Tag Archives: Mental illness

Why does the doctor keep changing my meds?

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Drugs

Medications.
Photo courtesy of Pixabay.com

Why is med compliance important?

More than once in my career as a therapist I have been asked to talk with a client about a subject that professionals call “Medication compliance.” The doctor wants us to be sure that the client is taking the medication as prescribed. People respond differently to different medications. There are reasons why clients might not take meds as prescribed. There are excellent reasons why the doctor wants their patients to take meds as prescribed.

I can’t give you advice on meds or counseling here, this is a blog, not on-line treatment, but maybe I can provide some general information on the issue of meds and why the doctor might change them.

There are five principle steps I see doctors go through in the process of deciding what meds a client should take. I am sure doctors think about a lot more than these steps but let me walk you through this process. If this raises questions about your medication please talk with your healthcare provider.

This blog post is about med management from the professional’s viewpoint. Next time some thoughts about side effects and other reasons clients don’t take meds as prescribed.

A. The doctor needs to do a thorough initial assessment. Sometimes they ask questions that sound like they are irrelevant. The doctor has their reasons. They need to establish a working diagnosis. You wouldn’t want to be prescribed cancer treatment if you didn’t have cancer, would you? They also need to know what your symptoms are and their severity. You want them prescribing meds that have some chance of helping with your problems and they need to know what your problems are to be effective at this.

B. The doctor who prescribes your psych meds needs to know if you have any other health issues and they need to monitor you for other problems and side effects. More than half of all psychiatric meds are prescribed by primary care physicians who know your medical history. The more complicated situations are usually managed by specialized doctors called psychiatrists. They will probably want lab work before prescribing medication. If you have high blood pressure they may avoid a drug known to raise blood pressure. If you have type two diabetes your psychiatrist may avoid drugs known to raise blood sugar levels or cause weight gain. I say may, because sometimes your psychiatric symptoms may be so severe that the benefits of a med will outweigh the potential risks. If a doctor does this he will probably be monitoring the effects that drug has on you. Sometimes the doctor will order regular tests, such as blood tests, to make sure the drug is doing what it is supposed to do and is not causing other problems.

At this point, the doctor will “start” a patent on a med. This initial med may not be the final med you will end up on. The doctor may need to change your med. Some meds need to be started high and then they may be reduced. Other meds may have side effects that go away over time so the doctor might choose to start with a low dose and raise it over time.

So now you are on meds, the problem should be controlled and all is well, right? Probably not. A lot of clients report that at this point the doctor starts changing meds. Why? And what makes them make the changes they do? Most often the changing starts because the problem is not under control. Either the client reports the med is not working or there are other symptoms that are causing problems. So the doctor might do three things in this order.

1.  Increase the strength or dosage of the med the client is taking and or vary the time of day or number of doses. If the doctor feels the diagnosis is correct and that the med should be helping, the first option is usually to increase the dose. If there are side effects like being sleepy during the day or not sleeping at night the doctor may choose to have the client take the meds at a different time of day. Nightmares might be another reason to move the dose to the morning instead of the night. The doctor may try increasing the dose several times to see if more of the preferred med is going to work.

2. If one or several increases in dose don’t help the doctor may try switching meds. Many doctors have a preferred med. This may be one they studied in school or did research on. It also might be a med they have used a lot and gotten good results from. Since not everyone is the same sometimes this first choice med does not work or causes other problems so the doctor tries switching. After the med switch, they may have to increase the dose of the new med. They may need to repeat the switch and adjust the dose process several times to find one that works for this client. This is frustrating for the client. It might frustrate the doctor also. He wants to help the client and nothing seems to work. This might be the point where he asks the therapist to have a talk with the client and see if the client understands and is taking the med as prescribed. Let’s say the client understands, is willing and able to follow directions, but none of the meds have worked. What might a doctor do next?

3. The doctor might at this point decide to try several meds in combination. This is a tricky one. He needs to select multiple medications from all the ones available and adjust doses of multiple meds. This process may continue for a long time as new meds are added, doses are adjusted and some meds may be discontinued. After a while, a discontinued med might get added back if it looks like the client was better with that med than after it was discontinued. During the process of juggling multiple meds, it is very important that the client is following the directions, telling the doctor about any effects and side effects experienced and it is also important that the doctor is hearing what the client is telling the doctor about their med experience.

I hope that this blog post helps you understand some of the things a prescribing doctor might consider or do in the process of trying to find the med that will help their client.

You are welcome to post comments on your experiences with meds. Just remember that as a therapist, I can’t give you specific advice about meds or prescribe any.

Another time some thoughts on side effects and why clients aren’t always able to take meds as prescribed.

Staying connected with David Joel Miller

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel

Are you Hyperthymic?

