Marks Psychiatry

A recent literature review showed that people who take Ambien at night for sleep are able to drive 5-6 hours later.  J. Jason Buckland, D.O. and associates reviewed 10 studies that involved driving tests after the administration of Ambien.  These studies showed that there is no residual impairments in the morning, approxminately 5-6 hours later.

Zolpidem, the generic of the short acting Ambien has a half life of 2.5 hrs.  The controlled release version, Ambien CR has a half-life of 2.8 hours.  What does this mean?  It takes roughly 3 half-lives for a drug to be eliminated from your body.  By two half lives, the drug level is at the low end of the curve (meaning little noticable effect if any).  So if a person only sleeps 6 hours, they have still passed two half lives of the drug and should show no impairment in their driving ability.  This is in contrast to drugs like Trazadone that has a half life of 4-7 hrs or Restoril which is 10hrs.  It’s the long half-life that can make people who take these drugs for sleep feel groggy in the morning.

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There’s a saying, “If you don’t have anything good to say, don’t say anything at all.” There’s merit to this statement and can work well in casual relationships. But with people who are close to you, if you often have little to say about their accomplishments, you can fall short of being a supportive friend.

People like being around people who make them feel good. I think if you frequently have trouble finding something positive to say, you need to examine yourself. Are you overly critical? Are your standards for acceptance too high? I’m not saying you should lie or be disingenuous. But is it really that hard to find something good to say?

For example, suppose your friend redecorates her home. You walk in and immediately notice you hate the loud purple color of the walls. This in addition to the mismatched furniture lead you to believe your friend doesn’t have good taste.How can you find something good to say? You could start by realizing that her “bad taste” is simply not your taste. Even though you wouldn’t have decorated your home that way, doesn’t mean there is not some since of style in it. You could comment on how much work she must have put into it. If she hired a decorator, you could compliment her on how much patience it must have taken to get to the finished product. You could comment how the boldness of the wall color accents the rug. Even though you don’t like the wall color, it still may be striking or rich-looking.

It takes more work to think of positive things to say in a situation, but with practice, it can come more naturally. In this example, if the friend asks openly “do you like it?” You should still be honest if you don’t. But honesty doesn’t have to be brutal or hurtful. You could say, “this isn’t my style”, or “I wouldn’t have picked this for me, but it does stand out and I can see how you put a lot of work into it.” Then in searching for something else positive to say, you could switch the attention to her family and ask “do they like it?” If the answer is yes, then focus on how that’s really what matters.

Why do this? Why not simply say what’s on your mind and be honest? You can if you don’t care how you make people close to you feel. And in some settings that’s the prudent approach. But if you want to build people up, take steps to think of positive things to say and be generous with the praise.

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Body Dysmorhpic Disorder is a condition whereby a person is preoccupied with a physical defect that either doesn’t exist or exists in a very minor form but is exaggerated by the individual. Common flaws are usually those of the face or head such as complexion flaws, thinning hair, blemishes, scars etc. It may also take the form of believing that the shape of a body part is abnormal. The person usually experiences tremendous anxiety and distress over their flaw(s). This can be very debilitating depending on the person’s reaction to their perceived problem and what actions they take to correct it. For example, a person who believes they have an abnormally shaped nose may have several plastic surgeries to correct the shape of their nose. This is not to say that the desire to have plastic surgery to enhance your looks is mentally abnormal, but a person with body dysmorphic disorder may not be satisfied after the first surgery and may have repetitive surgeries to the point that their nose ends up looking deformed.

Psychiatrists don’t often see these patients because they believe their defect is real and may visit multiple surgeons, dermatologists, dentists, etc. They may feel tormented by their problem and have little control over thinking about it. They may spend hours a day agonizing over their defect. Some people can become very isolated because they do not want others to have to view their flaw or feel mocked by those who don’t support their preoccupation.

Body Dysmorphic Disorder usually begins in adolescence, but can start in childhood. It is a chronic condition that may wax and wane in intensity, but tends to be present in some form over the course of a person’s life. Surgical interventions can actually worsen the disorder as the individual may find new body parts to focus on, or may end up with drastic alterations (such as the nose example) that make them more dissatisfied.

body dysmorphic disorder

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Dr. Ravi Dhingra and colleagues out of Harvard recently analyzed data from the Framingham Heart Study and found that people who drank at least one 12 ounce soda each day had a 44% increased risk of developing metabolic syndrome. The soda could be regular or diet and caffeinated or decaf. This suggests that it’s not just caloric intake that results in the metabolic syndrome.

What is metabolic syndrome and why is it relevant to psychiatry? In simple terms, Metabolic syndrome is seen as a precursor (condition that comes first) to developing type II diabetes. Mood stabilizing agents used in psychiatry such as Zyprexa, Geodon, Abilify, Seroquel and Risperdal all increase an individual’s risk of developing metabolic syndrome. These drugs can be very important in treating people with bipolar disorder and schizophrenia. We sometimes use it for other purposes such as difficult to treat depression. Many people will take Seroquel for sleep. But we now have to carefully monitor patients taking these drugs for the development of metabolic syndrome and weigh the risks/benefits of prescribing these medications.

Metabolic syndrome is defined by having three or more factors:

1. Waist circumference greater than 35 inches for women and 40 inches for men;
2. Fasting blood sugar of 100 mg/dL or taking insulin;
3. Blood pressure of 135/75 mm/Hg or taking blood pressure medication;
4. Serum triglyceride levels of 150 mg/dL;
5. HDL cholesterol less than 50 mg/dL for women and 40 mg/dL for men.

