How Do I Learn More About My Diagnosis?
Depression:
Depression is an emotion that all of us experience at some time in our lives, but Depression is also an illness that afflicts many millions of people worldwide. When we become depressed or sad because of something upsetting that has happened to us, this is an expected and normal response to our circumstances. In depression-the-illness we become sad at times there is nothing to be sad about or we become sadder than our situation warrants.
We call depression-the-illness “Major Depression” in psychiatry. It is often accompanied by other symptoms, including difficulty enjoying life, alterations in our sleep and appetites, poor energy and reduced activity, feelings of worthlessness and guilt, and sometimes even thoughts that we would be better off dead. Interestingly, Major Depression requires either that a person be unexpectedly sad or that they be less able to experience pleasure and joy than is usual for them. That “either, or” opens the way for a person to meet criteria for Major Depression and not to feel sad (based on the presence of a reduced experience of pleasure accompanied by the other required symptoms).
Our emotions give salience to our emotions. For example, if we unexpectedly pass a person on the street who was a close friend in high school, we may feel surprise, happiness, excitement, and other positive emotions that distinguish that person to us from the next person whom we have never seen before in our life. Our daily experiences of work, love, friendships, etc., are similarly colored by our emotional responses to them that in turn give these experiences meaning and importance, or lack of importance, to us. When our feelings of sadness become detached from our experiences, that is, when we feel sad when there is little to really feel sad about (“my life is so good – why, then, do I feel so sad”) or when we feel sadder than we should feel in the context of an experience (“it really wasn’t such a big deal, but I just can’t get it out of my mind”), this represents a distortion of our perception. Not only do we feel unnecessary pain and distress during these times of depression, but decisions we make based on these feelings may not accurately reflect our world and therefore may lead to other problems, like loss of relationships, jobs, friendships, etc, that in turn reinforce or maintain these very feelings of depression.
Major Depression, like most psychiatric disorders, reflects subtle malfunctioning of the central nervous system. Studies, for example, of identical and non-identical twins have shown that when one identical twin is depressed, the other is depressed about 55 % of the time. By contrast, when one non-identical twin is depressed the other twin is depressed only 15 % of the time. The rate of Major Depression in the general population is about 5 % at any given time. This is strong evidence that at least some depressions have a genetic basis. Other studies of the brains of depressed people have shown changes in the functioning in the frontal cortex, cingulate gyrus, hippocampus, and other structures of the central nervous system. Alarmingly, when the brains of people who have been depressed are compared to the brains of people who are not depressed, the hippocampus and amygdala actually have less volume, suggesting that when we are depressed parts of the brain we use less become smaller, possibly by losing neurons. This is additional evidence that Major Depression has a biological basis in many cases. This is also consistent with our clinical experience that the more time a person spends depressed the harder the depression is to treat, suggesting that being depressed is bad for the brain. By contrast, recent work has shown that antidepressants (and lithium) increase Brain Derived Growth Factor (BDNF), a protein in the central nervous system known to facilitate the healthy maintenance and even growth of normal nervous tissue in the brain.
Anxiety:
Anxiety is a symptom that occurs in many different diagnoses. There are five common anxiety disorders of adulthood and one other of childhood.
The common anxiety disorders of adulthood are Generalized Anxiety, Obsessive-Compulsive Disorder, Panic Disorder, Post Traumatic Stress Disorder, and Social Phobia. The anxiety disorder of childhood onset is Separation Anxiety.
There are effective medical and psychological treatments of all the anxiety disorders. The medical and psychological treatments are often most powerful when they are combined.
Bipolar Disorders:
There are, broadly speaking, two types of depressive disorders, informally known as unipolar and bipolar disorders. In unipolar disorder, formerly known as Major Depressive Disorder, one usually experiences only two mood states, euthymia (or “normal” mood) and depressed.
In Bipolar Disorder there is a third and often a fourth mood state, known respectively as “mania” and “mixed state”. Mania consists of times of abnormally elevated mood that may include reduced sleep, increased energy as reflected by increased activity, speech and racing thoughts. These times may be remarkable for particular feelings of well being or even euphoria. Note that “elevated” and “increased” implies that these symptoms may occur in intensity from mild to severe. When these symptoms are severe there is little difficulty in identifying them, but when they are mild they are often difficult to identify for a number of reasons, including failure of the person experiencing them to recall them as “abnormal” and thus significant for diagnostic purposes. Sometimes a reluctance to associate oneself with an ill parent also leads to reluctance to acknowledge and report symptoms as mania (“I’m not like my mother”…”I won’t be drugged up like my mother was”, etc).
