Aswad
Posts: 9374
Joined: 4/4/2007
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ORIGINAL: Termyn8or
I am seriously against SSRIs and anything that even resembles them. I guess they are necessary for some, but overused.
Well, the SSRIs are not the most effective, by far.
They are mostly popular because they're cheap, even cheaper to produce, and usually safe in overdose.
But you get what you pay for, a bit surprisingly.
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That comes from my beliefs, and I believe that they are wrong to assume that these hormonal imbalances are causing the disorder, and they are wrong to reject the notion that the imbalances are caused by the disorder. But western medicine only treats symptom usually, so that is what we got.
This demonstrates a somewhat skewed view of the topic.
First off, hormonal imbalances are very rarely addressed by western medicine when treating anxiety disorders, depressions, and so forth, despite the fact that hormonal imbalances have been demonstrated to have some effects in this department. The closest thing is that tianeptine (Stablon) reverses some of the hormonal and physiological effects of stress.
Second, the theory upon which western psychopharmacology is based, is related to neurotransmitter activity in various parts of the brain, not hormones. Certain illnesses that are usually treated with SSRIs, for instance, will almost universally be made worse by the SSRIs, while others will be greatly improved; for the average prescribing doctor, there is little to differentiate them before trying. fMRI, SPECT and so forth can give a clearer picture, while I have found that there are prognostic markers that work well if one is in a bit less of a rush. Note that there are other classes of drugs used in treating these things, including SNRIs, NARIs, SREs, DARIs, TCAs, MAOIs, CNS stimulants, GABA-transaminase inhibitors, triple / unselective monoamine reuptake inhibitors, H3-antagonists, κ-antagonists, µ-agonists, D2-agonists, VMAT reversing agents, and so forth... then, for acute anxiety and so forth, there's benzodiazepines and barbiturates; I'd add κ-antagonists and µ-agonists to that list. Either way, though, you get the idea; there's a lot more out there than the docs usually try.
Third, the causology is generally assumed to be "a bit of both". That is, it doesn't so much matter which came first, because there's a chicken there, and it's laying eggs. When you administer reserpine (a drug found in the Rauwolfia plants) to someone who isn't depressed, they will be, after a little while. This is one of the things that sparked off the theory. Conversely, when you administer cocaine, there will be an improvement for a while, then a big crash; and, of course, long-term problems with the VMAT pumps. Anyway, the idea is, as it has always been, to identify ways of interrupting feedback loops wherein, regardless of which came first, you have chickens laying eggs that hatch and the cycle repeats. Kill the chicken, grill the eggs, doesn't matter. You're stopping the progression. Psychotherapy has not, repeat not, been successful at finding any viable strategy for identifying the "eggs" in this analogy. Psychopharmacology has been quite successful at identifying several kinds of "chicken". If the docs could just learn to tell if they're roosting, it'd all be nice and dandy.
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Therapy with a psychologist, rather than a psychiatrist should always be tried first.
Why would you want to put a patient that cannot speak, hear, or respond to other stimuli in with a psychologist? If you haven't seen depression, etc., go that far, then you should go back to the drawing board with any theory about what should be tried when, because there are some vital pieces missing.
A psychologist, priest, social worker, or other comparably skilled listener, will usually have a fair chance at preventing someone from becoming ill when their problems are of a solvable nature with identifiable stressor elements. However, the only identified form of psychotherapy that has shown any improvement over a random "good listener", is cognitive behavioural therapy, which can take a long time and is less popular with the docs. Obvious, really- it doesn't give any spectacular or fancy theories about what makes a person tick ... it just solves their problem, and lets the mind sort it out.
There's that whole saying about "a stitch in time ...", and I'm all for that.
And I don't think that "stitch in time" should be soaked in drugs.
But when it's no longer a "stitch", it's time to consider the serious options.
Generic psychotherapy is applicable to preclinical problems without unresolvable long-term stressors.
Cognitive behavioural therapy, or (for certain illnesses) dialectic behavioural therapy, are applicable to preclinical and clinical problems up to "moderate" severity, without unresolvable, undeflectable long-term stressors.
Psychopharmacology and ECT are applicable to clinical problems up to "severe" severity, even in the presence of unresolvable, undeflectable long-term stressors. It can also be successfully applied to certain preclinical problems, but that should not generally be attempted by someone who isn't very good at that.