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Hyperthymia person

Are you Hyperthymic? Photo courtesy of Pixabay.

Recently I read an article in a peer journal about Hyperthymia. Here is an interesting point of view on the question of whether the mentally ill are really different from “normal” people. Maybe people with a diagnosed illness are on a continuum and just have more or less of the characteristics the rest of us take for granted.

I am inclined towards the idea of continuums, not discreet illnesses despite the fact that I need to give people a diagnosis to get insurance to pay for treatment. That says to me, some people’s problems keep them from having jobs, friends, or being happy and they need help. Other people get along fine as they are and don’t need help. For example, 70% of people report having at least once in their life heard a voice calling their name but when they looked there was no one there. Does this say that hearing “voices” is normal or that the other 30% are lying?

Bipolar disorder is especially troublesome. There are degrees of symptoms and as we have talked about in past blogs lots of people get another diagnosis first and then it gets changed later on, often when the antidepressants make it worse, not better. What if parts of Bipolar disorder are just normal personality characteristics? Could there be milder forms of bipolar disorder that are not getting recognized or does that start to pathologize everyone?  Some authors have suggested we need a Bipolar 3 and Bipolar 4 to capture milder forms of the disorder.

Hyperthymic temperament is a description given to people with 7 specific characteristics.  Sometimes the list is longer or shorter. It is currently seen as a personality characteristic which means it is not generally recognized as an illness. Most mental health professions avoid working with and diagnosing personality disorders as these are often seen as just the way a person is and not likely to change or as needing lots of treatment to change. Dialectic Behavioral Therapy is used to treat some personality disorders and long-term psychotherapy is used for treating aspects of personality that might be considered neurotic or psychotic personality features. Most of the time professionals leave this one alone.

People with this personality style do develop problems of living everyday life that result in them coming to counselors for treatment. Maybe it should be a disorder?

Here are the 7 characteristics of Hyperthymic Personality described by Glick. With MY explanations of how they might be recognized.

1. Cheerfulness

Hyperthymic people are annoyingly cheerful, cheerful to a fault. Hard to understand how someone could be too cheerful but I have learned to be suspicious of overly cheerful people. What are they up too?

2. Exuberance

This is clearly pathological, especially before I have had my coffee in the morning. These people are often described as needing a “chill pill.”

3. Meddlesomeness

To my detractors, I will say I am not meddlesome. I am just helpful even when you don’t realize you need my help. If this does not explain things try the “chill pill” described in 2 above.

4. Lack of inhibitions

Why can’t people just let last year’s New Year’s Eve party go? Occasionally letting your hair down is a good thing. However if this has resulted in more than one arrest, we are thinking you are beyond uninhibited.

5. Overconfidence

What I shouldn’t run for president? Have you seen who else is running? Now that is overconfidence.

6. Grandiosity

Genius is never recognized in its own time.

7. High energy levels.

Not sure about this one. I can be as energetic as almost anyone right after my nap. So there are people with high energy all morning?

So are there people who meet most or all of these characteristics? Sure. Do they sometimes get in trouble and have problems, yes again. Should this be another condition we diagnose and treat? The jury is still out on that one.

What do you think? Is Hyperthymia a legitimate issue? Does it need treatment? Are we making too many things disorders and trying to treat people just for being who they are?

This post was featured in “Best of Blog – May 2012”

Staying connected with David Joel Miller

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel

Bipolar or Major Depression?

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Depressed person

Depression.
Photo courtesy of Pixabay.com

Since episodes of depression are a feature of Bipolar Disorder, how would we know if this is indeed Bipolar Disorder? And does it really matter?

Yes, it does matter. People who have Bipolar Disorder are more likely to have major problems in many areas of their life. Certainly, depression is debilitating, it causes more disability than lots of physical disabilities but Bipolar cases more noticeable and life-threatening problems. Treating someone who has Bipolar Disorder for depression may result in creating manic episodes and make the condition worse. No professional ever intends to make the patient worse, at least I hope not, but not seeing the signs of Bipolar can result in incorrect treatment. Now in fairness to doctors and other professionals often the client, not knowing the differences, fails to report symptoms that might have helped in getting the correct diagnosis. Here are some things that might indicate that the condition under treatment was, in fact, Bipolar Disorder and not Major Depression.

1. Sudden onset of episodes.

Clients with Bipolar are more likely to have sudden episodes of depression and sudden remission of depressive symptoms. Major Depression is more likely to creep up on you. And Major Depression rarely just goes away suddenly without treatment or some other reason. Bipolar Disorder may strike suddenly and it may switch to an elated mood or mania all of a sudden.

2. Early age of first onset.

There was a time when we thought little kids did not get depression, not anymore. Very small children do indeed experience episodes of depression. One way we have found this out is that more and more people who struggled with depression or Bipolar Disorder as children have become professionals.

