January 10, 2013

Antidepressant Medication

Filed under: anxiety disorder,decreased energy,depression,Frustration,guilt,helplessness,Restlessness,sadness,worthlessness — Tags: , , , , , , , , — admin @ 3:59 pm

As described previously, depression has neurovegetative signs. These include:

  • sleeping too little or too much
  • problems with poor concentration
  • low energy
  • problems with memory
  • feeling hopeless, helpless and/or worthlessness
  • feeling suicidal or violent
  • getting no pleasure from life
  • having decreased sex drive
  • being withdrawn

In this first blog on medication I will talk about SSRIs, or serotonin reuptake inhibitors. (The SSRIs are a group of medications that block the reputake of serotonin, a neurotransmitter.) This has the effect of improving depression after 5 to 6 weeks. In the depressed state, the level of serotonin is low, and by blocking the reuptake, it increases the perceived amount.

These medications include:

  • Prozac (fluoxetine)
  • Zoloft (sertraline)
  • Luvox (fluvoxamine)
  • Celexa (citalporam)
  • Lexapro (escitalpram)
  • Paxil (paroxetine)

All of them are now available in generic form, and a decision to choose one would be made between the doctor and the patient.

In each case, the medication works as follows:

  • In the first 2 weeks, sleep and appetite improve
  • In the third, fourth, and fifth weeks, concentration, energy, and memory improve
  • In the fourt to twelfth weeks, anxiety and depression begin to improve. So other symptoms get better before the mood and anxiety improve.

This is true with the entire class of medication.

December 4, 2012

Holiday Blues

Filed under: depression,Frustration,guilt,helplessness,Irritability,sadness — Tags: , , , , , — admin @ 2:31 pm

At this time of year it is very common for people to feel sad about painful losses in their lives. This includes the deaths of loved ones:

  • parents
  • siblings
  • children
  • spouse
  • friends
  • pets

One remembers that this is the anniversary of the time that they did not have them in their lives during Thanksgiving and Christmas. On some occasions this is merely a transient phenomenon that passes after the holidays, but in many cases the patient requires some kind of individual treatment.

This is called bereavement, which may lead to depression. A number of patients become acutely depressed, stay depressed, and require medication and therapy to handle the situation. Another part of the problem is that people feel they should be happy and joyous during this time and feel angry and upset that they do not feel the good feelings. This is a far more common problem than it was thought to be, and a lot of people do not seek the treatment they need.

Still another problem is that people say, “Well, I will just wait until after the holidays to see if I feel better and not need treatment,” thereby going through the holiday season feeling bad.

I do not believe there is an advantage to suffering unnecessarily for those who need treatment with medication and therapy. They should seek it as quickly as possible. Sometimes talking about the problems and revisiting the losses will be all it takes to put things in perspective, but sometimes people have vegetative signs of depression, and they may require medication intervention.

November 12, 2012

Depression Part 5

Filed under: Anger,anxiety disorder,decreased energy,depression,Frustration,guilt,helplessness,Irritability,sadness,worthlessness — admin @ 3:32 pm

The inability to think, concentrate, and make decisions are prominent. Distractibility, memory difficulties, inability to concentrate on intellectual activities can be prominent. Children show a drop in grades reflective of poor concentration, and elderly individuals show memory difficulties, which may be mistaken for signs of dementia and are often called pseudo-dementia. The pseudo-dementia or memory problems will clear up if the patient is depressed and the antidepressant the patient is prescribed is effective. It is worth noting however that sometimes major depressive episodes are really a harbinger of irreversible dementia.

Suicidal thoughts, thoughts of death, and suicide attempts are frequent. Some patients have only brief, fleeting thoughts of this nature, but others have more serious plans and even make attempts, sometimes requiring hospitalization to protect the patient.

On some occasions a patient will present with delusional material, feeling the world is coming to an end, or they are responsible for the world’s problem. Often they cannot be talked out of this situation and may require special treatment. In general major depressive disorder is treatable with medications and therapy. The in the case of psychotic reaction, and antipsychotic may be necessary as well as an antidepressant.

In addition there are cases where the depression is due to alcohol intoxication, hypothyroidism, steroid exposure, or toxin exposure. These have to be ruled out as medical causes of a depression to delineate whether this is a true psychiatric illness.

October 12, 2012

Depression Part 4

Filed under: Anger,anxiety disorder,decreased energy,depression,Frustration,guilt,helplessness,Irritability,sadness,worthlessness — Tags: , , , , , , — admin @ 3:31 pm

Patient often present with anhedonia, which literally means “without pleasure.” They have lost interest in or have little pleasure in the activities that they previously enjoyed. Hobbies, for example, are not practiced anymore. Social withdrawal and isolation are prominent. Sexual desire decreases markedly.

