90 replies to this topic

[Tom_]

godot I'll be replying to you (disagreeing with you as per expected) in a few hours but its time to watch a movie and take a break from obsessing about mental illness as I'm sure my psychiatrist who shares some of the theoretical opinions with you would be looking at me rather disapprovingly and muttering something about defense mechanisms.

Although I am certainly looking forward to the conclusion of this totally meaningless debate as neither of us are very likely to change our opinions...but I at least am enjoying myself (if also getting rather irate at times) and hope you can say the same and hopefully we can end up coming up with a really great idea for the OP.

Edited by Tom_, 08 May 2013 - 04:18 PM.

[Godot]

Tom - I look forward to your disagreement. You should listen to your shrink, he sounds like a smart guy.

[Tom_]

You wouldn't have liked the shrink I had before... :L he was if its possible even more for a biological basis of disease.

[nowayout]

Any self respecting psychiatrist or clinical psychologist will tell you that a brain produces a persons psyche and that is the ONLY reason anyone would ever prescribe a medication. Meds and 'medical interventions' WILL relieve symptoms and in some cases, especially Bi-polar type 1, classical major depressive disorder with melancholic and delusional features, Seasonal affective disorders and certain subsets of Paranoid Schizophrenia be the only needed treatment.

In disorders that seem to be more the result of adverse environment with genetic factors as a secondary cause medication becomes important will not treat a disorder to remission.

Behavioral and occupational interventions remain a constant throughout any disorder.

Any self respecting psychiatrist or clinical psychologist will ALSO explain to you that cognitive and behavioral psychology give a much more scientifically verified, clearly defined and better clinical response than does psycho-dynamic therapy. They might also mention that other than behavioral therapy which could be regarded as a different class off intervention the vast majority of improvement is seen by having a good rapport with the therapist rather than the effectiveness of the therapy. However cognitive therapy remains the only therapy to date that can claim a treatment response roughly equal to antidepressant or antipsychotics not to mention it is also usually much shorter term. The only other therapy of realistically comparable efficacy across a range of disorders (but with less of an evidence base) is CAT or cognitive analytical therapy.

It is an interesting discussion that may belong somewhere else, but...

I am personally somewhat uncomfortable with the movement in favor of medication and away from evidence-based therapy. Of course nobody in his right mind denies that everything comes down to the biology of brain function. However, the brain has hardware and "software." Drugs, as far as anybody knows, mostly address what one might call the hardware. Guided psychedelic therapy might be an exception (and here the therapy seems important, so it's not just drugs). It's as if someone tried to improve a computer whose operating system keeps crashing due to a software fault by decreasing the processor clock speed.

Edited by viveutvivas, 08 May 2013 - 06:06 PM.

[Tom_]

Then start with what you can treat. Come off the anti-psychotics, if you are delusional or not they are unlikely to make a massive difference. One thing is very clear to me. You are NOT acutely psychotic. Any diagnosis of Schizophrenia or Bi-polar affective disorder at the moment would be a bad one.

Start with a high dose SSRI (paraoxetine) and Psychotherapy, I recommend CBT godot recommends psychoanalytic therapy. Maybe you should settle the deal by going and having an evaluation by a Clinical Psychologist and seeing what they recommend. Better yet, an assessment by a team of mental health professionals. Psychiatrists normally get it right (but they can be wrong) and clinical psychologists know what they are doing, although they are less likely to provide a diagnosis and more a formulation (describing stressors and thinking patterns (typically that develop in response to stessors or that you learned as a child) although many will provide both.

It all comes down to a point. If you try something for slightly longer than the recommended amount of time and it doesn't work, move to the next thing. There is no chance that NOTHING will work. You haven't tried SSRI's, you haven't tried proper psychotherapy try them as well as the behavioral activation. Its hard to think about things you don't want to while doing other stuff. SSRI's have been shown again and again to reduce obsessive rumination in depressed, obsessive and even in psychotic patients they even reduce day to day worries in the normative population. Psychotherapy will at the best provide you with a structured place in which to safely learn to manage your thoughts and control this constant niggling - which is quite understandably driving you nuts like a constant itch you can't quite reach, and at the worst someone to listen to you bemoan the world. If one therapist doesn't work for you, thats not a que psychotherapy won't work for you, that's a que to change therapist and/or therapy type.

The world doesn't owe you shit and it doesn't have to be fair. What you are doing now very clearly isn't working, it might not be fair that it isn't work, you seem like a nice guy with a butt load of shit going on in your life and you shouldn't have to go though this. Something however is going to have to change. You can wait for the world to - and it might. You might get a great job offer, move out and a Swedish blonde supermodel for a girlfriend and invest in a new company and become CEO. My bet however is on: you are going to have to change.