The younger the child is when they first experience a mood disorder episode the more likely they are to go on and develop Bipolar Disorder. Now we are not saying that the child is to blame for being moody. If they are able to control the mood swings then it is not Bipolar or Depression. We are also not talking about that day-to-day moodiness or event-triggered moods that all children experience. Each type of mood disorder, depression, Dysthymia, Cyclothymia, Bipolar one, and two each have a minimum length of time that is needed. This separates the events of living from a true episode of a mental illness.

3. Presence of Psychosis

With Bipolar Disorder there is almost always some disturbance of reality. This does not mean that the client is hallucinating. Psychosis also includes delusions, irrational thinking, and lots of grandiosity. During manic episodes, people with Bipolar simply try to do way too much. And they believe they can and should be able to do these things.

There is also a diagnosis of Major Depression with Psychotic Features, so the boundary between Depression and Bipolar gets blurry the closer you look. The good news is it doesn’t matter which label you get, the treatment is about the same. The bad news is that by sticking with the treatment for depression sometimes the diagnosis and treatment of Bipolar Disorder gets delayed. If you or those around you say you have thinking problems, grandiosity or delusions make sure to tell the professional who is treating you. If you don’t have someone treating you and experience delusions, seek help quickly. The sooner you get help the better the prognosis.

4. Presence of “Psychomotor retardation”

During episodes of depression some people get so tired they have trouble moving. Sometimes they literally can’t get out of bed. These extreme levels of impairment may signal that this is Bipolar and not Depression.

5. Having “Atypical features”

Many people with depression become very agitated. They can’t sleep and they can’t eat. People with atypical features are just the opposite. A shorthand way of explaining Atypical features is like a bear hibernating for the winter. These clients eat all they can. They may be over hungry at certain times of the day. Then once they get to bed they want to, need to, sleep far beyond what other people do. During extreme episodes of depression with atypical features, a client will be unable to do anything but sleep and eat.

These “Atypical” features can be seasonal as in Seasonal Affective Disorder or they can come and go with the rhythms of the year.  Having an episode of depression with atypical features increases the chances that an episode of mania or hypomania is just around the corner and with that episode comes a diagnosis of Bipolar Disorder.

6. Having a sudden overwhelming improvement in depression mood when given an antidepressant.

Antidepressant medications need time to work. Usually, the effects of antidepressants build up slowly over time. Antidepressants are not “happy pills” they do not suddenly make someone happy. They should usually be coupled with some form of therapy or addressing life’s problems.

When people with Bipolar Disorder take antidepressants they are sometimes propelled from depression to mania. A sudden huge response to antidepressants needs to be monitored for possible mania or delusional thinking. Too much response to an antidepressant suggests that this is, in fact, Bipolar disorder.

If you are unsure about this or think you may have Bipolar instead of depression talk with your doctor, psychiatrist, or therapist before making any changes in your meds. Your doctor needs to know what is happening in order to monitor your condition and there can be adverse results to suddenly stopping or changing a medication.

7. Family history of Bipolar Disorder, Psychosis, Schizophrenia, or excessive irrational behavior.

The more people on your family tree with an issue, especially close relatives, the more likely you are to have problems. Being Bipolar has had some advantages in some situations. Many people with Bipolar disorder are highly creative and productive as long as they can keep things on track.

Some families have avoided getting professional help and so there may be no formal diagnoses but most families have their stories about family members with mental health issues. Family trees with lots of depression in them seem to produce more people with a genetic risk factor for depression. Families with lots of people who had hallucinations, delusions or mania increase the risk for Bipolar Disorder. Lots of substance abuse in your family tree increases risks for substance abuse and mental illness, for a variety of reasons. Remember however that risk factor does not equal an illness. Lots of people grow up in high-risk families and have no problems, other people are the first in their family to get a diagnosis or have a problem. We are still trying to figure out why this happens.

Hope this was food for thought for you and that it encouraged some people to go for the professional help they need.

Till next time this is David Joel Miller, LMFT, LPCC saying so long.

If you have any thoughts on depression or Bipolar Disorder and the differences between them, please leave a comment on this blog.

Staying connected with David Joel Miller

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel

Stages of change – Late Action

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Change

Change.
Photo courtesy of Pixabay.com

Late Action – The change accelerates.

Last time we talked about how I might be full of enthusiasm as my self-improvement program gets going. In the weight loss example, I begin to exercise and maybe even get interested in nutrition and diet. Are deep-fried Twinkies a healthy diet? The diet guru says no. I eat low-fat and lots of greens. I hate greens but I eat them anyway. My efforts at change are taking shape and encouraged by my own persistence I may even expand my efforts.

