Soon after that you will find that you can begin to feel sorry for the other person within that 1/3 window and the anger that was harming yourself will not be there to manage.

Depression and Anxiety vs. Sorrow and Fear What is means to us.

In a recent discussion with Dr. Steven Brownlow (http://sgbrownlow.com) we discussed the difference between depression vs. sorrow and anxiety vs. fear. The thoughts were important and worthwhile sharing. The distinctions are not really clear to many folk, and can be really important when dealing with these emotions either in yourself or in loved ones.
The distinction can be especially important when you seek to set emotional goals for yourself. The type of work you need to do and what you can expect to achieve can be significantly different depending on what type of emotion you are actually experiencing.

While I have already blogged about the different types of depression and how one might deal with a non-clinical depression in a positive manner, in this blog I will use the term in a technical manner and not as the popular term. That will help us to see some characteristics of the clinical state that is not in the popular usage of the word “Depression.”

Depression and anxiety are the subjects of psychotherapy. One way of defining psychotherapy is that the therapist attempts to have the client’s subjective view of reality coincide with the objective view. When a person is clinically depressed (for purposes of this blog at least) one can say that the person feels sad, lacks motivation, etc., and attributes those feelings to circumstances that are not based in reality. He or she sees the world as a hostile or grim place and feels hopeless and helpless as a result.

Clinical anxiety has a similar dynamic. A person feels anxious because of a subjective perception that does not reflect the objective reality. One is afraid of spiders even though the spiders one sees are not dangerous. A person can suffer from overwhelming anxiety due to a trauma that happened in the past, even though it cannot happen in present circumstance. Such is the dynamic in PTSD, for example. A soldier will play out his or her anxiety at home far from the battlefield. And the anxiety might pervade his or her whole world-view. Now, you will argue that there is a real fear here and the behavior is caused by a real fear. That is true. But the fear is fueled and constructed from an anxiety that is based in an unrealistic, subjective perception and not objective reality.

Sorrow and fear might feel bad but they are positive emotions. Just like pain is not something we like, but without pain we would be in much greater trouble. We would not know when there is some damage to our bodies if we did not feel pain.

Sorrow is the real emotional pain that results from loss. Not a threatened loss. Real loss. Loss of anything can cause sorrow, and that is a natural and positive emotion. It tells us that we need to reevaluate our relationship with the object of the loss and refine our perspective. It could be the loss of a loved one, loss of a job, or loss of an ability. We still need to go on living and learn how to live without that thing we lost. This is the realm of coaching. It is not a pathology. It is not illness. It is a healthy process that we sometimes need help in order to redefine ourselves and set new goals for new levels of fulfillment, accomplishment and flourishing.

Fear, when it is based in reality, is also positive. It tells us that we need to prepare ourselves for possible impending danger. We need to muster up our innate strengths, set strategies and use our skills to deal with whatever it is that poses a threat. It is obviously very important, although it should not overpower the rest of our abilities. In our society we are not to be afraid, but it makes more sense to embrace the fear and the power it gives us to find extra strength to initiative to meet the oncoming challenge. Positive psychology coaching can give us the tools to meet such challenges by focusing on global strengths or higher values, or inner commitment. These are the tools that every healthy person who finds the power to meet scary situations uses, but many of us are not able to consistently muster up these potentials.

Hero – Without Issues

I spend a lot of time in the library. At the school where I teach, the librarians know me and are always looking for faculty suggestions. But I was surprised when the librarian at the New York Public Library recognized me. He was curious about why I delve so deeply into positive psychology. I told him how I help overwhelmed families and individuals learn how to use their strengths to live fulfilled lives. He asked me if I work with post traumatic stress sufferers. I told him that I work with the people who love and care for them.

He began to tell me all about his sister. She is married to a Viet Nam vet. The man has been suffering with flash backs and off and on substance abuse for 40 years. He told how she has sought help from therapists who have explored her issues with resentment.

How terrible! Is it normal for her to feel her own resentment? Of course! That should hardly be made into an “issue.” I pointed out that in most circles she would be considered a hero with great strengths! Here is a woman who has supported a wounded veteran with all her heart and soul, time and money for many decades. And one would have the “chutzpah” to find issues!

Some weeks later the woman called me. It wasn’t difficult to identfy her strengths and virtues. It was much more work for her to begin to identify her own personal goals- she had focused for so long on others. Once she began to experience celebrating attainment of short term family goals she began to allow herself to plan for her own pleasure.

She felt like she lost her life in her late twenties. Now, in her sixties, she is planning for a new beginning. By building on strenghts and incorporating her virtues she is able to make a life for herself without being overwhelmed by her continuing struggle to support her husband. And she reports that her husband has more productive times as well.