Dietics is a field I haven't studied thoroughly enough, past the "get enough B6, B12, magnesium, potassium, water and varied healthy food, while reducing carbs and dropping sugar and sweeteners" stage. According to a study, it was about as effective as regular psychopharmacology if supplementation (e.g. DLPA, l-tyrosine, l-5-htp, etc.) was added, but I do not recall what level of severity this study dealt with; most likely clinical light-to-moderate severity, where the bulk of research is done. Doctors often know little about this, and it takes a doctor to do it right.
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It is my firm view that drugs should be the very last resort.
It is my firm view- from seeing cases where (a) drugs were tried where they shouldn't have been, and (b) drugs weren't tried where they should have been, and (c) therapy was tried where it was an obvious waste of time, and (d) therapy wasn't tried where it would have been an obvious improvement- that each case should be individually evaluated by someone with the qualifications to make a proper assessment.
Blanket statements are what gives psychopharmacology a bad name.
Don't do psychotherapy et al the same disfavour.
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They know full well the truth, but want to make money.
The Truth(tm) is not known "full well" by anyone at the moment.
But, yes, there is a lot of money to be made, and the law mandates that the drug companies use any means at their disposal to maximize shareholder profits. However, if you have a look at the profit numbers, it will be apparent that they are not making more money than other companies. That is, there is no discrepancy.
In short, if the drug industry is being dishonest about anything, they're either doing a crap job of exploiting us, or all the other industries in the US are equally dishonest and corrupt. If that is the case, why single out the drug industry?
Sure, they cut corners. They suppress competition. They go where the money is.
But they do make an effort. And the first-line (primary care) health care is where the problem is at.
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Common sense, if you smack a guy upside his head you know he is going to have an increased level of adrenalin in his system.
Yes, well, that, and he might very well sustain injuries.
Most of the time, a light blow to the head is no problem. Sometimes, it is a big problem.
That's why the docs want to check it out.
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The same will happen if you shove a gun in his mouth, but the response is a bit different.
Quite familiar with the response, thank you very much.
I've had a 7.62mm assault rifle pointed at me from a distance of about 1m, and the trigger pulled, while convinced that it was loaded. For reference, the rifle in question is the AG-3, which is essentially the same as a G3 but with repeat fire, and used by the Norwegian army.
Unlike what is the case with the M-16, which is a 5.56mm assault rifle used by the US army, the user of an AG-3 is taught to ignore whether the target is behind cover, as no generally available cover will provide any significant protection.
It was my belief at this time that the weapon was loaded with Raufoss multipurpose ammunition, which effectively works like a hollow-point round against a soft target (i.e. human, in this case me) at that distance.
Did I get a response? Yes.
Did I have an adrenaline rush? Yes.
Did it have any long-term effects, or in any way contribute to- or resemble- what goes on with mental illness? No.
There is a vast difference between transient, short-term and long-term stressor response.
There is also a vast difference between stressors and dissonant distress.
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Our hormonal makeup is not simply the cause of our attitude, it is also the effect of our attitude. Adjusting it chemically is like putting a band-aid on a bullet wound. It is much better to get to the root of the problem.
Not so much.
It's more like applying direct pressure proximally to a bullet wound: it stops the bleeding.
Which is not to say it removes the wound, just that it stabilizes the patient.
In some cases, it is a viable option to treat the root cause without using any drugs at all. Other times, not so much. Some times, you just have to improve the symptoms a lot before you can even begin to treat the root cause; this is comparable to the bullet wound example again, where sometimes you'll just have to stop the bleeding and put in an I.V. line before you can think about putting them into surgery to extract the bullet. A patient who does not speak, and does not respond to stimuli, for instance, cannot be treated with psychotherapy.
The root causes are typically environmental, and may not always be resolvable.
When the root cause can be addressed, it should be, without neglecting patient care in the mean time.
However, when the root cause cannot be addressed, which is sometimes the case, then you need to address the symptoms in a robust manner to prevent further deterioration and aggravation of the root cause.
As I said before, it's a feedback loop. The root cause, whatever it is, causes mental illness, which in turn causes mismanagement of environmental factors, which in turn causes environmental stressors, which in turn reinforces the mental illness, which completes the feedback loop. Call it the downward spiral, if you will.
Drugs aren't a cure.
They are a way to break the downward spiral.
Sometimes, that's enough for the mind to heal itself. Other times, it's not.
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Just what does the anxious person think is going to happen ? And why ? If this is not explored you might as well deliver a trailer full of drugs, and they may be dependent on the drugs for life. In my view, that is to be avoided at all cost.