On days when I can’t get to the gym, workdays, I start walking on my lunch hour. It is a mile around the park. If I walk fast I can make two trips and eat during my lunch period. I discover that if I bring a healthy lunch, a sandwich, and some low-fat yogurt, and I walk around the park fast, some days I lose weight. Even if I don’t actually lose weight, at least those days I do not gain any more. At this point, the intensity of my workouts is increasing. I am really getting into this.

In substance abuse recovery terms, the person involved may not only be attending meetings, but they also have a regular home group they go to every week, maybe even a fellowship they attend every night. Some people “get into service” meaning they make coffee, take out the trash, and so on. We get trainers, sponsors, and a support system. At this point, my change is beginning to be something I tell people about.

For people who have an emotional problem, like depression or anxiety, their recovery action might be seeing their therapist on a regular basis, improving self-care, or journaling. There is a huge connection between emotional issues and eating problems. One of the key issues a professional looks for in making a mental health diagnosis is changes in eating and sleep. Binge eating, overeating or not being able to eat, as well as sleeping too much or too little are all symptoms of problems. They can also be causes. More about that mind-body connection and the relationship between sleep, eating, and other life problems in a future blog.

So in late action, I am getting somewhere on my self-change program. Losing a few pounds, not drinking or drugging and I am no longer so depressed I don’t want to get out of bed. Everything should be going fine. Right?

Then what happens? Why do so many people successfully make a change only to return to the place they were before? Why do most weight loss programs, diet, and exercise, end in putting on more pounds than we lost? Why do so many people get a thirty-day sober chip only to drink again? And how is it that depression and anxiety return after a period of time?

I start wondering, am I fixed? Do I have to give up those quadruple thick burgers with the pound of fries? How long will I need to take these psych meds? Can’t I just have a donut or a glass of wine? What kind of wine goes best with donuts? My mind starts looking for ways out of the change process.

For substance abuse, we call this relapse. For depression or anxiety, we are starting to think in those terms also. For weight loss programs the part that we don’t like to talk about is why after losing twenty pounds, do I put it all back on and then some. Every time I have been on a diet I have needed to get new larger clothes.

This is the point where people start talking to us about maintenance plans.  You mean I can’t just crash diet off ten pounds and then I will be able to eat like other people? Can’t you AA folks just teach me to control my drinking? So my depression is gone. I will never feel that way again. Time to get back to the way things were before my self-improvement program. So next time let’s talk about putting the weight back on, the relapse, and the return of emotional problems.

Other posts on this topic can be found at Pre-contemplation, Contemplation, Preparation, Early Action, Late Action, Maintenance, relapse, recovery, triggers, support system, more on support systems, Resiliency

Staying connected with David Joel Miller

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel

Am I a quart low on serotonin?

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Depressed person

Depression.
Photo courtesy of Pixabay.com

Low on Serotonin?

There has been a lot of talk about the way in which neurotransmitters affect the brain. Some of this has been helpful in understanding mental illness and some have not helped at all. On common expression has been that someone had a “chemical imbalance in the brain.” I wanted to talk about that and some other issues related to psychiatric medication in today’s blog. Please keep in mind that this is a highly simplified explanation. Remember I am a therapist and counselor, not a doctor so I need to find simple explanations for clients and myself without misleading them. If you have a background in biochemistry or research skip this blog now. If the doctor has told you to do or not do something please follow the doctor’s instructions or at the least talk with your doctor about these issues. The rest of you let me know if this helps explain things.

The expression chemical imbalance is a bit misleading. The frequent use of that expression has resulted in a lot of people coming in and asking to be tested to see if they have a chemical imbalance and if so what chemical do they need more of.  They get quite upset when we say that we can’t do that kind of test. Here are some of the problems with that approach.

Thoughts in my brain and yours also, are carried from one nerve (brain) cell to another by chemicals. So when I think something, anything, my brain sends out chemicals to carry that message. Once the thought has come and gone the chemicals are broken down and reused or disposed of. So as fast as I can think of something my brain chemistry is changing.

Now different brains may make, transport, and use chemicals at varying rates but we all use chemicals to move thoughts. This is why talk therapies like Cognitive Behavior Therapy can help to change someone’s thinking which results in a change in their brain chemistry. Now medication can also help and research seems to show that doing both medication and therapy for your problems can result in changes that are more rapid and longer lasting than either treatment alone.

Most everyone has heard of anti-depressants. So they think that if I am short on a brain chemical I should be able to take a pill, replace the missing chemical, and – presto – I am cured. Wish it was that simple. Let me give you one exaggerated example of how an antidepressant might work.  The most well known and widely prescribed antidepressants right now are ones called SSRI. SSRI stands for Selective Serotonin Reuptake Inhibitors. This has resulted in a lot of people thinking that the reason they are depressed is a shortage of Serotonin. Let me try to explain how this works. You will need to unpack your imagination for this one.

