Archive for the ‘Anti Depressants-Sleeping Aid’ Category

WHY YOU CAN’T STAY AWAKE: THE PHYSICAL CAUSES OF SLEEP APNEA – THE HORIZONTAL POSITION

Thursday, May 12th, 2011
One of the factor in apnea is the horizontal position we assume during sleep, which can lead to narrowing of the air passage. The breathing tube collapses somewhat because of the weight of the body pressing down from above, and it is further obstructed to a degree because the tongue moves from its usual waking position to a position farther back in the throat. Also, during the night the coughing mechanism is somewhat suppressed, and the lungs are less able to clear themselves of secretions. All of these slowdowns in breathing function are normal and pose no threat to the majority of people. When complicated by other factors, however, they can result in OSA.
Results of the physical examination of an apnea victim are often relatively normal. I may, and often do, find elevated blood pressure, or I may notice that the mouth and pharynx are smaller than normal or “crowded” due to some kind of unusual structural formation. On listening to the neck I may hear stridor—the harsh, high-pitched sound associated with obstruction of the larynx. In cases where the heart has been affected, I may detect signs of right ventricular failure, such as distension of the jugular vein or swelling of the ankles. Analysis of gasses in the blood may reveal a high level of carbon dioxide; if so, I will want to rule out some other form of lung disease by ordering further pulmonary tests.
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BDD – SUGGESTED GUIDELINES FOR FAMILY MEMBERS AND FRIENDS: DON’T GIVE REASSURANCE

Thursday, March 10th, 2011
Reassurance seeking is the BDD ritual that most often involves other people. It’s also one of the most frustrating for family members. If the questioning is reassurance seeking because they realize how bothersome it can be. But others simply can’t—the urge is irresistible. Parents of a 20-year-old woman with BDD told me, “We don’t know how to cope. No matter what we say, the questioning persists. We love our daughter and want to reassure her that she looks fine. She thinks we’re lying but we’re not. We don’t know what to do.”
The best response to this ritual—as to all others—is to not participate. In other words, don’t reassure the sufferer that they look okay. Even though they look fine, telling them this just feeds the BDD and keeps it going.
The typical—and understandable—response is to provide the reassurance the BDD sufferer seeks. After all, the person with BDD looks fine, so the natural tendency is to say so. Common responses include “You look fine!” “I can’t see it at all,” “It’s hardly visible,” or “It’s not as bad as you think—it’s hardly noticeable!” The problem with these responses is that although they’re true, they don’t stop the questioning for long, if at all. Furthermore, reassurance doesn’t put an end to the appearance concerns.
Paradoxically, responding to questioning with a reassuring reply can actually perpetuate the reassurance-seeking behavior. If the response does temporarily decrease the BDD sufferer’s anxiety, this transient relief fuels their attempt to obtain more relief by asking the question again. While it might seem cruel to refuse to respond to requests for reassurance, it isn’t. Refraining from providing reassurance may actually stop this time-and energy-consuming behavior.
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BDD – SUGGESTED GUIDELINES FOR FAMILY MEMBERS AND FRIENDS:  DON’T GIVE REASSURANCEReassurance seeking is the BDD ritual that most often involves other people. It’s also one of the most frustrating for family members. If the questioning is reassurance seeking because they realize how bothersome it can be. But others simply can’t—the urge is irresistible. Parents of a 20-year-old woman with BDD told me, “We don’t know how to cope. No matter what we say, the questioning persists. We love our daughter and want to reassure her that she looks fine. She thinks we’re lying but we’re not. We don’t know what to do.”The best response to this ritual—as to all others—is to not participate. In other words, don’t reassure the sufferer that they look okay. Even though they look fine, telling them this just feeds the BDD and keeps it going.The typical—and understandable—response is to provide the reassurance the BDD sufferer seeks. After all, the person with BDD looks fine, so the natural tendency is to say so. Common responses include “You look fine!” “I can’t see it at all,” “It’s hardly visible,” or “It’s not as bad as you think—it’s hardly noticeable!” The problem with these responses is that although they’re true, they don’t stop the questioning for long, if at all. Furthermore, reassurance doesn’t put an end to the appearance concerns.Paradoxically, responding to questioning with a reassuring reply can actually perpetuate the reassurance-seeking behavior. If the response does temporarily decrease the BDD sufferer’s anxiety, this transient relief fuels their attempt to obtain more relief by asking the question again. While it might seem cruel to refuse to respond to requests for reassurance, it isn’t. Refraining from providing reassurance may actually stop this time-and energy-consuming behavior.*406\204\8*