With some anxiety disorders, there is no specific thing that causes the anxiety. No cause.
With others, there is a specific thing, and they know full well what to expect, but the response is exaggerated due to various reasons. The most common one, according to some studies out of Israel, being that there is a defect in one or more enzymes that are responsible for breaking down the chemicals that cause the anxiety response, which leads to them accumulating so the response becomes a lot stronger, and also leads to them lasting longer in the body so the response lasts a lot longer.
With social anxieties, there are very well established means for dealing with the issue. And that is something that should be addressed with psychotherapy. But if the patient is so anxious that they cannot function socially, that will just aggravate the problem if they are not treated with drugs to suppress those symptoms enough that they can "unlearn" their fear of social interactions without making the problem worse.
A lifetime drug dependency only occurs when someone isn't doing their job, or when it is convenient.
Consider that you are hopelessly dependent on water, air and food.
It isn't a question of avoiding dependency. We are biological organisms. We depend on things. It's a fact of life. The issue is whether there are things we depend on that we can do without, and whether it would be more convenient to do without them or not.
In short, if an anxiety disorder can be managed by popping a Xanax every now and then, while treating it would require a lot of time and effort, it may be just as well for that person's quality of life to go for the convenient approach of keeping a box of Xanax in their purse.
And while you may find "at all costs" to be reasonable, I would say that indicates you probably do not have experience with severe (in the clinical sense of the word) illness, for the phrase "at all costs" indicates that even remaining ill is preferrable, which is patently not the case. Is death preferable to being ill? Yes, frequently. Then it comes down to whether you think killing the patient is better than leaving them dependent on drugs if there is no other option available.
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Trying to keep my mind open, I do realize that some people have had really bad childhoods, including abandonment, and possibly a plethora of different abusive behavior. If the child was not made to feel secure, the adult will not feel secure. It really is a shame that alot of people have forgotten how to raise, nurture and teach children.
I had an excellent childhood. I never experienced abandonment. There was no abusive behaviour. I felt completely secure in all respects throughout my childhood and my adolescent years. My parents did a model job of raising, nurturing and teaching me, as a child, as an adolescent, and even still do their best to offer their assistance in life (they have, after all, gone down the same road already; no need for me to repeat their mistakes).
This did not prevent me from becoming ill for biological reasons.
Nor did it prevent me from later becoming severely (in a clinical sense) ill for reasons of unresolvable stressors.
Now, I'd point out that what I do for a living, is solve problems.
Any problem.
Give me a description of the problem, and the authority and resources to fix it, and I will give you an estimate of how much time it will take to solve it. Then you say "go ahead", and I solve it. No exceptions, so far.
The reason I'm good at it, is because I can assimilate a huge amount of information in a short space of time, organize it, make a structured analysis, clearly identify the cause-and-effect chain, and find one or more (usually several) viable ways to correct the problem. I can also apply this to life in general, and have done so in the past.
Using these skills, I have prevented suicides, healed broken families, and resolved a host of issues.
But these skills also allow me to see when the only solutions available include drugs, or the patient essentially doing a complete refactoring of their gestalt and their life in order to cope. Losing their identity and self, in effect. This was the case for me, as concurred with by several skilled professionals and several skilled analysts / problem solvers, all of them highly intelligent, highly educated people with significant life experience.
In such cases, I do not hesitate to reccommend pharmacologic treatment options.
And, at least for the people that I have determined treatment for (I'm not a mental health professional, they just ask me what to do sometimes), this has not, so far, required anyone to remain on drugs indefinitely, though some need to stay on them for a few years.
Simply because that's how long it takes them to put their lives back in order, resolve or outlast the stressors, etc.
In short, I break the feedback loop, breaking the downward spiral, then I resolve the stuff that pulls them down.
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One must teach one's self. You get past it. You grow up.
Geriatric mental illness is a good example of something that is not resolved by "growing up". The patients are already in their terminal years. "Growing up" means dying for them. I doubt you mean to say that spending the rest of their lives miserable, then dying, is the reccommended mode of treatment for an elderly patient.
Similarly, "getting past it" works for subclinical problems in some cases (the rest end up becoming clinical problems). But you cannot always "get past" things. And at the point where I usually deal with patients, they no longer care to. They just want to die, as they no longer see any hope that things will ever get better, and no amount of quality time left in their life would make up for another year in their present state. Again, "getting past" that involves dying; not what I would reccommend as "treatment".
I agree that teaching oneself is useful, if one has what it takes to do so.
