Saturday, February 28, 2009

Magnetic Seizure Therapy

This one is very similar to TMS, but is more focused on the targeted brain region avoiding regions such as the hippocampus which affect memory. A strong magnetic field (stronger than the one used in TMS) is used to induce an ECT-like seizure. Because the magnetic is field is so much greater, different, but similar, equipment is used than in TMS. MST is a procedure that requires anaesthesia (as with ECT). Preliminary research is saying that cognitive side effects in treated depressed patients are less impaired than when treated with ECT. Not a whole lot of research had been done in this area yet and is ongoing.

References: 1, 2, 3, 4

Thursday, February 26, 2009

Science Playing Cards


When I was doing my undergrad degree, there was a common room where physics students could hang out. The room had a microwave, leather sofas, a study area, a foosball table…the essentials. And 86% (+/- 2%) of the time, you could find a game of Hearts being played.

And I have found (from physics and physicists blog) out that the American Institute of Physics has decks of cards with physicists on them for sale. There are two decks, a historic deck with physicists pre 1960 and a modern deck. Each deck can be purchased with (or without) a companion biographical booklet.

Educational Learning Games has a scientist deck.

For biologists, Educational Innovations has a bone deck.

For the chemists out there, I also found a periodic table deck at Amazon.

Amazon (and eBay) have a couple of Buffy decks.

Brian Berg is a famous card sculptor, and engineer, with one of his structures reaching a height of 25ft. And, all of his constructs are done without glue, bending, folding, taping, or modifying at all the cards he uses. Once again, the world is a cooler place because of physics.

PS - If anybody finds a 52 card deck with Summer Glau, let me know.

Monday, February 23, 2009

Helping Someone With a Psychiatric Disorder


This is another long one, but while all of this information is out there on the interweb, I didn't come across one site that had all the information in one place. So here is my extensive list of tips of how you can help someone you know cope with their mental illness:

Assure them you are there for them if they need you. It might seem obvious and trite, and they may never take you up on your offer, but knowing there are people who care about them can offer great relief.
• "You don't have to go through this alone. I'm here if you need me."
• “You can call anytime you feel like talking.”

Learn about their illness so you can better understand what they are going through.
• Mental illnesses are biological, directly affecting brain function, making it difficult or impossible at times for the person to think, reason, feel, or relate to others in a predictable, normal way.
• Educate others in the family and social circle as well. Remember to also inform any children of what is happening.
• Use this as an opportunity to increase self-awareness, sensitivity, empathy, and maturity.
• Avoid being judgmental. Don’t say, “You need to stop drinking. That’s why you’re doing stupid things.” Instead say, “If you ever want to stop drinking, I’ll do what I can to help.”

Engage them in conversation and listen attentively.
• Remain calm even though they may be experiencing distress. If they are feeling afraid, it doesn’t help if you get caught up in their emotions (folie a deux). Try to find out what the problem is in a non-threatening manner.
• They may experience delusions or hallucinations, but they still need to communicate their experience. However, do not pretend that you believe the delusion is real while at the same time do not discredit them. Just listen and ensure them that they are safe. Over time, treatment will help with symptoms.
• Generally speaking, you shouldn’t ever laugh at their feelings or delusions. However (and I may be executed for saying this), sometimes they know their thoughts are irrational and a kind, quizzical, joke might not only bring them out of their delusion, but also help them laugh. “So, you think I don’t exist because the cat thought me up? Are you sure about that?” A caveat, this will strictly depend on both the individual and the circumstance. If you don’t have a joking relationship with them, now is not the time to start. As well, if humour has worked previously, but you find their agitation is increasing, don’t keep making fun of them.
• Ask them what they need and be patient if they have a difficult time communicating those needs to you. There may be paranoia, confusion, or cognitive defects that make simple things extremely difficult. By talking openly, you are letting the person know you care about them.
• Talk about what you have learned about their disorder and ask how they feel about it.

Help them laugh. There will be times when they won’t be able to laugh and times when they are angry at you believing you are trying to make light of their situation. Remember that this is a part of their illness; they are not being mean on purpose.
• Do something silly.
• Send them a funny comic or article.
• Watch a funny movie or tv show.

Encourage exercise and motivate them by participating if you can.
• Take them out for a walk or hike.
• Encourage them into activities they used to enjoy; dance, sports.
• Go horseback riding.

Encourage other activities.
• Take them to the movies or a concert.
• Encourage them to participate in hobbies they used to enjoy or volunteering.
• Reminders for something as simple as bathing or washing dishes can also be helpful.

Do not be discouraged when your efforts do not take immediate effect.
• Be patient. Despite your best efforts, they may not improve as quickly as you would like and they will quite likely relapse.
• Relax your expectations and remind yourself it is an illness.
• Remember you cannot cure a biological illness with only talk.

Do not put too many demands on them, but also don’t let them let their illness control their lives.
• Allow them to have their personal space. Sometimes a person needs to be alone without having to feel obligated or pressured to be and act a certain way.
• If they say they are unable to do something, respect that.
• Do not pressure them into what you think they should be able to do. Medications might mean they can’t drink alcohol, and though you shouldn’t be pressuring them into a blitz, also don’t nag them to “just have one.” This will not only make them physically ill, but they will also feel as if they are falling short in their social obligations.


Offer practical support.
• Help with household chores like laundry or dishes. A clean house can have a positive impact on their mood, yet they may not be able to carry out these tasks themselves.
• Cook them a meal, or meals for the week they can freeze. Appetite in psychiatric disorders can vary from eating too much to not being hungry at all. Nutrition is very important. If healthy meals are at hand, they will be more likely to eat and to eat healthily.
• Offer to baby-sit, drive them places, or pick up groceries.