A child may not want to play sports or be with friends. An adult who had hobbies that he or she enjoyed ceases to practice them, saying they no longer have any interest.

When patient present with these symptoms, they almost all agree that they are “just existing” and not really living.

I strongly encourage them to become more active. In particular I recommend doing sports activities including walking to get their heart rates up and a good sweat going. This will cause a release of endorphins, naturally occurring chemical substances that provide a sense of pleasure and joy. They are naturally occurring and do not have side effects. After a hard workout and a shower people will have good feelings that will last 4 to 6 hours. Endorphins improve focus, mood, concentration, and energy.

September 30, 2012

Depression Part 3

Filed under: Anger,anxiety disorder,decreased energy,depression,Frustration,guilt,helplessness,Irritability,Uncategorized,worthlessness — Tags: , , , , , , — admin @ 12:00 am

It is worth noting that a patient with depression may be either agitated or show psychomotor retardation. The agitation is consistent with being unable to sit still, pacing, hand-wringing, or rubbing skin or clothing. On the other hand it may show slowed speech, thinking, and body movements, pauses before answering, and decreased speed in speech. The inflection, amount, variety, or volume of speech may also be slowed and decreased.

Lower energy and fatigue are common. The person may feel tired even without exertion, and the smallest tasks require substantial effort. The time to complete these tasks may be extended. Even activities of daily living such as cleaning, washing, eating, and showering may take up to twice as long as usual, and indeed, the person has trouble getting out of bed.

Guilt, worthlessness, hopelessness, helplessness, and uselessness may all be part of the depressive picture as well. Self-blame or “being hard on oneself” may also be experienced. Strikingly, blaming oneself for the illness is a very frequent occurrence. A lot of people feel that their depression is something they can control by willpower, and that they are being weak or morally inferior by not being able to control it. This is a feature that may only lift as the depression lifts.

August 26, 2012

Depression, Part 2

Filed under: depression,Frustration,helplessness,Irritability,Narcissistic character disorder,sadness,worthlessness — Tags: , , , , , , — admin @ 3:51 pm

The person with a major depressive episode often describes himself as depressed, sad, hopeless, discouraged, or “down in the dumps.” If a person denies being sad it is sometimes useful to point out that the patient looks as though he is about to cry. Sometimes people complain of having no feelings or feeling anxious, but the depressed mood can be observed in a patient’s facial expression and demeanor. Some people have somatic (meaning body pains) rather than feeling some sadness. Many complain of irritability (see my blog on irritability from April 27, 2012) or an exaggerated sense of frustration (see my blog on frustration from June 4, 2012). These are called neurovegetative or psychosomatic symptoms. One feels an assault on one’s personal narcissism (see my blog on narcissism from May 11, 2012). As noted before, anger, irritability, and difficulty tolerating frustration may all be part of a biological and psychological component. Medications can be helpful as can psychotherapy.

July 22, 2012

Depression Part 1

Filed under: Anger,decreased energy,depression,insomnia,Irritability — admin @ 10:22 pm

Major depressive disorder is characterized by patients experience two weeks during which either their mood is depressed or there if a loss of interest or pleasure in nearly all activities.

In addition, neurovegetative that is, physical symptoms) include:

  • Changes in appetite or weight (either up or down)
  • Changes in sleep (either insomnia or hypersomnia)
  • Changes in psychomotor activity (either agitation or retardation, meaning slowed down or sped up)
  • Decreased energy
  • Guilt
  • Feelings of worthlessness, hopelessness, helplessness, and uselessness
  • Difficulty in concentrating, thinking, and making decisions
  • Recurring thoughts of death or suicidal plans or attempts

To be included as part of a symptom of major depressive disorder, this symptom has to be newly present or clearly have worsened. The symptom needs to be present every day and for most of the day for two consecutive weeks.

This episode may be associated with clinically significant distress or impairment in occupational, social, or other important areas of functioning. In milder episodes, functioning may require markedly increased effort but may be normal.

Any four of the above mentioned symptoms must be present, and in some people. Irritability may be more prominent than sadness; however, for the most part, people complain about being depressed, sad, hopeless, or discouraged.

June 4, 2012

Frustration

Filed under: Anger,anxiety disorder,depression,Frustration,Irritability — Tags: , , , , — admin @ 6:34 pm

Frustration is a perennial and ubiquitous problem that we all face every day. It is largely characterized by not being able to get what we want and the attendant feelings, which give rise to anger and irritability. In general, we are frustrated when we cannot have what we want when we want is.