Absent that, having others teach oneself is also useful.
But one has to be at a point where it's possible.
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I can't think of any bigger impediment to that process than a chemical crutch.
Then you need to think about it a bit further.
Alcohol is a chemical crutch. So is any other unsupervised use of "street" drugs.
Proper use of psychotropic medication, however, does not constitute a crutch unless that's what is called for. By analogy, when both your legs are broken, a crutch (or similar "impediment" as you call it, or "aid" as I call it) will be needed up to the point where you can start walking on them again. If, however, your arm is broken, you just need a splint or somesuch and let it heal on its own.
Proper use of psychotropic medication is not an impediment to the process, but an aid.
Improper use is an impediment, however.
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It's like giving crutches to a baby who is trying to learn to walk. Take that analogy with a grain of salt, it about what I can think up right now.
I'll bury that analogy in a nearby salt yard, if you don't mind. 
Try this one instead: in light-to-moderate severity cases, it is somewhat like putting training wheels on a bike.
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I have my own theories about anxiety.
Everyone does.
That's how psychology came about.
And, unfortunately, very few people in that field care to test their "theories".
A theory, in the scientific sense of the word, is something that makes falsifiable predictions. Things you can test, which will disprove the theory if there are any flaws in the predictions made by that theory. "Proof" is the accumulation of failed attempts at disproving a theory.
In evidence-based medicine, or even evidence-supported medicine, a theory will be tested using large samples, randomization, double-blinding, placebo controls, and so forth. This is sadly lacking in the psychology field, with the notable exception being the trials done with cognitive behavioural therapy (and possibly DBT, I haven't looked too closely at that), which show about the same efficacy as SSRIs, and a significant improvement over all other "theories" that have been forwarded.
As for your theory, if it is based on your personal experiences, I'd suggest having a look at Dialectic Behavioural Therapy. There are similarities in what you describe to some of the things I've heard it strongly advocated for. This being a public forum, I will refrain from commenting on which things. Feel free to PM me if you're curious.
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You might be under the gun at work to meet a deadline or whatever. Would drugs that make you not care be appropriate at that time ? I think not. Hell I could do that with a few beers, but that would be completely out of place.
That isn't mental illness, just simple stress.
And, no, drugs that make you not care are not generally appropriate, unless that is what it will take to let you concentrate on the job, rather than on the stress. Then you can find another job. But, generally, drugs that make you not care would be drug abuse in this situation, just like the beers would be.
I'm not entirely adverse to the idea of cognitive enhancers, but that's an entirely different debate.
Stress management is mostly a learned skill.
For those who are unable to learn it, or whose lives would be seriously messed up in the attempt, there is tianeptine (Stablon) to reverse the stress-response (does wonders for asthma, too), and various other drugs that will make it possible for the person to carry on until they get to a point where they are able to remove the stress. Also, most of these will give a person enough breathing space to make it possible to teach them how to deal with stress.
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If you get through it you have a lasting permanent solution, a cure if you will.
No argument there. Caveats are the rest of the post.
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That word is not used much anymore, it is called treatment now.
Such is a shortcoming in the application of the method, not the method itself.
Treatment is the attempt to arrive at a cure.
Some do better at this than others. The bulk of the first-line health care service does not. And most patients (85% IIRC) don't comply with treatment requirements, meaning they don't get cured even in the cases where they could have been.
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And medicine is now called medication.
Which essentialy means "the medicine you're on". Don't see the problem.
There is no implication that you'll stay on it forever.
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Believe me or not, but I speak from experience.
Sounds like it.
But it sounds like personal experience; anecdotal.
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Psychologically I used to be one of the most fucked up people you would come across.
That seems less likely.
How much time have you spent out of secure lock-up before you arrived at this cure?
If the answer is more than 25% of your life at that point, you definitely aren't the most fucked up I've seen.
Which is a good thing. 
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I have identified the root causes of this and was able to put it all behind me. I highly suggest that people try to do the same. The cure lasts.
Glad to hear it worked out for you.
There are issues for anyone to work through in life. That is, as you say, part of growing up.
However, there is a line, albeit fuzzy, between "not coping" and "being ill".
Few have the skills to deal with the "wrong" side of that line.
_____________________________
"If God saw what any of us did that night, he didn't seem to mind.
From then on I knew: God doesn't make the world this way.
We do." -- Rorschack, Watchmen.
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RE: Anxiety Disorder and BDSM-- What should I do? - 
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