I once drove a car that had a leaky radiator. At the time money was tight, still is a lot of the time but that is another story. So I kept putting water in the radiator. This is sort of like the way my brain might try to keep putting serotonin into use. But as fast as I filled the radiator the water kept leaking out. So my engine overheated. When I get low on Serotonin my brain overheats (not really don’t get the thermometer to check for depression) and then I get depressed.

So every few miles I had to find a place to stop and put water in the radiator and still it didn’t last long, kept overheating.

So this friend of mine tells me there is this thing you can get at the auto store that stops the radiator from leaking. I get some, put it in the radiator and the leak slows down. A second dose and the radiator stops leaking altogether, well almost stopped but at that point, I only have to put water in the radiator once a week, not every day.  So it wasn’t the amount of that stop leak stuff that mattered. I didn’t need to fill the radiator up with it. It just helped me get more use out of the water I had already put in my radiator.

The SSRI works that way on our brains. It doesn’t put more serotonin in the brain but it slows down the leak so we get more miles or smiles out of the serotonin we already have.

Now, let’s say for illustration purposes here, I am bragging to my friend about what a great job that stops leak stuff did and he doesn’t believe me. So I do a demonstration. I get my trusty old shotgun out. Point it at the radiator and let it rip. Now the radiator starts to leak again. So out comes a can of stop up the radiator stuff and I pour it in. Only this time the stuff doesn’t work. The radiator keeps right on leaking.

This is exactly what happens to the brains of people who are on SSRIs or other antidepressants and then they drink alcohol. Alcohol, remember, is a depressant substance. Why we so rarely call it a drug is beyond me, given that it causes more problems with abuse, dependence, and suicide than all the other drugs. But that is just the way it is.

So the point of this story is that the problem for most people is not that the brain is low on serotonin but that the things we do to our brains use up the serotonin way to fast.  A good diet, plenty of sleep, avoiding drugs, and alcohol can all help you produce more serotonin. So can changing your thinking because happy thoughts release more neurotransmitters into the brain. But calling this problem a chemical imbalance shouldn’t take away the responsibility to get our thinking and our living fixed.

Staying connected with David Joel Miller

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel

ADHD Cure- – Treat Parents

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Sad child

ADHD?
Photo courtesy of Pixabay.com

Could we cure ADHD or depression in children, especially preschool children, by treating the parents?

Just read a report that concluded that the epidemic of ADHD in preschool children can be very effectively treated by training the parents in Parent Behavioral Therapy (PBT). This raised a lot of questions. Why the increase in ADHD? Why in Preschool children? And most importantly how could treating the parents – cure the children?

The Press Release about the report by the McMasters Center can be found here. 

The McMasters center report suggested a different way of viewing ADHD and the older ADD. As I understand their concept they are convinced there is one larger umbrella disorder – Disruptive Behavior Disorder meaning the kid is doing things or not doing things that cause the adults problems.  This more general description, which is a recognized diagnosis in the DSM-4-TR they then subdivide and refine into ADHD in all its varieties, Optional Defiant Disorder, and finally the most severe form Conduct Disorder.

This makes sense to me since most of the referrals for ADHD screening begin with things like – he won’t stay in his seat, is not doing his work, etc. These are complaints teachers and parents have, not things a child, especially a preschool child would complain about. Hence the child’s behavior disrupts an adult’s life and the diagnosis. They report that this disorder began with the label of “minimal brain damage” but when no one could find the specific brain damage we dropped that label.

Further, the study says that ADHD should be thought of as a spectrum disorder. So it might vary from no problem, through milder forms to “for sure you got it” forms. This like so many other mental illnesses are not a case of you got it or you don’t but rather how much of this disorder do you have. Also, there is no medical test for ADHD. We use screening tests and other ways of diagnosing this but the truth is who gets the diagnosis depends on who does the diagnosing.

So why an increase in ADHD cases in preschool children?

Calling them preschool children does not mean that they do not attend school. ADHD and related problems first began to be recognized about 1902 when most children on earth began to attend mandatory universal education.  Now a large number of children are attending preschool – hence lots of preschool-age children are attending school. The report on effective ADHD treatments included all children under six in the preschool group. They especially noted that at this age it is difficult to separate the effects of a condition like ADHD from normal maturation.

I think young children – by definition are immature, so we don’t diagnose “too young” as a condition unless they don’t act like we want them to then they have some kind of disruptive behavior disorder. Some countries in Europe have children wait until they are at least six to start school on the premise that before six they are too immature to benefit from school. In America, we go the other way and start them out at age two or three on the premise that the younger we start pushing them the sooner they will grow up.