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THE EVOLUTION OF INSOMNIA DRUG THERAPY: BENZODIAZEPINES – TRIAZOLAM

Thursday, December 16th, 2010
Marketed under the brand name Halcion, triazolam possesses the shortest half-life (four to six hours) of the major hypnotic benzodiazepines; thus the effects of the drug are usually completely gone by morning. It is especially useful in cases of transient insomnia, or for occasional use in chronic insomnia when sedative or antianxiety effects are not appropriate. With triazolam the onset of sleep occurs more quickly; REM sleep is delayed, but the total percentage of REM sleep is not affected. Sleep time is longer, but there is less deep sleep; there are also fewer awakenings. Triazolam has other uses as well; it can help to manage the disruptive behaviors in sleep-disturbed patients with Alzheimer’s. Furthermore, as I mentioned earlier, it may help overcome the symptoms of jet lag by causing rapid adjustments of the biological clock. Triazolam-is more rapidly absorbed than temazepam, but it poses the= risk of a number of side effects, including early-morning insomnia, memory impairment, psychotic symptoms, sleepwalking activity, and rebound insomnia if withdrawal from the drug is not handled properly.
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THE EVOLUTION OF INSOMNIA DRUG THERAPY: BENZODIAZEPINES – TRIAZOLAMMarketed under the brand name Halcion, triazolam possesses the shortest half-life (four to six hours) of the major hypnotic benzodiazepines; thus the effects of the drug are usually completely gone by morning. It is especially useful in cases of transient insomnia, or for occasional use in chronic insomnia when sedative or antianxiety effects are not appropriate. With triazolam the onset of sleep occurs more quickly; REM sleep is delayed, but the total percentage of REM sleep is not affected. Sleep time is longer, but there is less deep sleep; there are also fewer awakenings. Triazolam has other uses as well; it can help to manage the disruptive behaviors in sleep-disturbed patients with Alzheimer’s. Furthermore, as I mentioned earlier, it may help overcome the symptoms of jet lag by causing rapid adjustments of the biological clock. Triazolam-is more rapidly absorbed than temazepam, but it poses the= risk of a number of side effects, including early-morning insomnia, memory impairment, psychotic symptoms, sleepwalking activity, and rebound insomnia if withdrawal from the drug is not handled properly.*275\226\8*

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ANTI-DEPRESSANT LIFESTYLE: TACKLING STRESS

Tuesday, December 22nd, 2009

There are many ways of tackling or managing stress, and mastering these techniques inevitably pays off by promoting an antidepressant lifestyle. Improving interpersonal skills, for example, is one way of reducing the feeling that others are a constant source of unavoidable and uncontrollable stress. When I first began to supervise research assistants, I would observe that they often seemed harried and anxious. On one occasion, as a result of a shuffling of government personnel, a senior manager was temporarily assigned to me as a research assistant. I delegated several tasks to him and, after the first week of working under my direction, he asked to meet with me. He explained that the number of tasks I had assigned him were more than he was able to manage competently in the course of his working hours. Would I be good enough, he asked, to indicate to him my priorities so that if he was unable to complete all the tasks by the week’s end, only the least important task would remain undone. This research assistant taught me two invaluable lessons: Not only did I learn to become a better manager, to set priorities and be more realistic about what could be accomplished in the time available, but I learned how someone who is subordinate in an organization can politely set limits and manage his or her level of daily stress. If you are feeling under pressure at work, take some time to analyse the situation. Make a list of all the sources of stress and then try to figure out solutions to each of them. It is in the interest of the other parties involved to have these stresses resolved as well. Consider ways of presenting the problem to your boss, co-workers or even those working for you in such a way as to point out how it would be mutually beneficial if the stresses could be alleviated. For example, the final product might be superior, production might be more efficient, or the working environment more conducive to creativity or productivity. All of these goals can be legitimately presented as being in the interests of both workers and management.