Assist with medical needs.
• Encourage them to attend therapy and regular visits with their doctor.
• Encourage them to take their medication and help them organise and keep track of their medications. If they need it, you can organise their medications in a daily container available at pharmacies or you can as the pharmacist to package their medications in a blister pack.
• Help them identify their symptoms. Often times with a chronic illness, the person is not aware of how their behaviours and moods are interfering with their life because it’s all they’ve ever known. As well, depression overshadows the good they’ve enjoyed and they might remember events as unhappy despite how they felt at the time.
• Medical professionals vary in their competence; if you feel one treatment isn’t working discuss this with your loved one, but do not force them unless you think they are in danger. Recovery takes time and the process might make things seem worse at first.
• Make sure they are getting their vitamins. Omega 3 fatty acids from fish or flax oils have been reported to have an affect on mood stability. Insufficient vitamins C and D and magnesium have been shown to have adverse affects on depression. It is also possible that magnesium might have sedation effects and may help temper manic episodes.

Do not ignore the severity the condition may take.
• Help them organise a crisis plan; make a list of numbers they can call and other things they can do besides hurt themselves. Remind them that they can always go to the hospital emergency if they need to. Let them know they can call you.
• Keep the crisis plan somewhere visible. Put it in writing or type it up and post it on the fridge.
• Keep a no-harm contract with them. Put the contract in writing and have both of you sign it. Let them know if they break the contract they will have to donate money to charity or accompany you for coffee. Whatever you decide on, do not make the contract breaking event a punishment, keep it positive.
• Don’t be afraid to ask them if they are having suicidal thoughts and seek professional help if they need it.
• If a manic person is engaging is risky behaviour, let them know you are concerned.

Acknowledge their work and progress.
• Let them know you are aware of the courage and effort they are putting into their recovery and that you are glad to see them working towards getting better.
• Point out their accomplishments; “You are smiling so much today.” “I think it’s great you’ve decided to start drawing again. You’re so good at.”
• Recognise their individuality and support their autonomy. There will be times when they need your help and times when they don’t and you need to back off a bit and let them learn how to cope and take care of themselves.


Take care of yourself. Especially if you are a child of a parent with a mental illness. There may be extra responsibilities put on you, but you have to ensure you are taken care of first.
• Spend time with people whose company you enjoy and do things you like to do.
• Take some time off if you feel yourself getting caught up in their illness or becoming too stressed.
• Talk to others who are going through the same thing, either in person or online.
• Read about how others have coped.
• Seek therapy yourself with a counsellor or in a support group.
• You are not their doctor or therapist. Continue in your usual role in the relationship. Set boundaries if you need to, but make sure you communicate this clearly to them so that they will not be confused. If they are bipolar, for example, you may want to set a rule that they are not allowed to call you after 2am. Also remind them of other available resources for when they can’t come to you.
• Ensure other family members are not being neglected.
• Do not allow their illness to interfere with your school work.

Give physical attention.
• Hug them, hold their hand, rub their back; compassionate touch is very therapeutic.


This is an extensive list, but by no means complete. Each different disorder and each different individual will require different approaches. The most important thing is to be kind. And keep in mind the person you care about is always living with themselves and their illness. Therapy, medications, and concerned family members are all reminders of their illness. If you find yourself becoming tired and stressed dealing with their illness, imagine what they must be going through. Try not to put the focus on the illness.

Instead, help give them a break from being in their head by bringing them out into your world. Don’t feel guilty if you want to talk about your problems and joys. Much of the time it is a reprieve for the other person to not have to think about their own issues. As well, if they feel they have helped you in some way, you have given them a positive and meaningful experience, and that is exactly what they need more of. Support them in their autonomy.

Resources:

The North Shore Schizophrenia Society offers programs and services for family members struggling to care for a mentally ill relative. Located in Ambleside Village in West Vancouver, 205 - 1865 Marine Drive. info@northshoreschizophrenia.org. 604-926-0856.

A comprehensive list of resources in the Vancouver area.

The FORCE society is a Langley support group for parents of children with a mental illness.

Kids in Control is a psychoeducational group for children ages eight to 13. The eight-week group helps children understand their parents’ mental illness and learn how to take care of themselves. For more information contact the BC Schizophrenia Society at 604-270-7841 or 1-888-888-0029.

Here to Help is a collection of BC mental health organisations. Their site has lots of info, toolkits, and fact sheets.

Explaining depression to children.

Tips for youth of parents with a mental illness.

Sunday, February 22, 2009

Caveman vs. Astronaut


If a caveman and an astronaut got into a fight, who would win? If you have ever watched Angel you know how important this question is.

At any rate, once the declaration was made that the astronauts don’t have weapons, I began to wonder how it was anyone would think they stood a chance in a fight.

An astronaut is anyone who travels into space professionally. So if the astronaut in the fight was also a professional kung-fu master, I would say he stands a fair chance against the caveman. If the astronaut is a normal type person and the caveman is an atrophied, lazy chief, the astronaut again probably has the advantage. If the astronaut is military trained, as some are, hands down the astronaut will win.

An astronaut pilot needs to have a degree in science (physics, math, engineering, biology), giving him a clear mental advantage over the caveman. The question does not stipulate whether there are other materials besides weapons around, but if there are, the astronaut could, in theory, build the same weapons as a caveman. But the caveman has been making these things his whole life; he knows what kinds of rocks make the best spears and how the trajectory never quite goes according to simple physics. Here, the astronauts education would be a disadvantage. But if the astronaut can see the caveman, he should be able to copy him well enough so that now we have both the caveman and astronaut with the same weapons, but like I said the caveman know how to use them better. And weapons aren’t technically allowed in this debate anyway.

