Tuesday, September 29, 2009

Art Therapy

I have already posted about creativity being associated with mental illnesses.

If you are one of those people struggling with a psychiatric disorder, art therapy might be something you will want to try. You already have a statistical advantage of being able to creatively express yourself, and you have to do something in order to start feeling better, and mood diaries (as helpful as they are and you shouldn’t stop doing any other homework you are currently doing) and cleaning the cat box can get dull pretty quick. As well, as your condition improves, you will need to add more activities to your schedule in order to keep your mind healthy and active.

The creation of an artistic piece of work can be emotionally difficult or it can be a relaxing process. It has been my experience that artists using a realistic approach tend to receive more positive effects of the process. I believe this has to do with the concentration and focus needed for such art working as a sort of distraction; if the mind is occupied trying to get the texture of a tree just right, there isn’t a lot of room left for depressive thoughts.

But if you aren’t skilled in realism, you can still enjoy your hobby/profession without having to be tormented by negative emotions during the process. And if you aren’t trained in any art form, you can use art as a cognitive behavioural exercise.

You get to choose whatever medium you like. Even if you are an established artist, I think it is healthy to use a variety of methods. This break from routine and structure not only alleviates the boredom many people with depression and BPD complain of, but also takes you out of your usual thinking patterns to learn new ways of seeing things.

The project is what I call ‘what-if’ art. Whatever it is you are working on, writing, painting, collage, instead of using your current emotion as the driving (or overruling) force, ask yourself, “What would this object/thought/feeling look like if my depression/confusion/disappointment wasn’t overshadowing it?”

Already at this point, before you’ve even started working, your depression is probably telling you that that point of view is a disillusioned lie and you shouldn’t even entertain the thought of it because will do more damage than good. Ignore it as much as you can. If you practice mindfulness or if you have dissociative abilities (I do not recommend acquiring pathological dissociation, but separating yourself from something painful is sometimes the best approach; just as long as you don’t ignore the problem indefinitely), you will likely be able to completely override the depressive thoughts.

Do whatever you need to in order to keep yourself focused on the positive feeling while you work – put on inspirational music, set up the lighting however best suits the positive feeling, work outside, keep a cup of coffee beside you. When you notice depressive thoughts resurfacing stop working, take a few breaths, listen to the music, and concentrate on that positive stimulus guiding your work. You may have to do this many times, but the more you practice the less time it will take to refocus.

When you are done, the depressive thoughts might return and they might even be worse than before you started your art project. But this is just the depression’s way of trying to convince you it had always been right, you were wrong to think of anything else, and that you shouldn’t ignore its warnings again. DO NOT LISTEN TO IT. And do not listen when it tries to tell you that what you’ve made is inadequate.

That’s easier said than done, and you may find it quite painful to look at this ‘beautiful lie’ you’ve created, but the very fact that it exists means that it isn’t a lie. And you didn’t create it from a lie, only from how you would feel without the depression distorting your perceptions. What you have created is a something beautiful, something that came from you. Even if you’re not an artist you will be able to see the beauty in your work, as will others (I also encourage you to share your creations with others. If you have a small social circle, you can post images online).

I myself have more manic paintings than I know what to do with, but it’s the ‘what-if’ paintings that other people find most appealing. I think that is indication of the truth of beauty, because your depression can’t control what other people see and think. External validation isn’t necessary, but it does help when your own perceptions become muddled.

Sunday, September 13, 2009

Internet Communication between Therapist and Patient

The ethics of email communication between a therapist and a patient has been readily discussed in recent years.


• Supportive therapy from a familiar source when a patient travels (for some people, travelling may raise specific issues that would otherwise not be addressed in regular treatment).

• Having a boundaried (the therapist replies on their own time and in their own manner) means of communicating during distress. The act of writing the letter itself, regardless of being sent, may aid in attenuating emotions.

• Being able to communicate thoughts before they are forgotten (note taking without emailing is also an option in this case).

• Provides an un-intruding way of reminding the therapist of small details that may have been forgotten during session (prescription refills, rescheduling appointments, etc.).

• Patients having difficulty discussing certain issues may find email a way of beginning discussions (though encouraging patient confidence would eventually need to be addressed).


• May promote ruminating through overuse.

• Patient distress may increase if there is no response or the response is felt to be inadequate.

• Patient may become overly attached to the therapist.

• Information may be misinterpreted.

Email can provide some support to patients in special circumstance and I certainly not opposed to its use. However, as in structured DBT strategies, boundaries as to content and frequency of such communication (as well as whether or not a reply can be expected) need to be well defined.

There are many private companies that offer email-counselling. I am wary of these. Certainly, as a one time effort to gain assistance with a situation, this may prove affective. But as a long-term therapy, I would not recommend it. Another, free, option which may prove beneficial to the same situations would be to join an online discussion group.

A newer area of internet interpersonal accessibility is through blogs. Patients have blogs and therapists have blogs. Patients Google their therapists (therapists probably do not do the same). A therapist may develop a blog in order to make extra information available, should anyone be looking for it. Yet, they have to know that patients will probably use the anonymous comments function to interact with them.