So who gets diagnosed with ADHD?

Most new diagnoses of ADHD occur when children begin to attend some form of formal education and are asked to sit still and concentrate on things the adults want them to learn instead of the things kids want to learn. The majority of diagnoses are made between the ages of five and ten years of age. Diagnoses of ADHD after the sixth grade drop sharply and those first diagnosed after age eighteen are even rarer.

The majority of those diagnosed are boys. In fact, boys in the primary grades are four times more likely to get the diagnoses than anyone else. In my own experience, the time children are more likely to get referred for assessment for ADHD is when they first start school, preschool, kindergarten, or first grade. The next big surge in referrals is between the third and fourth grade when there is a shift from learning to read to reading to learn, and the poor readers get really bored.

The number of adult cases is half of those in children, so either a lot of people outgrow this condition with or without treatment or it is not so much of a problem once you are out of required school.  Or maybe a lot of kids get the diagnosis because they are bugging someone in the position to make a diagnosis.

The poor, especially those on Medicaid are much more likely to be diagnosed, but the rich (higher Socio-economic status) are much more likely to receive medication. The poor are more likely to stop taking meds after one prescription. For much the same reasons the poor are much more likely to drop out of parenting education programs.

When meds work for someone it is wonderful, unfortunately, the only way to see if a med will work for you or your child is to try it and there are side effects to worry about. Note that any meds may have side effects but some are worse than others.

In very young children – under the age of six, treatment with a stimulant ADHD med is likely to reduce the ADHD symptoms, but it increases the depression and other mood symptoms. Or maybe the sadness was always there but it becomes more noticeable when the child is able to sit still. The meds also suppress growth, something that a forty-year-old who is overweight might hope for – but not something we want to see in a child under six. And there is another problem.

In one well-documented study children who took a placebo – a non-active pill – did almost as well on managing their ADHD as children who took the real med. When the meds were stopped, 97.5 % of the kids on ADHD meds did not have a relapse, pretty impressive. But of the kids on a placebo who were treated with nothing resembling a drug other than the pill form it was given in, well a full 88% of these non-medicated kids did not relapse either. The conclusion here could be that the thing that helped the kids was the extra attention involved in treatment, not the medication.

Now, why not just send all these kids for therapy? Well as much as that helps some kids, and remember I am a therapist, there is a limitation on therapy. We see the kid for one hour a week. What happens the other 167 hours? So when parents take a class in Parent Behavioral Therapy or work with the therapist on how to help their child, they are able to maintain the treatment all week not just in the therapy hour.

Now if your child is on meds, please do not suddenly take them off, talk to your child’s doctor or psychiatrist first. But for very young children consider approaches other than medication.

The moral of this story? The more we adults work on our skills the more we can help kids with ADHD, with or without medication. So if your child has ADHD or depression or any other emotional problem, consider participating in therapy and learning new skills that might help your child.

Staying connected with David Joel Miller

Seven David Joel Miller Books are available now!

My newest book is now available. It was my opportunity to try on a new genre. I’ve been working on this book for several years, but now seem like the right time to publish it.

Story Bureau.

Story Bureau is a thrilling Dystopian Post-Apocalyptic adventure in the Surviving the Apocalypse series.

Baldwin struggles to survive life in a post-apocalyptic world where the government controls everything.

As society collapses and his family gets plunged into poverty, Baldwin takes a job in the capital city, working for a government agency called the Story Bureau. He discovers the Story Bureau is not a benign news outlet but a sinister government plot to manipulate society.

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Dark Family Secrets: Doris wants to get her life back, but small-town prejudice could shatter her dreams.

Casino Robbery Arthur Mitchell escapes the trauma of watching his girlfriend die. But the killers know he’s a witness and want him dead.

Planned Accidents  The second Arthur Mitchell and Plutus mystery.

Letters from the Dead: The third in the Arthur Mitchell mystery series.

What would you do if you found a letter to a detective describing a crime and you knew the writer and detective were dead, and you could be next?

Sasquatch. Three things about us, you should know. One, we have seen the past. Two, we’re trapped there. Three, I don’t know if we’ll ever get back to our own time.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

For videos, see: Counselorssoapbox YouTube Video Channel

Am I Bipolar?

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Am I Bipolar?

Occasionally I get asked this question. More often the person asking the question is asking if their child, spouse, or friend is Bipolar. Almost no one ever asks me if they are depressed. Why the difference?

Most of us know when we are depressed. We know that we can be a little depressed and get over it naturally or we can get a lot depressed and need help. It is also easy to see that there is a difference between being a “little depressed” and suffering from Major Depressive Disorder which is the technical term we professionals use when we diagnose clinical depression that needs treatment.  We also have some other lesser degrees of depression we can diagnose like Dysthymic Disorder. Not so much with bipolar disorder.