I’m still going to say the caveman would win. He is trained to fight and kill whereas the astronaut is trained to do math. And only River Tam can kill people with her brain. And Fred Burkle, the scientist who loses her fight against an ancient and primitive being, agrees – “Cavemen win. Of course the cavemen win.”

Caveman vs. Zombie, now that would be a fair fight. And Puppet vs. Vampire, apparently.

Saturday, February 21, 2009

Mental Health Treatment

I attended a conference yesterday on mental health issues in youth (which are applicable to adults as well), and thought I would share some of what I learned. Or my opinion on what was being said, at least.

Firstly, I found it refreshing to hear speakers from all different areas in mental health work including community based shelters (Covenant House), psychiatrists, and public relations, emphasising the need to recognise that individuals with a mental illness are not behaviourally dysfunctional or purposely defiant, but they are actually ill. The importance of this recognition comes in when anyone wants to help a person who is mentally ill as it requires a different approach than trying to reprimand or criticise atypical behaviours. Instead, one has to accept the difficulties of the illness, for both the helper and the helpee, in order to best structure a treatment plan. Specifically, the therapist needs to be tolerant of the patient’s relapses (substance use, self harm) and expressions of individuality (and I think this can be extended to separation behaviours that youth need to go through) such as non-compliance, rudeness, and missed appointments.

One point that was made at the conference regarding programs for the mentally ill, and which I think should and can be extended to include therapists (because let’s face it, they’re not all as understanding as they should be), is a certain amount of discrimination about who gets into the programs. The specific example was that many individuals who have substance use issues will not be accepted into a program until they have cleaned themselves up. The speaker’s opinion on this was that what we are saying is that we are not willing to treat you until you are better. So, those in most need of help are being neglected.

You see this in other areas as well. If anyone has tried to get a referral to see a psychiatrist, you know how difficult it can be. On the opposite end of the scale, when an individual is seeking help and they hear that they can’t get it and unless they are more sick, this might encourage the person to make themselves more unwell in order to get the attention and treatment they require. Even though depression is prevalent (23% of approved CPP disability claims in 2000 were attributable to "mental disorders" compared to 12% in 1990) and causes significant work loss (89% of people say stress related mental health issues have affected their work and an average of 40 days/year where they were unable to work) treatment is greatly under-resourced. Especially when you consider that almost ¾ of mental disorders begin before 24 years old, that suicide is the second leading cause of youth aged 10 – 24, and that depression is treatable.

For those who seek and find help, we are seeing that therapists and other helpers are discovering that validation and autonomy are practices that work best. While there are aspects of some disorders, especially for those who have had a chronic illness and never learned other behaviours, people generally know what they want and need to change in order to achieve their goals. So instead of pedagogically stating the obvious (‘you need to stop shooting heroin’), we need to accept the patient as an individual and let them come to the decision to stop on their own, because they will and they will feel more powerful for owing this decision and their recovery.

An aspect in treating substance use disorders which one psychiatrist applies to his practice is that he informs the patient that as long as they don’t use anymore than what they are currently using, the two of them can work together. And he seemed to find that even during the first week (though he didn’t state how people coped with the decrease of their addiction later), people would actually use less, and they did it on their own.

We can have programs with their associated mandates and protocols, but it is the people who are working with those with psychiatric conditions by their involvement with the individual (in a formal session or an informal session where the therapist buys them a sandwich) and meeting them at their level respecting the burden of the illness, who make the programs work. This is the major responsibility of the therapist.

Resources:

If you are a youth in need of shelter or any other assistance.

References: 1

Wednesday, February 18, 2009

TMS

There are two types of TMS, one delivers a single pulse of current/magnetic field and the other delivers a repetitive series of pulses (rTMS). Usually, rTMS is used for psychiatric purposes. A physical difficulty with TMS is targeting specific areas of the brain with a specific intensity. The strength of the field that reaches the brain is affected by skull thickness, distance of the coils, and shape and number of coils. The coils come in two varieties, circular and figure-eight shaped (the figure-eight allows for more specific targeting).


A current is generated in the coils of the device. This current generates a magnetic field (magnetic flux) oriented perpendicular to the coil (towards the head). The magnetic field passes through to the brain where a current opposite in direction to the stimulus occurs.

For a moving point charge q travelling at velocity v a magnetic field B is given by:


where µ0 is the permeability of free space constant.

For a current in a loop, the magnetic field is:

where R is the radius of the loop. (This equation is the Biot-Savart Law).

And (thank-you Faraday) if the strength of the magnetic flux bounded by a circuit (here, the neural network) varies, a current in the circuit which is opposite to the original current (perpendicular to the magnetic field) will be induced. How fun is that? God, I love physics.





where ф is the magnetic flux, A is the area of the circuit, and ɛ is the generated EMF.

Obviously, metal objects must be removed before TMS is started and people with non-removable implants such as pacemakers would be excluded from this treatment.

The benefit of TMS over ECT is that magnetic fields travel through body tissue without losing energy and magnetic stimulation does produce any heat or pain (because there is no loss of energy which causes things like heat and light). As well, it appears that the memory problems of ECT do not occur with TMS (there is some memory dysfunction, but this returns to normal, or near normal, more quickly).

One of the major risks of TMS is seizure. Other side effects include temporary hearing loss (from the sound of the apparatus) and headache.