I think your best options are an SSRI, psychotherapy (CBT) and behavioral activation.

[Tom_]

I'm pretty sure I've posted about the problems and inconsistencies of the brain-computer metaphor both in the sense of the brain paralleling a computer and the brain being hardware and the psyche being software. My use of the term computer is following that of a physical computer not a theoretical one. A computer after all is binary, a brain is not.

I'll just post a link rather write a million incoherent words.

http://scienceblogs....-not-like-a-co/

[Olon]

Have you tried naloxone or naltrexone? They are said to be effective against depersonalization disorder, maybe you could at least get rid of the "possessed" feeling.

[Heh]

To give an example of what this is like, something keeps trying to force me to do everything recommended in this thread. Most of this advice has already been tried, and yet the idiot harassing me is still trying to force me to do it all over again. That and, "take some supplement now, take some supplement," and anything else that involves forcing me to do something I don't want to do. This is such a miserable experience.

I'll look into the SSRIs, etc, but I'm getting pessimistic about supplements/medication. Supplements that worked well for me in the past (for other issues) have had ZERO effect on me since this all started. It's like supplements/medication pass through my system and go right back out without being absorbed. I'm annoyed. How can I take this much stuff and not notice anything whatsoever?

Edited by Joel, 08 May 2013 - 09:42 PM.

[nowayout]

I'm pretty sure I've posted about the problems and inconsistencies of the brain-computer metaphor both in the sense of the brain paralleling a computer and the brain being hardware and the psyche being software. My use of the term computer is following that of a physical computer not a theoretical one. A computer after all is binary, a brain is not.

I'll just post a link rather write a million incoherent words.

http://scienceblogs....-not-like-a-co/

Computers do not have to be binary.

As a first approximation (I know this is not the whole story), the brain can be considered to be a neural network (hardware) with modifiable synaptic weights (real-valued, not binary, but still software). Learning changes synaptic weights, and learned behavior (say, learned helplessness in depression) is encoded in the synaptic weights (software). The synaptic weights live in a vector space with billions of parameters (dimensions). With SSRIs, for example, you are modifying at best a handful (say 5) of those billions of parameters. An analogy would be trying to fix a computer program that has an unknown error by flipping every 100th bit. Given this, it is a miracle that drugs actually do work for the minority of people they work for, for some value of "work".

For the OP, just a suggestion (not interested in forcing anybody) one thing you have not tried is indeed the CBT or psychodynamic therapy mentioned, either of which can probably be done in a way that is more "targeted" to your learned behaviors and assumptions than any drugs you may have tried. Something else targeted at your "software", so to speak, would be the very good suggestion by Tom that you get out and socialize as much as possible.

Edited by viveutvivas, 08 May 2013 - 10:48 PM.

[Olon]

How can I take this much stuff and not notice anything whatsoever?

The most recent review also implies it's not easy.

Brand et al⁴ reports that atypical (or second generation) antipsychotic drugs that block both dopamine (D₂) and serotonin (5-HT_2A) receptors may be of use in treating complex trauma cases with psychotic features, although care should be taken to distinguish auditory hallucinations, which originate from an external locus, versus internal “voices.” Opioid antagonists, such as naltrexone have also shown some promise in the treatment of dissociative symptoms. The mu and kappa systems may be associated with symptoms of analgesia. Stress-induced analgesia, a form of dissociation, has been shown to be mediated by the mu opioid system.⁴
Most medications (e.g., antidepressants, anxiolytics) are prescribed for comorbid anxiety and mood symptoms, but these medications do not specifically treat the dissociation. Presently, no pharmacological treatment has been found to reduce dissociation.¹⁸ Although antidepressant and anxiolytic medications are useful in the reduction of depression and anxiety and in the stabilization of mood, the psychiatrist must be cautious in using benzodiazepines to reduce anxiety as they can also exacerbate dissociation.^17,18 In treating patients with DID, there are reports of some success with selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, beta blockers, clonidine, anticonvulsants, and benzodiazepines in reducing intrusive symptoms, hyperarousal, anxiety, and mood instability.^17,18 Atypical (or second generation) antipsychotics have also been used for mood stabilization, overwhelming anxiety, and intrusive posttraumatic stress disorder symptoms in patients with DID, as they may be more effective and better tolerated than typical (or first generation) antipsychotics. Other possible suggestions for pharmacological interventions for DID include the use of prazosin in reducing nightmares, carbamazepine to reduce aggression, and naltrexone for amelioration of recurrent self-injurious behaviors.¹⁷ See Table 3 for a description of pharmacological interventions for DID.

http://www.ncbi.nlm....les/PMC3615506/

[Tom_]

Olon, there seems to be one small problem...he doesn't have any symptoms of DID.