Exactly the same principles apply in a marriage or other type of relationship, only more so. In these situations all parties involved usually have major investments at multiple, different levels. For example, in a marriage or relationship it is in both parties’ interests to get along, not only because it is more pleasant to do so, but also for the sake of mutual investments in the form of children and other common goals. Once again sources of stress can be identified and communicated to your partner, and if this is done in the right way the outcome can diminish levels of stress, relieve the tension in the relationship and promote an anti-depressant lifestyle. The key is always to present the situation as a shared issue which it would benefit both individuals to solve together. Let us say, for example, that a husband comes home from work and goes straight to the fridge for a can of lager, ignoring his wife in the process. She is bound to feel neglected, angry and perhaps depressed. At this point she has a choice. She can attack her husband for his callous and brutish behaviour or she can take a more collaborative approach. Attacking him may make her feel better in the short run but is bound to make the problem worse. A collaborative approach may have a better chance of working in the long run. This could involve: (1) empathy – ‘I understand that you are stressed and tired at the end of a hard day’; (2) communication of her feelings – T feel the same way after running after the kids all day’; (3) involving him in solving the problem – ‘Can you think of some way that we can unwind together?’; and (4) demonstration of what’s in it for him to do so – ‘so that we can support each other at difficult times and maybe even figure out a way of having some fun in the process.’ Obviously the way in which she chooses to handle the communication is likely to influence the outcome of the evening and either exacerbate or ameliorate her depression.

Part of the skill involved in such communications is picking the right time. A perceptive husband might recognize, for example, that the three days before his wife’s period are not the best time to discuss the large charges they have run up on the credit card. Conversely, an insightful wife learns to discern her husband’s moods and bides her time before discussing with him how she could use more help from him around the house or with the children.

It is also important to recognize that depression frequently causes stress in a relationship. This is of course an additional reason to treat the depression biologically. The partner of the depressed person often feels neglected. Feelings of depression can be contagious and there is a natural tendency to want to avoid a depressed person, which can isolate the person further and deepen the depression. There are some important pointers for the partner or family member of a depressed person to bear in mind. First, don’t take the depression personally. It is not your fault. Frequently the family member feels responsible for the depressed person’s mood, which makes him or her angry since at times nothing seems to cheer the depressed person up and there is a tendency for friends and family members to give up on the depressed person and withdraw. Second, it is not your responsibility to turn the depressed person’s mood around. You can and should be supportive. It is particularly worth trying to help your friend or loved one get appropriate assistance. But you cannot expect to have a direct effect on the other person’s mood. It is too much of a burden to place on yourself and is bound to leave you feeling resentful. Finally, don’t ignore the depressed person and enhance his or her sense of isolation. Do what you can to include the person in activities in a non-demanding way. For example, a husband might suggest going out to a restaurant for dinner with his wife, who may feel cheered up by the food, the setting and the friendly attention. On the other hand, suggesting that it might cheer her up to have guests over is unlikely to have its intended beneficial effect because of the demands this will place on her to perform and be sociable, which might be the last things in the world that she feels like doing.