In terms of psychiatric applications, studies are still relatively new and have the difficulty of not having a placebo control group. From my knowledge (and this lecture was given last year), TMS appeared to be no more beneficial than pharmacological treatment. To me, this doesn’t mean much because of each individual’s response to different treatments. Compared to ECT, preliminary results suggest TMS is less effective, but there are other contradictory reports, as well as evidence that both methods are about the same in terms of effect.

New research is being done on BP depression, with the same limitations as all the other studies, but again, results look promising.

Last year, a study was published that demonstrated rTMS had a positive impact on bulimia nervosa patients. This was attributed to the fact that bulimia and depression both have serotonin defects and that bulimia can also be treated with antidepressants.

Research is just starting on the effectiveness of rTMS for anxiety disorders, but preliminary research (and this is very preliminary) suggests there might be some positive effect.

There are also trials being conducted in the schizophrenic population.

Relapse does occur and, as with ECT, maintenance rTMS is recommended. Long term effects are unknown.

References: 1, 2, 3, 4, 5

Not Your Grandma's ECT

ECT started back in the 1930’s as an alternative to medication induced seizures. The type of current generated then was sinusoidal whereas now physicians use a brief pulse of constant current (to reduce side effects). For the following two decades the procedure was carried out without the use of muscle relaxants resulting in injury caused by the convulsions associated with seizure.

How It Works

ECT may be given as either inpatient or outpatient treatment. The patient is anaesthetised and given a muscle relaxant to prevent injury during the process. Electrodes are placed on the scalp either on both sides of the head (bilateral ECT) or with both electrodes on the non-dominant side of the head (unilateral ECT). A current is administered for a few seconds to induce seizure. The strength of the current and the length of time the current is applied also vary depending on the history of the individual. For bilateral ECT currents are given at 1.5 times the patient’s seizure threshold and for unilateral ECT the currents can be up to 12 times the threshold.

In depressed and/or psychotic patients, the anterior cingulated cortex (ACC, Brodmann area 25) shows decreased theta band activity. Theta rhythms occur with the hippocampus and function in memory and voluntary behaviour. Response to ECT in patients with psychotic symptoms is related to increased theta band activity.

Who Receives It

ECT is used in people with depression, schizophrenia, and mania who do not respond to medications (Treatment resistance can be defined as low as two different types of medication, but given the variability of individual response to the many antidepressants available, as well as long term psychotherapy, I think this number should be closer to four). It is also used in the geriatric community and in pregnant women where medication is not an option. Additionally, it is used to treat psychiatric side effects of dopamine in people with Parkinson’s disease and to treat pain in factitious disorders.
Because results can sometimes be seen within two weeks, ECT may be used in severely affected people where waiting for the medication to, maybe, take effect isn’t desirable.

In depressed patients, unilateral ECT appears to have a slight advantage over bilateral ECT in that patients respond to it with a fewer number of treatments. One study demonstrated that manic patients responded more quickly to bifrontal ECT than to bitemporal treatment, with comparable post-ECT cognitive function.

Side Effects

Side effects include memory loss, confusion, disorientation, delirium, and transient amnesia. Though memory dysfunction is the side effect causing the most concern, reports vary on the severity and tolerability of the effect. Neurobiologically, the memory loss associated with ECT is related to a decrease in hippocampal volume (the hippocampus is an area of the brain that functions particularly in short-term memory and the formation of new memories. Damage to the hippocampus can also affect access to previously formed memories. These two memory dysfunctions are termed anterograde and retrograde amnesia, respectively.). Evidence suggests that bilateral ECT produced greater memory dysfunction and the time to return to regular memory processing was greater than in unilateral ECT.

Generally, memory function returns to normal within a few months of treatment though there are patients who report noticeable dysfunction years after the ECT. Whether these memory problems are associated with reoccurring depression (as depression is itself associated with decreased memory ability and subjective reports of cognitive function is lower in depressed patients) is debatable. Interestingly, though memory deficits definitely occur post treatment, subjective reports of those who responded to ECT were that they experienced no difference in their memory.

Other side effects include muscle tension, headache, and nausea.

A high number of patients do relapse after treatment. Therefore, maintenance treatments of psychotherapy, pharmacotherapy, and further ECT treatments are necessary.

Because of the associated memory dysfunction during treatment, it is advisable that post-treatment measures to help function during this time be set up beforehand. Depending on the person’s cognitive abilities, things like notes and lists may need to be made to assist with daily function. Some may want to record upcoming events in a calendar before their ECT. Others may want to set up a therapeutic network of family, friends, and therapist to assist with decision making and for emotional support during treatment. It may also be helpful to keep a daily record after treatment to help with short-term memory dysfunction.

Dr Shock’s stance is that ECT causes no clinically significant cognitive deficits and there are many studies supporting this. However, from the papers I have reviewed, cognitive assessments were done within weeks or months of treatment. As well, there are studies demonstrating persistent memory dysfunction and, of course, personal stories of severe adverse affects.

That’s all fine and dandy and the benefit certainly makes the risks more tolerable, but what if you’re a scientist or a literary professional where your life is centred around your cognitive abilities? Some people say that their cognitive impairment was so great, they were unable to return to work. Others say that impairments and lost knowledge were regained through practice and study. Brain exercises such as number games, crossword puzzles, math exercises, statistical mechanics (ok, maybe not that last one) may aid in redeveloping neural networks. Yet, impairment can persist to the point where cognitive abilities are never fully recovered and there are many stories of scientists and other workers who have had to give up their careers. For some people, living without depression is well worth having to use a calculator to do math and spending an extra two hours to write a short letter to a friend.