The fourth, or mixed state, is thought of as the co-occurrence of the high energy of mania and the negative emotions of depression. This high-energy unhappy state manifests as irritability, anger, or anxiety, or a combination of all three. The increased energy of the manic portion of mixed states often leads to reduced and broken sleep, physical agitation or even aggression, racing thoughts and highly distractible attention. These mixed states contrast sharply with the usual depressions of bipolar disorder that include increased sleep, lethargy, and cognitive dulling. In bipolar depression, one often feels one cannot get enough sleep, in mixed mania, one cannot sleep well. In bipolar depression one’s mind is dull and slow, in mixed states one’s mind often feels like a popcorn popper, with thoughts exploding into consciousness only to be replaced by other, often unrelated thoughts, the thoughts usually, however, all running along markedly negative lines. In bipolar depression, one has too little energy (lethargy, fatigue, poor motivation being common descriptors), in mixed states one has too much energy, but the energy is unproductive, nervous, agitated or angry.
Mixed mania is the “great impersonator”, during which virtually each of the six common anxiety disorders can occur, eating disorders become active, impulses emerge to self destructive behaviors like self mutilation, and psychoses intrude. Untangling these symptoms and identifying the primary from the secondary diagnoses is often difficult, even for skilled and experienced diagnosticians. Parsing the symptoms that are due to mixed states that do not represent independent disorders (i.e. “secondary” conditions) can lead to years of ineffective and even harmful treatment with inappropriate medications. There are several very important observations about Bipolar Disorder to be made here: the proportion of depressions to manias is not relevant to the diagnosis: one may have experienced 30 or more depressions for each (brief) mania, but the diagnosis is still Bipolar Disorder (studies have shown that in Bipolar II this is precisely what happens). Many, if not most people with Bipolar Disorder do not experience the classic “euphoric” (or happy) mania, but rather mixed states. The anxiety of mixed mania may be overwhelmingly the most distressing part of a patient’s experience, but it is still primarily due to a mood disorder and will not improve until treated as such (As such, an anxiety disorder may be an incorrect diagnosis as the primary problem is still Bipolar Disorder). As many as 1% of bipolar patients will never have experienced a true depression and some of these patients may only have experienced mixed states and euthymic (“normal”) moods, confounding the “two mood states is unipolar depression” rule noted above and presenting particular diagnostic challenges.
Historical points suggesting the presence of bipolar disorder include any family history of Bipolar Disorder, multigenerational mood disorders (“my grandmother was like this and my mother had problems too.”
Bipolar Disorder is more heritable than unipolar depression, family members who abuse drugs or have alcohol or a personal history of substance abuse (up to 60% of people with bipolar disorder have a significant history of such abuse, much higher than the general population or people suffering from unipolar depression) early (childhood or adolescent) onset of a mood disorder, feeling “great” within days of starting an antidepressant (referred to as “switching”; “too good too soon is not good”), failure of many (more than two) trials of antidepressants consistently to improve a depression; becoming manic or markedly agitated or anxious while taking an antidepressant; and others.
Bipolar Depression is distinguished from Major Depressive Disorder because the treatment of Bipolar Disorder is different from the treatment of Major Depression. The use of antidepressants alone is appropriate in Major Depression, but can make Bipolar Disorder worse, leading to the rapid switching between moods noted above and increasing the rate of cycling. This leads to the paradoxical, but very important principle that antidepressants are not appropriate for all depressions. In fact, there are certain kinds of depression that should not be treated with antidepressants. This in turn leads to the axiom that no depression should be treated with medications before a thorough and complete assessment of lifetime symptoms has been accomplished by a qualified and experienced mental health clinician.
The treatment plan for Bipolar Disorder should recognize that Bipolar Disorder consists of two components, the mood fluctuations as the moods move from depressed to normal to manic or mixed mania, and the mood itself. This is to say that one cannot really identify what the mood of a person may be when it will be different tomorrow from what it is today from what it was last week. Only when the mood fluctuation has been stabilized into a more consistent state can the question of mood be addressed. Medications that stabilize mood can reduce these mood fluctuations by holding the mood in a more constant state, but that state may be a normal mood or it may be depression (manic states are unstable by nature). Once stabilized, in other words, the mood itself may be depressed. This is progress. Once the mood is stable, then one can address the remaining depression while maintaining the stability previously achieved. Stabilize the mood first and then address the depression, if still present.
ADHD:
Background
There are systems in our central nervous system that enable to us to concentrate and to attend to particular things around us while excluding other things from our consciousness. For example, when a shopper looks at a particular item in a display and her central nervous system excludes the other people walking by, the overhead music, and the items in neighboring displays. Once she has seen what she wanted to see, she withdraws her attention and at the same time she notices the people walking by, the overhead music and the neighboring displays again. Or, as another example, a student concentrates his attention on an examination, and while doing so the student won’t notice the cars driving by outside, the birds singing outside the window, or the other kids whispering in the back of the class.