There is a great deal that a depressed person can do to keep his or her loved one involved even while in a depressed state. Simply acknowledging the depression and its impact can be helpful. For example, a wife is likely to respond favourably to her depressed husband if he says T know I have been down and not much fun lately, but I am trying to turn things around as best I can. Thanks for hanging in there with me.’ The partner of a depressed person becomes starved for any positive feedback and comments such as this are generally greatly appreciated. Even if you are feeling sad and detached, as is often the case when one is depressed, it pays to make a point of expressing appreciation to your friend or loved one for gestures of kindness. It can be also useful to pinpoint specific things that your loved one can do that would make you feel better. This helps him or her to feel useful and counteracts the powerlessness typically experienced by those who surround and care about a depressed person.

So important are interpersonal skills in helping people overcome and avoid depression that an entire type of psychotherapy for depression, called Interpersonal Therapy, has been developed around these principles.

There are many types of stress other than interpersonal difficulties which may confront a depressed person and make matters worse. These include physical illness, financial difficulties and loss of a loved one. For all these different types of situations, help can be obtained from different types of experts, for example a sympathetic and competent doctor, a financial advisor or a religious or spiritual leader. A good doctor should not only provide specific help for symptoms but also comfort and reassurance. I have seen people in serious financial difficulty who have been greatly relieved after turning their affairs over to a debt counsellor or obtaining help and guidance from a financial planner. And innumerable people have been comforted and supported over the centuries by their priests, ministers or rabbis. Of course, caveat emptor applies whenever one turns to any guide or authority figure for help. Ultimately you have to be the judge as to whether a so-called expert is helping you or not. As always, stay tuned to your mood barometer to judge the quality of assistance you are receiving.

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THE CLINICAL DIAGNOSIS OF DEPRESSION

Tuesday, December 22nd, 2009

The diagnosis of depression has always been – and continues to be – made largely on the basis of a person’s subjective history. Although a skilful clinician will see traces of depression in a person’s face, observe sluggishness or agitation in the body’s movements and hear the slow cadence in the voice, it is the depressed person’s own story that will carry the day in making the diagnosis. A few decades ago there was great optimism that a laboratory test for depression could readily be found. No such luck. For better or worse, in your recollections of how you have been feeling and your accurate take on your present mood you hold the key to determining whether or not you are depressed. What the skilled clinician does is to organize these recollections and evaluate whether or not they meet modern diagnostic criteria for depression.

I remember well, before modern systems of diagnosis had been developed, how the question of diagnosis would be debated in teaching hospitals. A patient would be interviewed and there would be discussion to and fro as to the exact diagnosis. Finally the professor would opine as to whether he (and yes, it was almost always a man) thought that the patient was depressed or not. And his opinion would prevail because he was the boss. Well, clearly that was a most unsatisfactory state of affairs. For clinical, research and, more recently, insurance purposes, it became necessary to define depression.

The latest diagnostic classification system is called DSM-IV, a handbook referred to by insurance companies and others to determine a person’s clinical diagnosis. Each diagnosis is given a specific code number. The diagnosis for many psychiatric conditions, including clinical depression (referred to officially as major depressive disorder), was reached by the so-called Chinese menu approach. In Chinese restaurants, the fixed-price menus permit you to have a certain number of items from Column A, a certain number from Column B and so on. That’s how it is with the DSM-IV criteria for major depressive disorder, which I have modified and listed below. It is worth checking whether you meet the criteria for major depressive disorder. It is important to remember that these are strict criteria.

DSM-IV Criteria for Major Depressive Disorder

A Five (or more) of the following symptoms have been present for two solid weeks. This is different from your usual functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

depressed mood most of the day, nearly every day, either experienced by yourself or observed by others

markedly diminished interest or pleasure in all, or almost all, activities, most of the day, nearly every day

significant weight loss when not dieting, or weight gain, or decrease or increase in appetite nearly every day

sleeping too much or too little nearly every day

being agitated or depressed to such a degree that others could notice it – not just internal feelings of restlessness or being slowed down

fatigue or loss of energy nearly every day

feelings of worthlessness or excessive or inappropriate guilt nearly every day – more than just feeling guilty because your depression doesn’t enable you to function adequately

decreased ability to think or concentrate, or difficulty making decisions, nearly every day

recurrent thoughts of death (not just fear of dying), recurrent ideas of suicide or attempting or planning suicide

AND

B These symptoms cause significant distress or impairment in your social, occupational or other important areas of functioning.