My advice – do a very serious, as objectively as possible, risk-benefit analysis of your situation before entering into ECT. How severe are your symptoms? If you are suicidal, how often do you self-injure/attempt and how serious are the consequences of this behaviour? How important are your memories to you (some people are glad to have lost the memories of their suffering, but miss memories like raising children or being with friends)? How important is it to you to retain new information (are you comfortable being dependent on others for reminders, do you have a strong network for support)? How much of your life/joy/ambition is dependent upon cognition and memory? How much time can you take off from work while your memory returns? Have you exhausted all other treatments? Is your illness preventing you from working?

It’s difficult to say much from personal stories without more information on what type of ECT they had done and how it was performed, but the stories do exist which means these problems are real. But there are also many success stories where people have undergone ECT and not only been relieved of their debilitating depression, but also retain their d=cognitive abilities and go on to graduate school and other professions. This may be things they would have accomplished without ECT, but it may also be that their illness would have interfered with goal setting/achieving, and with ECT they not only were able to accomplish their goals but did so without the weight of depression.

New alternatives to ECT include magnetic seizure therapy (MST), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). I will report on these in the coming weeks.

I am including here one person’s personal story of how ECT has helped him, not because of any bias of mine (ECT like any psychiatric treatment depends highly on the individual), but because the author does a wonderful job of narrating his experience with depression and with ECT. It is actually very well balanced; he doesn’t over-emphasise the good without mentioning the bad. But my reason for including it is because I think it is important for anyone suffering from what seems like an endless illness, that things can and do get better. For those with treatment resistant illnesses, this hoping and believing is probably the hardest thing to do, but there are people out there who have been in it and come out to live better lives. If something isn’t working for you, don’t give up, keep trying.

References: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10

Sunday, February 15, 2009

Tracking Your Moods With a Mood Diary

An important step in changing your mood is understanding it and recognising patterns and events that affect your emotions. There are many exercises out there to help with tracking and changing moods. Here, I am only going to explain one of the simplest. Because starting any therapy is difficult when you are depressed/manic, these easy mood diary can help get you started on designing a treatment plan. For those with severe mood disorders, these charts should be reviewed regularly (weekly if possible) with your doctor or therapist. There may be things that are difficult for a person in distress to recognise, while someone who is trained to look for certain patterns might have an easier time in helping you identify what is working and what isn’t.


The design of each diary listed here is basically the same. Each has a section where you rate your mood for the day as well as record any medications you took and how much you slept. The only real difference between the different diaries is aesthetics, so choose whichever one is easiest for you to fill in.


Try to set aside a few minutes at the end of the day to complete the diary. You don’t need a lot of time, nor should you spend your pre-bedtime evening ruminating about any stressful events that occurred during the day. This is simply a mood tracker, not a mood changer.


You will notice the diary has a small space on it for daily notes to record any significant events. Do not try to over-analyse these events. Keep it simple using the space provided. Your therapist may have you working on other exercises as well, or you may be keeping a personal journal, but for this exercise try to keep things simple. I know this isn’t easy; emotions don’t rate on a scale of 1-10 and sometimes there are combinations of events that lead to a specific feeling or action, but try to record what YOU think is most relevant. Again, this doesn’t mean you have to limit how you describe how you feel in other areas (writing, talking to friends or a therapist), it’s just for this particular work.


For women, if the chart type you choose to use does not include an area for recording your menstrual cycle, you should add in an extra line for this.


The major benefit of this simple, small task is getting a more subjective view of your moods. Depression can be so strong that it overshadows any times when you were feeling better. It is not uncommon for those with depression to perceive their depression as being constant. This chart can help show you that there are variations in your mood. For very severe depression, this might not be evident right away, so don’t be discouraged, but with regular therapy and/or medication you will start to see some changes. Even if these changes are small, it means THINGS CAN CHANGE.


Each of these charts allows for recording more than one mood during the day if you find your moods are cyclic, which they can be in bipolar disorders. If you rapid cycle, a slightly different approach would be to use arrows on calendar to rate your mood as it changes (see below for an example). It is still important to fill out the mood diary though, recording your most intense manic and depressive episodes for the day.



Chart for recording cyclic moods. The direction of the arrow indicates type of mood; an up arrow indicates positive/manic moods and a down arrow indicates low/depressed moods. The length of the arrow indicates the strength of the mood with longer arrows indicating a more intense mood.


Another way of recording moods in more detail is with an hourly chart rating your mood on a scale of 0 – 10 (with 0 being no depression and 10 being severely depressed). For bipolar moods, I suggest having a scale that ranges from -10 – 10 (with -10 being severely depressed, 0 being no symptoms and 10 being severely manic). What I like about this type of monitoring is that it can give a better idea of how small activities during the day (unlike the one major event recorded in the previous charts) can influence your mood. One drawback of this type of monitoring is that some activities do not have an immediate effect which can lead to some misinterpretation of how the event is affecting your mood, e.g. If you eat breakfast when you wake up at 9am and you have a tendency to feel more depressed first thing in the morning, you might think that eating has no positive influence on your mood. However, during the next hour, your mood will most likely be higher.



TIME

MOOD

ACTIVITY

7AM

-3

Wake, shower, breakfast(cereal)

8AM

0

Watch tv

9AM

2

Go for walk, coffee

10AM

5

Couldn't concentrate on work, watched tv



A slightly more detailed version of the above is to include two more categories, mastery and pleasure. Mastery indicates your sense of achievement at completing the task of the hour in relation to your mood and Pleasure indicates how much you enjoyed the activity.