When these systems that control attention and concentration malfunction, we are unable to exclude the competing stimuli from our consciousness to allow us to attend to particular stimuli. That is to say, the shopper’s central nervous system does not exclude the people walking by, the overhead music or the neighboring displays from consciousness. Similarly, the young person trying to take the test notices the cars driving by, the birds singing and the other kids whispering in the back of the class. Consequently, the shopper has trouble deciding whether she wants to buy the idem in the display and the student has trouble completing his test.
There are related systems that allow us to be still while we concetrate. As an example from the animal kingdom, consider what happens when a dog perceives something new in its evironment, say a bird in its yard. The dog typically looks, listens, and smells in the direction of the bird while at the same time becoming still and quiet before rushing the bird. Something similar happens when we concentrate on something. Consider a person reading a book while waiting for a flight in the airport. While reading the person is usually still and quiet, with little physical movement and no speech. When we attend to something, in other words, our physical activity and speech is suppressed. When the systems controlling this suppression in the central nervous system malfunctions we have difficulty being still and quiet. Instead the person with ADHD fidgets and wiggles, talks too much, and in extreme cases runs and jumps at times the person is expected to be still and quiet (school, a movie, church, etc).
Possible misunderstandings
Note that a person with ADHD can through force of will be still and quiet and concentrate, but this force of will requires effort, work, and consequently the person tires or fatigues after a short time and the activity, talking and inattention reemerge. Sometimes parents or teachers perceive this ability to be still, quiet and concentrate for short periods and conclude that the person with ADHD is lazy or that they lack desire to be still, quiet and attentive. This is incorrect – the person with ADHD actually works very hard to be still, quiet and attentive, much harder than other people without ADHD. A person without ADHD, by contrast, does not have to work to be still, quiet and attentive.
Diagnosis
The diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD) requires symptoms from one or both of two categories: inattention and hyperactivity/impulsivity. The inattention symptoms include distactibleness, difficulty maintaining attention, forgetfulness, disorganization, difficulty following through on tasks, losing things, making hasty mistakes in tedious work. The hyperactivity/impulsiveness symptoms include difficulty sitting still, difficulty sitting for long periods of time, talking too much, being loud, impatience, blurting things out in groups, interrupting people, finishing sentences or cutting people off in conversation.These symptoms must have been present before a person is 7 yo (some experts say 10 yo and some are now urging the consideration of adult onset ADHD). The ADHD is categorized as inattentive type when inattention predominates, hyperactive/impulsive type when there is little inattention, and combined type when there is both inattention and hyperactivity/impulsiveness.
Note that ADHD of any type is different from intelligence. Many people who suffer from ADHD are very bright and as a result the ADHD symptoms may not become problematic until later in life even though the symptoms have been present since early childhood. Patients who are of the inattentive type are often not identified until later in life for several reasons. The division of ADHD into these subtypes was not made until 1994 with the publication of the current diagnostic critieria in the Diagnostic and Statistical Manual, fourth edition. More importantly, most people suffering from ADHD, inattentive type, are not trouble makers and consequently in school they were perceived as lazy or too social or uninterested in school rather than suffering from a disorder of attention.
And finally, we find that many people suffering from ADHD are visual and imaginative so they enjoy reading fiction and do so for hours on end, from which they conclude they do not have problems with attention. The real test comes, however, when they are required to read non-fiction that does not lend itself to visualization. This task is often painfully difficult, revealing the problem with attention.
OCD:
Obsessive-Compulsive Disorder (OCD) consists of the presence of obsessions or compulsions that cause significant distress or impairment. Obsessions are thoughts a person knows are their own that contain possible events that upset and worry the person having them. These worries often consist of actions that are repugnant to the person having them (“I would never do that …”) but they nevertheless fear they may do them. Similarly, some compulsions consist of fears of harm coming to the person having the obsessive thoughts (“If I touch the doorknob I might get germs …”). One of the common properties of all obsessions is that they cause the person experiencing them to become anxious and upset. Compulsions are behaviors, like checking, washing, arranging, etc, that are intended to reduce the anxiety precipitated by the obsession. However, the compulsions seldom allay the fears from the obsessions, so the behaviors are repeated over and over in an effort to extinguish the obsessive fears. Note that repeated behaviors that seek pleasure are not truly compulsions (gambling, shopping, etc) and should not be referred to as “compulsive shopping” or compulsive gambling.”