AND

C The symptoms are not directly due to the physical effects of medications, drugs or alcohol, nor the result of a medical condition, such as underactive thyroid functioning.

Now, many people who feel quite depressed do not exactly fit into the DSM-IV criteria for major depression. The diagnostic schema allows for these types of depression as well. These include briefer depressions that occur premenstrually (premenstrual dysphoric disorder), milder depressions (minor depressive disorder), and recurrent depressions that can be very severe even though they may last for only a few days at a time (recurrent brief depressive disorder). The good news is that all of these depressions, as well as those that accompany medical conditions or may be associated with drugs and alcohol, may be helped by the same treatments that are helpful for major depression.

One diagnosis, which has its own code in DSM-IV, is dysthymic disorder, a milder form of depression that causes a great deal of misery because of its chronic nature. I have modified the DSM-IV criteria for dysthymic disorder and have listed these below.

DSM-IV Criteria for Dysthymic Disorder

A depressed mood for most of the day, for more days than not, either experienced by yourself or observed by others, for at least two years

AND

B presence, while depressed, of two or more of the following:

poor appetite or overeating

insomnia or sleeping too much

fatigue or low energy

low self-esteem

poor concentration or difficulty making decisions

feelings of hopelessness

AND

C during the two-year period, you have never been without the symptoms in A or B for more than two months at a time AND

D the symptoms are not due to the direct physical effects of medications, drugs or alcohol or to a general medical condition, such as underactive thyroid functioning.

As you read through the criteria, it will become obvious that they are somewhat arbitrary. What if you were free of symptoms for two-and-a-half months? Does that mean that you are not dysthymic or wouldn’t benefit from treatment? Although systematic diagnostic schemas have been useful for standardizing diagnoses for research and other purposes, the seasoned clinician and the clued-up patient should realize that diagnosis is not a precise science and not get too hung up on whether someone exactly meets the criteria or not before deciding on whether and how to treat.

It is clear that when we are dealing with depression in all its forms, we are dealing with a continuum, with happy normal mood at the one end and serious depression at the other and all sorts of gradations in between. The same treatments that help the more severe forms of depression will generally also help the milder forms and vice versa. The most important determinants of whether or not you seek and receive treatment are therefore how bad you feel and whether you are willing to reach out for help.

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SIGNS OF DEPRESSION: BIOLOGICAL DISTURBANCES (SLEEPING, EATING, WEIGHT AND SEX DRIVE)

Tuesday, December 22nd, 2009

One major difference between sadness and depression is that the latter is often accompanied by changes in biological functioning. These biological changes are among the most reliable tell-tale signs of depression, and when doctors and therapists look for depression they carefully inquire about changes in sleeping, eating, weight and sex drive. You should certainly pay special attention to these important behavioural functions in evaluating whether you are depressed and, if so, how severely depressed you are.

In depression, sleep is often disrupted. Some depressed people have trouble falling asleep; others toss and turn or wake during the night; and early morning waking, often with difficulty returning to sleep, is very common. Sleep doesn’t seem to have its usual renewing properties and people are often left feeling tired during the day and desperate at night for sleep that stubbornly refuses to arrive. Some depressed patients sleep too much, at times for hours each day more than is normal for them and yet, once again, find that no matter how much they sleep, they still don’t end up feeling refreshed.

These two patterns of sleep disruption – insomnia and oversleeping — may signal two distinct types of depression, one representing a state of hypervigilant overarousal and the other a state of torpid underarousal. These patterns may reflect exaggerations of different types of response to stress.