Even my more liberal colleagues are uncomfortable with the idea that people could be “a little bit bipolar” even though all people have some of the characteristics of bipolar from time to time. It would be more comfortable to think that there are “those people” meaning the mentally ill – over there and then “us people” the normal ones over here. Forget for a moment that our friends and family may think we belong with the over-there folks. Why is it so hard to accept that most of the symptoms of mental illness are on a continuum from a few to a lot?

With depression, we all accept that if someone in your family dies – say, grandma, for instance, you should be sad. That is assuming, of course, you like grandma. If someone close to you dies we expect you to be sad, depressed even, we have a special name for that – Bereavement. But if five years later you are still stuck at home, too depressed to go to work because of this loss, then we think there is something excessive going on here and you will be diagnosed as depressed, probably diagnosed with Major Depressive disorder. So why don’t we do that with Bipolar disorder?

One caution is in order.  DO NOT ATTEMPT THIS AT HOME! Diagnosis is not a do-it-yourself project. This blog is meant to be informative and as you will see below most of this is not a matter of yes or no answers on a questionnaire. Some “clinical judgment” needs to be used, which is why even professionals sometimes need to consult with other professionals on close calls.

Let’s look at the criteria for Bipolar and see how someone might have all the signs or symptoms and still not qualify for the diagnosis. Some of you who read my earlier blog about Bipolar Disorder will remember that the main difference between depression and bipolar disorder is the occurrence, at least one time, of an episode of large mania or small mania (Hypomania.) I have simplified these descriptions so if you want the long-form, check the DSM.  After the 7 criteria will come the big stuff.

Here are the 7 criteria:

1. Inflated self-esteem or grandiosity.

So this sounds like an occupational disease. Wouldn’t all politicians, entertainers, and sports personalities fit this description? So thinking a lot of yourself could be good self-confidence or it could be grandiosity depending on whether you win or not. Certainly, people with bipolar disorder may be attracted to these kinds of occupations but not everyone in those fields should be diagnosed with bipolar disorder. As with all the other symptoms, this is not a yes or no answer, it is a matter of degree.

2. Decreased need for sleep.

Many people experience a night or two when they are doing something exciting and they get by on less than normal sleep for a day or two. As a society, we like people who get a lot done. But eventually, the novelty wears off and the need for sleep returns. Bipolar people have extended periods of high activities with a reduced need for sleep.  Parents with bipolar children report the child never slept that much. Though most parents don’t think their child sleeps enough when the kid keeps waking you up at night. So again the sleep issue is a matter of degree.

3. More talkative than usual or a pressure to keep talking.

Now we have all met people who talk a lot. And when you are with someone who has not seen you for a while you both may feel the need to say a lot. Some kids are so needy for attention that once the mouth opens they will talk nonstop. None of these things meet the criterion of it only happens occasionally. To really be bipolar disorder the person needs to have an out of control need to do these things.

4. Racing thoughts.

This is from the client’s point of view. They feel that even they are having difficulty keeping up with their own thoughts. Writers have this happen sometimes; the muse strikes and we have trouble getting it down on paper. That is not the same thing. Being a writer does not make you Bipolar. (We are not all bipolar are we?) These fast thoughts are also called flights of ideas, hard to stay on track when your ideas jump from subject to subject.

5. Distractibility.

This involves being pulled away easily or getting stuck on irrelevant things. Now, this is perilously close to ADHD. Kids with bipolar disorder are sometimes given an ADHD diagnosis the first time until the symptoms of bipolar disorder become clearer. More on ADHD at another time.

6. An increase in goal-directed behavior.

This is also a tricky one. If it means studying a lot and getting all “A’s” or making lots of money we may let this go. But if you are really good at having sex with lots of people or working so many hours you forget where you live – then you get diagnosed.

7. Excessive involvement in pleasurable activities that may cause you pain.

The official guide lists too much sex, buying sprees, sexual indiscretions, and foolish business investments. This leaves out gambling, substance abuse and some other impulse control problems.  What is a foolish business investment is also open to question. Should we dump the internet stock and invest in a sound carriage manufacturer’s stock? So see how some interpretation is needed?

Now all the above notwithstanding, for anything to be diagnosed – yes you heard me right – for anything to be diagnosed as a mental illness it must cause one of three things.

A. The problem keeps you from having or keeping a job. For kids, this includes going to school. In fancy-speak, we call this interfering with occupation functioning.

B. It keeps you from having good relationships with your friends or family this is called social functioning.

C. It causes you pain. So if the problem is causing you pain we are much more likely to think it is a mental or emotional disorder than if you and your friends are OK with your difference and you can keep a job.