When recording pleasure in any of these diaries, the scale I suggest using is 0 – 10 (with 1 being no pleasure, 10 being very pleasurable, and 0 being bored). The reason I think it’s important to include boredom in monitoring activities is because it is a feeling that is extremely important, especially in personality disorders which often co-occur with mood disorders, yet it doesn’t fit on the typical scales.


TIME

MOOD

ACTIVITY

MASTERY

PLEASURE

7AM

-3

Wake, shower, breakfast(cereal)

7

2

8AM

0

Watch tv

0

0

9AM

2

Go for walk, coffee

4

7

10AM

5

Couldn't concentrate on work, watched tv

0

0


For geeks like me, or for those who think more visually, graphing how your moods rated during the week/month might be something you want to do.


Also, just ignore any pharmaceutical advertising.


Mood Diary 1 (My Design)

Mood Diary 2 (PDF)



Saturday, February 14, 2009

The Science of Love and Hate

For all of those who believe love and hate are the same thing, they’re not. Love and hate, in two fMRI studies done, showed distinct neural networks.

Hate was actively visualised in the insula, premotor cortex, putamen, and frontal medial gyrus while the superior frontal gyrus showed deactivation.

Interestingly, there was no activation in the amygdala, an area associated with instinct and emotional memory and learning. As well, the hippocampus, an area involved in forming new memories, showed no activity. And well there was no visualisation of activity in the amygdala, this region is functionally connected with the insular cortex which did show activation.

The insula is involved with emotions of anger, fear, disgust, happiness and sadness. Interestingly, it is also associated with pain. So while such emotions may be stored in the instinctual amygdala, hate, like pain, is not remembered as evidenced by the inactivity of the hippocampus. Environmental and cultural influences which play a role in types of hate such as racial prejudices can as such become a default response to emotional stimuli. The insula, also showing brain activation with feelings of love, is also involved with addiction.

The amygdala did appear in association with love, but as a deactivation. A recent study suggests that impaired amygdala function corresponds with reduced (emotional) pain sensitivity, thereby suggesting that when painful stressors occur within the context of love, we feel them less than we would otherwise.

Also showing de-activations in the love-brain were the prefrontal, parietal and middle temporal cortices. The authors cite an article demonstrating that de-activation of these areas is associated with happiness while activation is associated with depression. A different study claims the opposite:

"Sadness was accompanied by specific activations of the subgenual cingulate area (BA) 25 and dorsal insula, specific deactivation of the right prefrontal cortex BA 9, and more prominent deactivation of the posterior parietal cortex BAs 40/7. Anxiety was associated with specific activations of the ventral insula, the orbitofrontal and anterior temporal cortices, specific deactivation of parahippocampal gyri, and more prominent deactivation of the inferior temporal cortex BAs 20/37".

Another study demonstrates “disgust and happiness imagery provoked activation of the insula, anterior cingulate cortex, and parietal cortex. Trait disgust was negatively correlated with localized brain activation (e.g. insula, amygdala, parietal cortex, anterior cingulate cortex) during disgust imagery.” With all the studies being done on happiness and sadness, there is much contradiction in the results. This is not surprising given the complexity of and variety within such emotions.

The other brain area love shares with hate is the putamen. The putamen functions in motor activity as well as memory, specifically implicit and reinforcement learning. Therefore, the more you are exposed to feelings of love or hate, the more likely you are to develop these feelings more deeply. This explains the we-covet-what-we-see-everyday and let’s-be-friends-if-you-don’t-like-me-now-because-eventaully-you-will strategies to courtship.

Another area imaged with feelings of love is the anterior cingulate cortex (ACC) which functions in autonomic functions (heart rate, blood pressure), conscious emotional awareness, reward-based learning, and empathy. The caudate nucleus (also seen in love) shares some similar functions with the ACC in the role of learning. Additionally, a dysfunctional caudate nucleus is associated with obsessive-compulsive disorder.

Also interesting is that disgust is associated with love. And isn’t this so very true? The exchange of bodily fluids, not liking the way a particular part of their body looks, being annoyed with their mannerisms, pretending to care when you actually don’t because it’s socially expected. This could also explain how we becoming blinded by love (or hate). Not wanting to admit to either ourselves or the object of our affections (dislike) that they fall short of our expectations and desires (or that they exceed contradict our feelings of hate), we reinforce the deep and passive learning of the emotion.

Euphoria inducing drugs activated the same regions as those in the love study suggesting love being an euphoric state. The authors also found that sexual arousal differed neurologically from love, though the regions of the brain activated in arousal were adjacent to those activated in love. Also, the feeling of love is very specific with only a few, well defined areas in the brain showing activations and deactivations.

An fMRI study of your brain before entering into marriage would be an interesting way of determining whether or not you are really in love.

Following is a formula I developed to rate the probability you are in love:

PL= ∫0 →t [(N(t)-U(t))(H) + d/SG]

= ∫0 →t[(N-(D+P))(H) + d/SG]

(where t=length of relationship)



N(t) = Need = (Tothers/Talone)(A)

A=Your age, Tothers=Time spent with others (besides your partner) during course of relationship, Talone=Time spent alone during course of relationship


U(t) = Unhappiness = D(t)+P(t)

D=Time spent disgusted with other person, P=Time spent in pain caused by other person.


H(t) = Happiness = h(t)/s(t)(X+I)

h(t) = #happy days during time together, s(t) = #sad days during time together


X = Sex = (#times sex was good/#times sex was bad) + (#times sex was adequate)/2


I = Income (of partner) = (actual income/desired income)


D = # digits of pi your partner can recite


SG = # of episodes of Summer Glau tv you have watched



For other relationship formulas check out this site and The Math of Love.