When people (or animals, for that matter) are stressed, a part of the brain known as the hypothalamus activates a stress-response system, which results in release of certain hormones from the adrenal glands, particularly Cortisol. In addition, the fight-and-flight part of the nervous system, known as the sympathetic nervous system, is activated. These changes result in arousal and vigilance, qualities that are necessary for combating stress, and are associated with decreases in sleep and appetite. The type of depression associated with decreased sleep and appetite and weight loss may represent an exaggeration of these arousal responses. Evidence to support this theory is found in the form of elevated Cortisol levels in the circulation and other signs of overactivity of the stress-responsive hormonal system in these depressed patients.

The heightened arousal and vigilance that are part of our normal response to stress should be time-limited in order to be most effective. Ideally, such responses should kick in following a stressful situation, such as the loss of a loved one, a physical challenge or an important deadline, and taper off when the stress has been successfully handled or resolved. In depression, the stress response may be triggered either by a definable stress or by some unknown factor, but whatever its original trigger it then takes on a life of its own, persisting long after the stress is over. Consider, for example, a person susceptible to depression who is told that he has lost a large sum of money on the stockmarket, whereupon he plummets into a deep depression. If that same person is told a week later that his stockbroker has made a mistake and that he has actually made a lot of money instead of losing it, will his depression immediately disappear? Probably not. Such is the nature of depression that once it gets going, it can continue indefinitely. As you can imagine, this wears the system out and the person is left feeling exhausted and depleted.

The second type of depression – the one associated with oversleeping, overeating and weight gain – may represent an exaggeration of the energy-conserving responses seen frequently in animals. The hibernating bear, for example, goes into a state of low activity and torpor designed to conserve its energy and resources. Such shutting down of bodily activities enables the bear to make it through a winter of severe weather and scarce food. Most people with seasonal affective disorder (SAD), many of whom compare themselves to hibernating bears, experience this second type of depression and tend to oversleep, as well as overeat and gain weight, during their winter depressions.

Withdrawal and seclusion often occur in animals as a response to stress or injury as part of the recovery process. An injured lion, for example, will retreat to its lair until its wounds have healed before venturing back out into the savannahs and exposing itself to the dangers of the wild. An infant monkey separated from its mother initially goes into a state where it cries out pitifully, which was termed the stage of protest by John Bowlby, a pioneer in the area of separation and loss. Later the infant goes into another state that Bowlby called detachment, where it withdraws from contact with other animals. It has been suggested that these stages are ways by which the animal adapts to the loss of its mother. Initially, it makes noises, which would have the function of attracting the attention of the mother, who might not be far away. After a while, however, if the mother has not responded, the infant goes into a state of withdrawal at this point and waits until another parental figure might chance to come along. In the course of evolution, it has probably proven far more adaptive for the infant not to carry on crying, which might attract a predator, and instead to go into this detached state. There is a final stage that has been described in such separated infant monkeys – a stage of reattachment, whereby the infant will reattach to such a new parental figure that might arrive on the scene. Over the millennia, certain adaptive behavioural changes to injury and loss have evolved so as to maximize the chance of survival. It has been suggested that some of the behavioural and physical symptoms of depression may represent disturbances of the normal biological systems responsible for mediating such adaptive responses.

When an animal is stressed, the emphasis is on survival, as well it should be. Having sex is the last thing that will be on that animal’s mind. And so it is that with the depressed person, the sex drive diminishes and may shut off completely. Every aspect of sexual functioning may be affected – arousal, enjoyment of sex and the capacity to function. Needless to say, this does not much help the self-esteem of the depressed person, which is already at a very low ebb.

So we see that in depression there may be an exaggeration of some of our very useful responses to the stresses and challenges that life deals us. When these responses – such as hypervigilance or excessive withdrawal – go too far, they hinder rather than help our ability to adapt. They continue for much too long and we are unable to turn them off by an act of will.

If your sleeping, eating, weight control and interest in sex are disturbed and this has been going on for more than a few weeks, consider the possibility that you may be suffering from depression.

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