[Olon]

Olon, there seems to be one small problem...he doesn't have any symptoms of DID.

"Dissociative identity disorder will include reference to possession as well as identity fragmentation, to make the disorder more applicable to culturally diverse situations."

http://www.ncbi.nlm....pubmed/23394228

But DID and depersonalization disorder are probably hard to discriminate and treated similar.

Edited by Olon, 09 May 2013 - 02:36 PM.

[nowayout]

Maybe your difficulty in deciding what "disorder" he has is that most of these diagnoses are creative fictions that have little to do with any underlying diseases, as shown, for example, by the scary high levels of disagreement in studies among any two psychiatrists in diagnosing disorders as apparently uncontroversial such as MDD or GAD or bipolar disorder using DSM criteria, not to mention the controversial oft-abused ones, like ADHD or Asperger's. The infighting and politicking over what should be in DSM-5 has made this more public, but it has always been an open secret. Psychiatrists are not diagnosing diseases or disorders, just largely arbitrary collections of symptoms. We are unfortunately at the level of saying someone has "fever-and-rash disorder", and we cannot distinguish whether they have measles or rubella or poison ivy.

That's not to say we cannot treat the symptoms with therapy or drugs and and that it is not useful to do so (in the above analogy, we can bring down a high fever with acetominophen or ice no matter the etiology), but arguing about a diagnosis underlying a group of symptoms is really an exercise in creative mythology.

Edited by viveutvivas, 09 May 2013 - 04:31 PM.

[Tom_]

He's from the US. No they are not hard to discriminate. DID requires that there are alternative personalities that may control the persons behavior. There also needs to be most or total loss of memory from one personality to the next.

There is a massive rate of extreme abuse mostly sexual in nature among suffers and the 'primary identity' presents most commonly as meek, anxious and depressive. Most of the research links DID and borderline PD as almost inseparable.

Both clinical features and diagnostic features don't point to anything like DID. While its not a reason not to diagnose its a bat shit rare disease to boot. Not to mention its almost unheard of to here of a male with it.

I would remain dubious that there is even depersonalization in this case.

Depersonalization is either the feelings of being detached from ones emotions or body or reversely the world seems to have taken on an abnormal quality (becoming smaller or larger for example).

Getting angry and breaking stuff is not a sign of multiple personalities, its a sign of poor temper control brought on by executive dysfunction, primarily in personality disorder, mood disorder, psychotic disorder or adhd.

In reply to you viveutus, there are certain well defined syndromes with have similar etiologies. ADHD (when diagnosed properly), Schizophrenia, Depression, Bi-Polar...we even have progressed to the point in some disorders we can differentiate between which drugs are likely to be most effective for a particular sub-type.

Atypical depression responds better to MAOI's
Melancholic depression responds better to TCA's

ADHD 'ADD' responds better to DRI effects, ADHD mixed, hyperkentic disorder NRI

Diagonosis is not perfect and its got a lot to do with making the right one. However with a proper diagnosis treatment is usually effective.

Btw, the only study was of US vs UK psychiatrists given a case vignette and asked to distinguish between in acutely psychotic patients whether they had Bi-Polar or Schizophrenia - it was done in the 70's or 80's so quite some improvement has been seen since then.

[Godot]

Maybe your difficulty in deciding what "disorder" he has is that most of these diagnoses are creative fictions that have little to do with any underlying diseases....

I strongly agree with this sentiment.

A good effort has been made to extend psychological diagnosis in a direction similar to functional medicine, in the form of the Psychodynamic Diagnostic Manual (PDM), which starts diagnosis by understanding first how a person's mind is organized and works its way up to the level of symptomology.

NIMH has officially withdrawn support from the DSM (see http://www.psycholog...s-support-dsm-5) because its constructs are arbitrary and poorly supported. Unfortunately, they are going in the direction of pure biological psychiatry, which is equally arbitrary and unsupported.

[Tom_]

The PDM gets chucked out straight away as being unscientific in the extreme. I then add, understanding how a mind works requires understanding how a brain work since the two are one in the same.

Biological psychiatry is the future. How can something reductionist in nature be arbitrary and it certainly isn't unsupported, quite the opposite.

[nowayout]

@Tom, actually, melancholic depression is an interesting example. It has been removed from the DSM-5, despite the fact that it's one of the best understood disorders in psychiatry and the only mood disorder (AFAIK) whose diagnosis can be supported by actual physiological markers and tests (i.e., dexamethasone stimulation test for abnormal cortisol response).