References: 1, 2, 3, 4

Friday, February 13, 2009

The Anti-DSM Part 2 - The Good Side of Depression



This is my second instalment of Anti-DSM, this time focussing on depression.

A list of positive traits in depression:

1. Serves as a reminder that something is wrong.
2. Allows for serious self-reflection.
3. Gives the opportunity to recognise less healthy aspects of daily life in order to change them.
4. Gives your body and mind time to regain their strength to tackle stressful life situations.
5. Can lead to production of creative works.
6. Increases personal understanding of other people’s difficulties.
7. You can get lots of hugs.
8. Crying is physically good for you.
• The chemical composition of stress tears is different than that of non-emotional tears. Since tears, in the non-emotional realm, serve to secrete toxins and protect the eye, it is hypothesised that stress tears which secrete hormones associated with sadness work by the same mechanism.
9. Eating more can be healthy.
10. Being angry can allow you to vent built up feelings.

After I wrote this, I googled ‘depression good’ and found an interesting article of the positive health aspects of depression to which the author adds that depression is an evolutionary positive trait. However, and I don’t like to dispute any positive points in these articles, I do disagree about the non-benefits of anti-depressants. While studies may show that they are not statistically more effective than placebo, it is very obviously clinically beneficial, it’s just that each individual person responds differently to different types of medications. If you are on medication and want to stop, please talk to your doctor before discontinuing. Even if the medications aren’t helping, some of them need to be discontinued slowly to avoid withdrawal symptoms.

Also, look at this article in the LA Times Opinion section exploring Keats’ view of melancholy and its positive aspects.

Resources:
(There are so many, I’m not going to list them…)

1 800 SUICIDE

Info on depression, symptoms, treatment.

References: 1

Thursday, February 12, 2009

Bipolar Disorder in Children and Adolescents

Bipolar disorder is notoriously difficult to diagnose and the diagnosis in youth isn’t any easier. However, there is importance in regarding a BP II or BP NOS diagnosis as preliminary since children falling into these categories are likely to develop BP I.

In comparing childhood and adolescent onset, a recent study showed that early onset BP was associated with more severe symptoms in adolescence. As well, children had a greater length of illness and greater mood lability. Suicidal behaviours including attempts, gestures, and ideations are common among the paediatric BP community.

Symptoms are similar to those in adults, though children tend to show more irritability than euphoria in manic episodes. Consequences of social factors, poor academic performance and leaving home, which do not apply to adults will also have severe impacts on later quality of life.

The two most common misdiagnoses are ADHD and schizophrenia. Particularly, the comorbidity of BP and ADHD increases the difficulty of diagnosis. There are five symptoms not overlapping with ADHD (uncomplicated) which are used to distinguish the two disorders in diagnosis. These five manic symptoms are elation, grandiosity, flight of ideas/racing thoughts, a decreased need for sleep, and hypersexuality (in the in absence of sexual abuse or overstimulation). Additionally, given the rapid-cycling nature of paediatric BP, the episodic manic states may help in differentiating from ADHD.

The differentiation of schizophrenia from psychotic depressive states is made by noting the affect of speech (which is more emotionally consistent in depression), presence of delusions (less likely in depression), and quality of delusions (mood consistent with depression),

Treatment

Medications used in the treatment of paediatric BP are the same as those used in the treatment of adult BD. However, pharmacotherapy in adolescents is an area that is still grossly under-researched.

As with adults, the use of anti-depressants can induce manic episodes. As well, treatment of misdiagnosed ADHD with stimulants can also worsen manic symptoms.

A recent study showed no difference in cognitive function between medicated and unmedicated manic BP adolescents and another study demonstrated good tolerance and quality of remission with quietipine.

It is important to continue pharmacotherapy even when symptoms improve because of the high rate of recurrence.

For non-pharmacological treatment, I think FFT-A (Family Focused Therapy for Adolescents) is especially important as children are not yet fully independent and the support of family can improve recovery significantly. However, participation of parental figures and other family members may not be possible because of, unfortunate, disinterest in the child’s health. Interpersonal Social Rhythm Therapy encourages the practice of daily routine and stable relationships. Other therapies (art, music, play, animal) can also be used to augment individual and family therapy.

Resources

1 800 SUICIDE

UBC has a site with a comprehensive list of resources available in Vancouver.

A U.S. self-help organization, The Child and Adolescent Bipolar Foundation, has a website for parents.

A non-profit source for bipolar disorder.

MySpace. Also has links to other resources.

References
1, 2, 3, 4, 5, 6, 7, 8

Wednesday, February 11, 2009

My DSM V Contribution

I wrote this a couple of years ago. A friend and I discovered we shared a common problem of having a house cat scent things like freshly-washed laundry and that we both found ourselves smelling our clothing in places like on the bus, getting us strange looks. The inspiration to write this came during a discussion we had at the opera about psychopaths. At the time I was reading the DSM casebook and so….