More next time on some of these problematic diagnoses and on some other relationship issues that you have emailed me about.

Bye for now

David Miller, LMFT, LPCC

Bipolar doesn’t mean moody

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By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Bipolar doesn’t mean moody.

Three psychiatric diagnoses (ADHD, Bipolar, and Schizophrenia) have left the scientific literature and taken up residency in the media and in everyday conversation. The problem with these usages is it devalues the term and pretty soon it is being misused more often than it is used correctly. Bipolar is one of those terms.

Kids report that their peers call them or others “Bipolar.” We hear about it on talk shows. Sometimes parents call their children or their partner Bipolar with no clear idea what the term means. Children are being diagnosed with bipolar disorder at younger and younger ages. Early diagnosis and treatment is a good thing; it may reduce a lifetime of suffering. Referring every kid in first grade who is irritable for a bipolar evaluation is probably not warranted.

Lots of parents want their child “tested” for bipolar disorder. I wish there was a simple test, say blood or urine that would detect the disorder. There may be physical signs or markers, but so far no one seems to be able to detect bipolar disorder other than by a psychological evaluation that involves descriptions of mood and behavior. When many parents want to know if their child is bipolar, what they really mean is the child is irritable or difficult and they need help.

People refer to others who are moody as Bipolar. Bipolar disorder does not mean moody! Some people are naturally moody others get moody when something upsets them. Lack of sleep makes most anyone moody and grouchy. Not everyone with sleep disturbances has bipolar disorder by any stretch of the imagination.

When we talk about bipolar disorder we are talking about a condition, not a person. A person may have bipolar disorder that does not make them “bipolar.”

So what is Bipolar – really? It used to be called Manic Depressive disorder. I see client questionnaires where they report they have family histories of both manic-depressive disorder and Bipolar. I won’t go into the politics behind the name change but it is important to note two things. Bipolar is a mood disorder so it is in the same “family” or chapter as Depression and other mood disorders. The second characteristic is that for the problem to be bipolar it must include Mania or its cousin Hypomania.

Update – In the DSM-5 they did away with the term “mood disorders.” More and more professionals are thinking that Bipolar and Major Depressive Disorder are for-sure two separate things. You may have periods of depression for a while before the mania but we need to be careful to separate the Bipolar from the Major depression.

So what is mania? I won’t repeat the whole DSM-4-TR criteria here if you want that please go to the source. But a couple of things that separate mania and therefore bipolar disorder are important. For some clients, this looks like someone on Meth – without the drugs. This is not a little bit thing that comes and goes. When it occurs the person is debilitated.

Mania involves a period of time where the client’s behavior is elevated, expansive, or irritable. In short, they are “off the hook” and this is not deliberate but uncontrollable. During this time frame, they have a bunch of behaviors that are far too excessive. The DSM lists 7 characteristics and the person should have the majority of these symptoms. Not sleeping and not needing to sleep is a red flag. They are up all night doing things and they don’t even feel tired. They are likely to show grandiosity and excessive self-esteem. They talk faster than those around them can listen and they think faster than they can talk. But the thoughts may make sense only to the person with bipolar disorder. They are likely to get “stuck” on things, too much work, buying sprees, excessive sexual activity, and other risk-taking activities.

Since mania is seductive, who wouldn’t like to be able to have fun twenty-four hours a day and not need to sleep, during manic episodes the client with bipolar may be strongly attracted to stimulant drugs like methamphetamine and cocaine. Alcohol abuse is also common which increases the crash when the manic episode ends. And it always ends.

Most people who truly have bipolar disorder are first diagnosed with depression. One indicator that makes me suspicious is when a depressed client takes an anti-depressant and recovers suddenly and now is “better than ever.” A manic episode is about to occur.

So far talking about Bipolar disorder, with its depressive and manic symptoms makes it sound like the person runs from manic (which is not happy by the way) to depressed. That’s not the whole story. Kay Redfield Jamison writes about what we might call mixed states. It is possible, probably more common than we might think, to have both mania and depression at the same time. Think of the shifting moods like a tire on your car. When it is parked we could mark one side of the tire and call that the back, the other would be the front. But once the tire starts to move you don’t drive on the front or the back but the whole tire. So the person with bipolar may experience a mixture of depression and mania at the same time.

Another feature of Bipolar disorder that separates it from moodiness and depression is the tendency for the elevated thinking to become first delusional and then it may progress to include hallucinations. So the person with bipolar disorder is not only thinking odd thoughts but is very irritated with others that they don’t “get them.”

Hope this explanation got you thinking about Bipolar disorder. If you would like more information, check out the Depression and Bipolar Support Alliance.

As always your comments are welcome. If you like this blog spread the word. If not let me know what might improve it. Till next time.

David Miller, LMFT, LPCC