The reason it was removed may have had to do (based on one of the committee member's remarks) with the fact that it can be supported by actual physiological markers - it may have made the rest of the DSM look too bad in comparison.

As for kappa-values indicating agreement between psychiatrists on a given diagnosis for the same patient in trial runs applying proposed DSM-5 criteria for various disorders (1 means they are in full agreement, 0 means they could have flipped a coin):

Schizophrenia: 0.46
MDD: 0.32
GAD: 0.20

Pretty frightening.

Edited by viveutvivas, 09 May 2013 - 05:01 PM.

[Godot]

The PDM actually is quite well-grounded in science.

The supposition that the mind is wholly contained within the brain is unsupported. Neural networks throughout the body, endocrine functioning, metabolic processes, and even gut biome play tremendous roles in psychological functioning.

Cognition has appeared to occur within the brain, and much of the problem with the model of psychiatry that currently predominates is conflating cognition with psychological functioning. This is a remnant of the failed theory that cognition precedes and controls affect -- the very theory on which CBT is based.

In fact, the affect-cognition distinction is not respected within the human brain (http://www.ncbi.nlm....les/PMC2396787/), and the determination of primacy between the two processes appears to depend upon unknown contextual variables (http://www.ncbi.nlm....les/PMC3398397/). Perhaps those processes are located elsewhere in the body, perhaps they exist in some nonlocal mind structure.

CBT techniques work equally well when the theoretical model is reversed to assume a primacy of affect over cognition (https://webfiles.uci...usCogTher04.pdf), showing that, like psychiatric medication, even when they do work the people developing them have no idea why.

Biological psychiatry is at the point where it has the tools to modify gross neurochemical variables in ways that appear to do something, but nobody knows what that something is. We can say that a particular antidepressant might be more effective for a certain presentation (although I don't think even this is very reliable), but nobody can say why.

On the other hand, a study you posted showed that psychotherapy initiates structural changes in the brain, and 200 years of psychotherapy research and practice suggests that those previously unknown biological changes correspond to psychological healing processes. It is therefore a more elegant and sensible solution to address psychological problems by activating the body's own healing processes, which are likely to be a lot more specific and sustainable than any medications.

[Heh]

I looked at these therapies again by watching a video on YouTube, and I just see the same old thing. I can see how normally these techniques would work, but in my case they do nothing. My problems are very specific: intrusive thoughts; feeling like someone steps in, takes me over, then makes me angry and break things; and zero resistance (I get bothered with an intrusive thought about eating outside the 8 hour window I try to eat within, and rather than dismiss it like I normally do, I end up eating, or I ignore the thought, but then forget and soon after find myself eating). Eating can be replaced with anything that's stupid, or anything I'm trying not to do, like responding to certain specific comments in this thread.

Intrusive thoughts, and a hard to resist urge to do the stupid things these thoughts harass me with. That's it. Everything stems from these two things.

Edited by Joel, 09 May 2013 - 06:03 PM.

[Godot]

Joel - What therapies/techniques were you looking into? Maybe you could post a link to the video you mentioned?

[Olon]

Frontal tumors can cause lack of impulse control.

[Tom_]

Yes they can. So can ADHD and malaria but unless he is having chronic and severe headaches, frontal lobe syndrome in general, signs of IH, and possible respiratory problems or metastatic symptoms I don't think he has Cancer or another tumor.

[Olon]

...frontal lobe syndrome in general,...

I agree about that, but a meningioma needn't make other symptoms.

[nowayout]

So can hormonal factors. When I was on testosterone replacement I was going seriously bananas (impulsiveness, rage, depression) to the point where I had to stop it. You don't need to be on exogenous hormones for that to happen either. So a hormone panel wouldn't hurt.

Edited by viveutvivas, 09 May 2013 - 08:01 PM.

[Tom_]

A meningioma causing symptoms causes IH in most cases. Its also gonna be causing focal seizures - getting angry and breaking stuff isn't a sign of that, before you say it.

Less than 3% are anaplastic and less than 10 are atypical. Its not typically in the frontal area and more likely to be around the back two lobes and/or temporal.

[Olon]

Maybe I get such outlandish thoughts because I myself don't know what rage is.

[Tom_]

Eh?

[Olon]

Been suffering from anhedonia and emotional blunting all my life.

[Tom_]

What does that have to do with the possibility of frontal lobe syndrome?

[Olon]

I mean that I need strange things like DID, depersonalization, frontal tumors to explain common symptoms.