PTSD:
Post Traumatic Stress Disorder (PTSD) consists of a constellation of symptoms in response to a life threatening event that includes avoidance of reminders of the trauma, emotional numbing, and emotional withdrawal from other people. Reminders of the trauma, which may be people, places, or events, cause the person suffering from PTSD to become distressed, often similarly to their feelings at the time of the original trauma. The trauma often leaves people emotionally numbed, meaning that they have difficulty feeling common human emotions like joy and happiness. The trauma itself often leaves the person who has suffered the trauma separate and apart from other people because other people have not experienced anything like their trauma, and consequently other people cannot understand them. Interestingly, PTSD is one of only two diagnoses in our current schema that require a preceding event (the other is Reactive Attachment Disorder).
GAD:
Generalized Anxiety Disorder (GAD) is a condition in which people fret and worry excessively, to the point of personal distress and even functional limitation. People suffering from GAD worry out of proportion to the things they worry about – that often are remote from them (e.g. world events, local contingencies – “what if the trucks can’t come to the markets?”, etc.) – and that are certainly not under their control. Physical tension and insomnia often accompany the worrying, so that people suffering from GAD look anxious and mildly agitated most of the time. The fact that “stop worrying” seldom helps and may even make the worrying worse, often leads to frustration or emotional withdrawal by friends and family members. Generalized Anxiety tends to run in families (“my grandmother was just like me”).
Mood Disorders:
Mood disorders afflict millions of Americans and hundreds of millions of people worldwide. Our moods are particular kinds of emotions that give salience or meaning to our experiences.
For example, when we happen on an old friend with whom we attended high school and whom we have not seen for many years, we feel surprised and happy. By contrast, the next person who walks by, whom we have never met, rouses no such feelings within us. The difference in feelings distinguishes our relationship to these two people. Similarly, we feel strongly positive and joyful emotions when we behold our someone we love, but feelings full of hurt and anger when we turn a corner to see a person who has intentionally harmed us in the past. All these feelings and emotions, and many more, allow us to distinguish people, places and circumstances that are meaningful to us in different ways from those that are not.
These feelings and emotions are products of biological processes in our central nervous system. Like all systems in our body, for example our lungs, our vision, or our heart, the central nervous system sometimes malfunctions. When our vision malfunctions we might call it nearsightedness or farsightedness, when our lungs malfunction in a certain manner we call it asthma, when our heart malfunctions in a particular way we call it tachycardia. Similarly, when our central nervous system malfunctions, it may lead to depression, mania, or mixed states (the combination of mania and depression). These disorders of emotion lead us to perceive our world inaccurately, so that we become angry at people who have really done nothing to offend us, depressed and sad when there is little or nothing to be sad about, or inexplicably giddy and happy. The decisions we make and the way we relate to people are distorted by these inaccurate perceptions. Like nearsightedness, asthma and tachycardia, these disorders of mood can be treated medically to enable us emotionally to perceive the world accurately again.
The Mood Disorders Clinic of Scott P. Hoopes, M.D.,& Associates is designed to accurately diagnose and treat mood disorders. We use diagnostic instruments developed for use in psychopharmacological research to establish reliable and reproducible psychiatric diagnoses. These diagnoses become the foundation for all subsequent treatment.
Panic Disorder:
Panic Disorder (PD) consists of sudden attacks of terrible fear that occur without warning, come on suddenly, and usually do not last more than fifteen excruciating minutes. The emotions of fear and terror are usually accompanied by physical symptoms like shortness of breath, chest pain, nausea and even diarrhea, trembling, chills and sweats, and others. People who have had panic attacks sometimes worry about having other panic attacks, and this worry can sometimes lead the person to avoid leaving home (agoraphobia). PD often starts with one very memorable panic attack in response to a particular circumstance, but then the panic attacks become independent of stimulus and occur unpredictably.
Separation Anxiety:
The common childhood anxiety disorder is Separation Anxiety (SA). As the name implies, the anxiety of SA features fears of being away from people, including family and sometimes friends, to whom the person with SA is close.
Manifestations of SA include difficulty sleeping alone, nightmares of harm to the person with SA or people close to them, distress when parents or siblings do not come home when expected, and difficulty leaving home and family to go to school or even the inability to go to school unless there are siblings or close friends at school (in which case the person with SA moves between friends and siblings, careful always to have someone they are comfortable with close to them). It is thought that SA often becomes GAD in adulthood. Think of the possibility of undiagnosed SA in young adults who have trouble leaving home to live independently.
Social Phobia:
People who suffer from Social Phobia (SP) experience marked and distressing anxiety when they must interact with other people. When not called upon to be with other people these patients experience little or no anxiety. When with people, however, the anxiety people with SP suffer often causes them to appear awkward or even to have difficulty speaking. This, unfortunately, fulfills the worst fears of the person with SP, and further reinforces the fear of social interaction. People with marked SP sometimes cannot leave their home or keep a job. They sometimes develop secondary panic attacks.