An approach to dealing with these feelings is to get perspective and accept the need for delayed gratification. To delay gratification is the ability to postpone having one’s desires met until a more appropriate time or place may occur. The delay of gratification comes from our ability to tolerate not having our desires met immediately. This is expressed in terms of using the more mature parts of our mind to compensate for the childlike part of our mind.

For example, if a two-year-old wants a piece of candy, and he is denied, he cries and has a tantrum. This is not unusual behavior at this age; however, the same behavior in a twenty-year-old would be unacceptable. One must look for more mature ways to cope with the frustration of desires. One way is to accept that we do not always get what we want. The second is to look for ways to obtain gratification by other means. In the above-mentioned example, the twenty-year-old can accept that he or she needs to go without a treat and look for satisfaction in other areas, such as exercise or gardening, that do not involve candy but do give satisfaction.

In my practice, my patients experience the problems of frustration everywhere. People have trouble tolerating it. One of the hallmarks of my work with people is to help them identify the nature of the problems and develop the abilities to cope more effectively with these problems.

In seeking treatment for depression, anxiety, and stress, people are often frustrated if I cannot provide an immediate answer or cure. I reassure them that while I may not be able to work magic in one session, there are satisfactory resolutions, but it requires time and effort to obtain them. The ability to tolerate frustration successfully is one of the features of adulthood as is the ability to understand that immediate gratification seldom occurs in reality.

April 27, 2012

Irritability: A Potential Symptom

Filed under: ADD,anxiety disorder,bipolar disorder,depression,Irritability,Narcissistic character disorder,Personality disorder — Tags: , , , , , , — admin @ 10:09 pm

     Irritability is defined as a state of extreme or marked sensitivity to criticism or insult from internal or external sources. It typically comes about as a result of stress and is characteristically found in a number of psychiatric disorders.

     It is important to understand that irritability is often ignored or overlooked because people think or are told they are just being overly sensitive. In actuality irritability can be a symptom of a psychiatric disorder for which treatment should be sought.

     Irritability often leads to anger and sometimes extreme anger. The person is said to have “a short fuse” and can lash out at those whom he or she believes are criticizing him or her.

     Irritability can be a symptom of several psychiatric disorders. They include:

  • Major depressive disorder
  • Adjustment disorder with anxiety
  • Bipolar disorder, especially in a manic or hypomanic state
  • Intermittent explosive disorder
  • Attention deficit disorder
  • Personality disorders, especially borderline personality and narcissistic character disorder

     Major depressive disorder can include people who have symptoms of anger and irritability as well as depression. Again, this disorder is well treated with medication and therapy.

     In adjustment disorder a person experiences some stress related to his outside life, whether it is work, home, or family. Irritability can be prominent.

     Bipolar disorder is characterized by mood swings. The range frequency varies from anger to depression. People often think that mood swings generally involve going from being grandiose and happy to being depressed and sad; however, in my experience the scope is more often from anger and irritability to sadness. (Note: Bipolar disorder is frequently misdiagnosed as a form of character disorder, which may or may not be present as well and is best treated with therapy and medication. Irritability is a psychophysiological response to the mental disorder.)

     Intermittent explosive disorder is as the name suggests. It is best treated with medication.

     Attention deficit disorder is also characterized by difficulty focusing and concentrating and extremely noticeable irritability coupled with inability to stay on task.

     Borderline personality disorder is characterized by rejection sensitivity, that is to say being hurt by someone saying something or doing something they do not like, and becoming unhappy and angry very, very quickly.

     I will cover narcissism in the next blog.

March 27, 2012

On My Mind

Filed under: ADD,anxiety disorder,bipolar disorder,depression,obsessive-compulsive disorder,post-traumatic stress disorder,social phobia,Uncategorized — Tags: , , , , , , — admin @ 7:16 pm

Welcome. My name is Dr. Michael Madow, and this is the launch of my blog.

This blog will contain topics pertinent to various aspects of the practice of adult outpatient psychiatry. It will also address the nature of the many types of mental and emotional illnesses for which people seek psychiatric help. Although not everything is currently understood about these illnesses, science and medicine now offer a tremendous array of therapeutic agents and strategies to achieve the reduction and in some cases elimination of troubling symptoms.

This blog is intended for informational purposes only. It is not designed to be a substitute for seeking assistance from a licensed mental-health professional. It will be interactive, but it will be closely monitored, and I will respond to appropriate comments and questions.

In upcoming posts I will address such issues as: the diagnosis and treatment of depression; anxiety disorders; stress; bipolar disorders; ADD; post-traumatic stress disorder; social phobia; obsessive-compulsive disorder; and many others. This site is intended to be user friendly. I look forward to answering questions as well as providing psychiatric care to people in the greater Las Vegas area, including Boulder City, Henderson, and Summerlin.

Welcome aboard.