So, I suppose the ethical questions here are:

1. Should therapists publish a blog under their own name?
2. Should therapists advertise their blog to patients?
3. Should therapists publish anonymous comments?
4. If a therapist suspects a patient of abusing the forum, should they confront that patient?

I may discuss this in more detail in a later, “Is It OK…” entry, but for now here are my short answers:

1. Everyone is aware of the accessibility of information on the interwebs. So, if a therapist publishes a blog under their own name, they should do so with the full expectation that patients will be reading it and therefore ensure that the content is appropriate for that audience. If the therapist wishes to discuss more sensitive subjects or if they want to remain anonymous, then they should publish under a pseudonym.

2. This depends on the content of the blog. If it is primarily worksheets and therapy strategies, it could provide a useful, impersonal, resource to patients. If the blog is opinion based and not directly relevant to treatment, such advertisements may weigh in on the narcissistic side.

3. As long as the comments are not-offensive and are related to the article, sure.

4. Of course. Tactfully. Therapy is a place to practice interpersonal skills and is (or should be) a safe place to confront awkward issues.

Tuesday, September 8, 2009

Typical Antipsychotics

As per the name, antipsychotics are used to treat psychosis, most commonly in schizophrenia though other disorders may also feature psychotic symptoms. Due to their sedative and tranquilising effects, antipsychotics may also be used as a mood stabiliser, anxiolytic, or sleep aid. The two types of antipsychotic are typical and atypical.

Typical antipsychotics (first generation antipsychotics, conventional antipsychotics, classical neuroleptics, or major tranquilizers) are older medications, developed in the 1950’s.

Types of typical antipsychotics:
• Chlorpromazine (Largactil, Thorazine)
• Fluphenazine (Prolixin)
• Haloperidol (Haldol, Serenace)
• Molindone
• Thiothixene (Navane)
• Thioridazine (Mellaril)
• Trifluoperazine (Stelazine)
• Loxapine (Loxapac, Loxitane)
• Perphenazine
• Prochlorperazine (Compazine, Buccastem, Stemetil)
• Pimozide (Orap)
• Zuclopenthixol (Clopixol)

Side effects include dry mouth, muscle soreness, tremors, and weight gain. Extrapyramidal side effects (EPS) are also common and include akathisia (restlessness), parkinsonism (tremor, hypokinesia), and dystonias (repetitive movements, abnormal posture). EPS can be treated with certain anticholinergics.

A more serious, possibly reversible, side effect is tardive dyskinesia in which involuntary, repetitive movements occur. Tardive dyskinesia usually develops with chronic antipsychotic use and may remiss upon discontinuation.

Depot injections (decanoate salts or ester forms of medications which have consistent, long-term release) of some typical antipsychotics may be used in cases where non-compliance is an issue. Common depots include haloperidol, fluphenazine, flupentixol and zuclopenthixol.

Thursday, September 3, 2009

Atypical Antipsychotics

As per the name, antipsychotics are used to treat psychosis, most commonly in schizophrenia though other disorders may also feature psychotic symptoms. Due to their sedative and tranquilising effects, antipsychotics may also be used as a mood stabiliser, anxiolytic, or sleep aid. The two types of antipsychotic are typical and atypical.

Atypical (second generation) antipsychotics are the newer variety.

Types of atypical antipsychotics:

• Amisulpride (Solian)
• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Clozapine (Clozaril, Leponex, Fazaclo, Froidir, Denzapine, Zaponex, Klozapol, Clopine)
• Iloperidone (Fanapt, Fanapta, Zomaril)
• Melperone (Buronil, Burnil, Eunerpan)
• Olanzapine (Zyprexa, Zyprexa Zydis, Zalasta, Zolafren, Olzapin, Rexapin, Symbyax)
• Paliperidone (Invega)
• Perospirone (Lullan)
• Quetiapine (Seroquel, Ketipinor)
• Risperidone (Risperdal, Ridal, Sizodon, Riscalin, Rispolept, Belivon, Rispen)
• Sertindole (Serdolect, Serlect)
• Sulpiride (Meresa, Sulpirid, Bosnyl, Dogmatil, Eglonyl, Sulpiryd)
• Ziprasidone (Geodon, Zeldox)

Atypicals are a common first line of treatment because of the reported decrease of extrapyramidal side effects (EPS), which though still occurs, appears to be attenuated. Research is still being conducted on the long-term effects of atypicals and tardive dyskinesia (a common and serious side effect with typical antipsychotics).

Other side effects include weight gain, diabetes mellitus, hyperlipidemia, myocarditis, sexual dysfunction, cataract, somnolence, and syncope.

Elderly patients with dementia should not receive either olanzapine or risperidone because of an increased risk of stroke.

Atypicals have yet to be approved for use in paediatric patients. In the news recently was discussion of prescriptions of quetiapine for children. The case was argued that physicians shouldn’t be prescribing medications, and ones with serious side-effects at that, without having more knowledge about the subject. An argument I agree with, and yet research involving children is difficult to accomplish due to reservations and ethics.

References: 1