Why is the soda consumption important? I thought it is significant that even diet sodas are linked to metabolic syndrome. Often people think they are protected from weight gain issues if they consume caffeine free, diet drinks and will consume them in large quantities. This is important information for anyone maintaining healthy eating habits. But those taking any of the mood stabilizing agents mentioned above, it is especially important to be cautious about soda consumption so as not to multiply one’s risk of developing metabolic syndrome.

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In psychiatry, a prodrome refers to the period of time a person may exibit psychiatric symptoms that may not be serious enough to generate medical attention, but significant enough to cause problems in the person’s functioning. This period precedes the development of the full blown psychiatric disorder.

One example of how this may manifest is as follows: You may notice the person isn’t quite right for some period of time. They may have mild depression or be irritable or overly suspicious of others raising concerns about their mental health. Since the problem comes and goes, no one may say much about it. The person may feel like they are losing control or feels depressed, but also may not say much to others about it. Then it seems things build and the person has a “break down” with more obvious depressed, manic or psychotic symptoms.

A person may have a prodromal period lasting months to years. We often see prodromes in illnesses such as bipolar disorder and schizophrenia. Since the incidence of these illnesses peak in early 20’s for males and late 20’s for females, the prodrome may be seen as early as late teens or early 20’s. Studies show early medical intervention during this period can make a big difference in the course of the person’s illness.

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An article published in the October issue of the American Journal of Psychiatry (164:1539-1546) concluded that the earlier in life a person develops major depression, the more likely they are to have long term social and occupational problems. The authors studied a group of 4 thousand people ages 18-75 with major depression from both primary care and psychiatric offices. For each individual, they established the person’s age when they had their first depressive episode. The age groups were defined as childhood onset (age less than 12), adolescent onset (ages 12-17), early adult onset (ages 18-44), middle adult onset (ages 45-59) and late adult onset (age greater than 60).

The authors found that pre-adult onset (age less than 18) was associated with higher rates of never being married, impaired social functioning, more lifetime episodes and impaired occupational functioning. The people in this group also tended to have more medical problems and concurrent psychiatric illnesses in addition to depression. This is in contrast to those who developed their first episode in middle or late adulthood. These individuals experienced less comorbid psychiatric and medical illnesses and were overall higher functioning.

These aren’t encouraging findings, but it makes sense that the longer a person is depressed or struggles with depression on and off throughout their lifetime, the more opportunity for the illness to impair their quality of life.

Many people have difficulty with the idea of needing a medication “forever” and may spend years resisting treatment. We know that depression causes significant disability in some and rivals other illnesses such as heart disease in lost time from work and over decreased productivity. This study is another in the growing literature that describes the long term affects of having depression long term. Getting good, consistent treatment early can help one’s course so that developing depression early in life does not have to result in having your life permanently derailed.

[tag]depression, depression treatment, early depression[/tags]

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The Substance Abuse and Mental Health Services Administration published a report on the incidence of depression in adults by occupation. They found the 2 occupational categories with the highest incidence of depression were personal care services and food preparation. They also found that that 7 percent of all full-time workers experienced an episode of depression in the past year.

Personal care service is a broad category but included childcare workers, home care aids and animal caretakers. Food preparation included cooks, bartenders and servers. The lowest rates of depression were found in the job category of engineers, architects and surveyors.

The report offers no explanations for these findings. However, it did show that part-time workers and they unemployed had higher rates of depression, 9.3 and 12.7 respectively compared to the 7 percent of full time workers. This suggests that working full-time is somewhat protective for developing depression.

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The short answer is nothing, if you don’t want to have close relationships. There are people who really are content to live as an island. But most people aren’t built this way. The usual scenario I see is the person who spends their young adulthood (20’s and 30’s) charging forward with their career, with limited intimate relationships (usually because they don’t have time) and then at 45 or late thirties for women, decide they are tired of being alone now want to settle down.

There is nothing wrong with choosing to delay marriage or a serious relationship because of other priorities. In fact, it’s better to be honest up front about your focus rather than string someone along feigning interest just to keep them around. However, it can be very difficult to connect with someone quickly if you’ve spent 10 – 20 years being self-centered and avoiding closeness. Once you decide you want a companion, you have to learn how to be a companion who can meet other’s needs.

What does emotional unavailability look like? I think another term that could be used is psychological independence. They don’t need anyone. This person usually feels threatened and uncomfortable when people ask too many questions. Rather than see this positively as someone taking interest in them, they see it as prying or being nosey. They may be easily suspicious of other’s motives; having difficulty trusting others. They may feel smothered by their partner’s attention or desire to spend time together. This often comes from needing to feel in control. When they start to fall in love, they feel less in control and prefer to push the other person away to regain some control. Staying too busy is a passive way of avoiding closeness. In your mind, you have a legitimate excuse for not “wasting” time building relationships.

There are other ways a person can demonstrate emotional unavailability; these are just a few. As you can see these behaviors are not conducive to building intimacy and connectedness in a relationship. The person, who is emotionally unavailable and wants to have a serious relationship some day, should expect to need a running head start to learn how to be close to others. Don’t expect it to all come together just because you’ve met your financial or career goals. You’ll still have some work to do break old habits so you can be a better partner for the person you choose.

The other side of this coin is emotional neediness. I’ll discuss this in a future post.

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