Urinophobia, Feline Type

The fear of having a cat urinate on your clothing, bedding, and/or furniture most typically as a result of forgetting to close a door (closet or room type). This phobia is often accompanied by an obsessive-compulsive behaviour of the subject to smell the articles of clothing they are wearing and this behaviour can be extended to other fabrics. This can lead to social exclusion as such behaviour may be regarded by others as odd. Non-bizarre delusions of being scented will often cause the subject to isolate themselves from contact with others in order to avoid embarrassment. At its most severe, and if the condition is prolonged, urinophobia may develop into antisocial personality disorder. Typically, the feline responsible for the onset of this disorder will be the first kill the subject engages in. However, the lingering smell of feline urine, which is nearly impossible to remove from fabrics, will cause the subject to believe they are still being victimized. As a result, the killings will escalate as the subject destroys any feline they encounter and believe responsible for present or future scentings. Human attacks are not uncommon if the subject feels another person is interfering with their need to murder cats. Subjects may experience financial difficulty as they feel the constant need to replace clothing and other fabrics. If bedding has been soiled, or is believed by the subject to have been soiled, subjects will often sleep without covers in order to distance themselves from the urine. There have been two documented cases of subjects dying of hypothermia as they attempted to sleep naked in the snow believing their entire mattress and bedding has been urinated on by a cat. (In one case, this was actually the circumstance. Although the subject lived alone without pets, his mattress had been purchased from an ad on a telephone pole offering used king-sized beds for fifty dollars). Treatment of urinophobia can be successfully achieved in 86% of cases through a combination of antipsychotic medication and cognitive behavioural therapy. Depending on the severity of the condition, subjects may require treatment for up to two years. 5-8% of recovered subjects will re-experience urinophobia, but remission times are greatly reduced (2-12 weeks) for subsequent occurrences of the disorder.

Tuesday, February 10, 2009

Favourite Fiction

If you need some quiet time after all that loud music, here are some of my favourite (non-psych) novels:

• Faust, Johann Wolfgang von Goethe
• Inferno, Dante Alighieri
• The Plague, Albert Camus
• The Curious Incident of the Dog in the Night-Time, Mark Haddon
• Shantaram, Gregory David Roberts
• The History of Love, Nicole Kraus
• My Sister’s Keeper, Jodi Picoult
• Watership Down, Richard Adams
• Great Apes, Will Self
• The Sun Also Rises, Ernest Hemingway
• The Wind-Up Bird Chronicle, Haruki Murakami
• The Miraculous Journey of Edward Tulane, Kate DiCamillo

The Benefits of Loud Music

There are times when listening to music at high volumes is beneficial. I would put those benefits into three categories – distraction, venting, and association, though all three occur together in varying degrees.

Loud music can be used by people suffering from physical pain as a pain management strategy. As well, loud music is sometimes used by schizophrenics to drown out the noise of hallucinations. (An interesting aside: decreased PPI (Prepulse inhibition – reduces the startle response of a stimulus) in schizophrenics is being used as a diagnostic tool and research area for understanding positive symptoms in schizophrenia.)

Loud music can also be invigorating, and even depressing songs can be uplifting. They may inspire a depressed person to sing/scream along or dance/jump/stomp to the beat, all of which are more motivating than lying in bed lamenting. Once you’re up and moving, even if all you are moving are your vocal cords as you scream along to an angry song, you will be that much closer to taking the next step to feeling better.

On lazy or lethargic days, it can help you get out of bed in the morning, as irritating as it might be at 7:30am. And it can make monotonous work, like chores or running Matlab scripts over and over again, more tolerable, fun even.

The benefits of loud music to social situations are a decrease of the stress of verbal communication and an increase in non-verbal communication (though admittedly, this can be stressful as well, but it still allows us to develop an under-appreciated, yet extremely important, method of communication). The increased awareness of the physical self can be beneficial in dissociative states of psychiatric illnesses. (This is something that can be practiced at any time, without loud music, but if you are out at a club dancing, allow yourself to be aware, without concentrating too hard, of all the sensations around you – your dance partner’s hand on your arm, the different colours of the flashing lights, the tempo of the song, the beads of sweat on the back of your neck… Trust me, if you get good at this kind of mindful perception, you won’t need alcohol or drugs. A caveat though, even though there are no chemical, toxic side effects like those of drugs, this kind of mindfulness can have upsetting ‘highs’ and ‘lows.’ If at any time, during any mindfulness exercise, you feel yourself losing control or becoming uncomfortable, stop and do something else.

At home, you can still have lots of fun and lots of sensory awareness dancing with your spouse, kids, friends, or by yourself.

On the distraction side of sociability, a set of headphones can give you sense of personal space in public areas like a crowded bus or it can replace the really bad music they play at stores making your shopping experience more enjoyable. Even without headphones, a decent set of speakers can drown out irritating external environmental noises like your roommate having loud, obnoxious sex…again or the stupid humming of your out-of-date-but-the-landlord-won’t-replace-it refrigerator.

There is some music – classical, opera – which just simply must be listened to at higher volumes in order to appreciate all of the artistic nuances and variations.

Obviously, too much loud music is physically damaging. Also, you adjust to the volume of the music you are listening to, so be careful to watch if you are continually turning up the volume of your speakers. Try to pick a volume that isn't too loud, before you've listened to anything for an extended period of time, and leave the volume adjustment at that level. Except, of course, when you want to bang-out the Pixies on air guitar.

(see here for comic alt text)

If you are looking for some new music to add to your playlist, here are a few of my favourite high energy songs:
• Guitar Hero, Amanda Palmer
• Trompe le Monde, The Pixies
• At the Bottom of Everything, Bright Eyes
• Girl Anachronism, The Dresden Dolls
• Jason’s Basement, The Gossip
• Rod Stewart, The Lovely Feathers (probably my long-time favourite for chaotic, living room dancing)
• The entire We Were Dead Before the Ship Even Sank album, Modest Mouse (especially for summer cruisin’)
• Dirty Town, Mother Mother
• Wraith Pinned to the Mist, Of Montreal
• You’re So Damn Hot, Ok Go
• The Arm, Islands