WHY I PRESCRIBE ABILIFY AND SEROQUEL XR FOR PTSD

Abilify [aripiprazole] and Seroquel XR [quetiapine XR] are called atypical antipsychotic medications with their atypicalness relating to the fact that they increase levels of the neurotransmitters serotonin and norepinephrine as well as decreasing the neurotransmitter dopamine which the typical antipsychotics do as well.  Research studies have shown that Abilify and Seroquel XR can treat bipolar and depressive mood symptoms as well as psychotic symptoms.  Both Abilify and Seroquel XR have low doses available that are helpful for people with mood symptoms without psychotic symptoms as they are more likely to respond to lower doses.  

I have also found that low doses of Abilify and Seroquel XR are helpful in reducing the anxiety that people with Post Traumatic Stress Disorder [PTSD] experience.  PTSD is felt to be caused by someone experiencing an overwhelming event and then recalling the traumatic nature of the event by having a very sudden intense recalling of the event [a flashback], and/or avoiding situations that are likely to lead to a recollection of the event, and/or re-experiencing smells, or sounds or emotions connected to the event. It used to be thought that only people who have been in combat situations developed PTSD.  It is now recognized that many types of events can lead to the development of PTSD.  This is very important as in my experience,  PTSD is often overlooked as people adapt to chronic stress and are reluctant to report past traumatic events as they are afraid that they will re-experience the trauma, especially as avoidance is a commonly used coping mechanism.  

So, why are powerful medications with the risk of metabolic and glucose metabolism side-effects necessary to help in the treatment of PTSD? [As a side note, these side-effects are not common and if any occur the medication is stopped and the side-effects also are stopped with return of normal functioning].  When we are traumatized and we continue to react like we will be traumatized again, our brains are ever alert to any possible threat and will   react instantly to alert us to possible danger.  This reaction causes stress and anxiety and yet from a survival standpoint is better than not reacting and being overwhelmed and possibly going into shock.  In other words, the brain seems willing to have many false positive reactions to avoid the one false negative non-reaction. It seems that our brains would rather have us react thousands of times when we don't need to in order to avoid not reacting when it is critical that we do react. Other medications can help to lower anxiety levels and reactivity but frequently do not stop the majority of the brains instantaneous anxiety reactions.  To stop our brains from reacting to these perceived threats we need to have our anxiety levels lowered so that our brain's alarm system is not triggered.  We can then learn ways to cope with stress that keep our anxiety levels low and then we will no longer need these medications.

Non-pharmacological treatments for PTSD include: Trauma-Focused Cognitive Behavioral Therapy [TF-CBT]. This treatment can be very helpful in reducing or even eliminating symptoms of PTSD if someone's anxiety level is low enough that they do not feel threatened with being re-traumatized. Interpersonal therapy has also been shown to be helpful in treating PTSD. In addition, mindfulness practices are also helpful and I have blogged about studies that support using these treatments for PTSD.

WE SHOULD LISTEN TO OUR CHILDREN!

Recently a woman who I am treating for PTSD told me that her two year old child repeatedly would ask "where are we?"  As we talked about this it seemed that her child was responding to her mother being preoccupied and not available to her child.  It seemed that her child was sensing her mother not being with her when her mother in effect removed herself.  After I listened some more to my patient we concluded that her child reacted to her dissociating by asking "where are we?"  Dissociation is a coping mechanism when someone removes themselves from a situation by holding in feelings and removing thoughts as well.  It is like not being there and can even involve having no memory of the time when dissociation occured.  Her child responding like she did helped my patient to identify when she dissociated and to use other coping skills so that she did not need to dissociate.  She knew she was successful when her child no longer asked "where are we?"

Frequently our children respond to us with insights and wisdom that we as parents would be wise to listen to.  This requires that we actually listen to our children versus reacting  to what they say.  When we react to what our children say we aren't really listening and are separating ourselves from them.  We are also sending our children a message that we do not have confidence in them. This doesn't sound good does it?  The other advantage to really listening to our children is that we will then know what to say or do as we have not clogged our brains with our reactions, worries, etc.  Our brains will then provide us with a good response to our children.  

Importantly, the importance of listening applies to whomever we are listening to!

WHY DO I PRESCRIBE LAMICTAL (LAMOTRIGINE) ?

Recently my business manager noticed that a question was raised about my prescribing Lamictal [lamotrigine] for a 9 year old girl.  I realized then that I needed to clarify why I made this choice.  I have blogged about it in the past but I felt that I needed to write about it again.

Lamotrigine was introduced as an anticonvulsant [antiseizure] medication and received negative publicity after some people who were taking it developed a very serious rash that led to a Stephens Johnson reaction resulting in the death of a few people.  It was prescribed for people with very serious and dangerous seizures and as is typical for this type of problem, the dose was maximized in a couple of days.  These people were also taking valproic acid [also an anticonvulsant] and this medication more than doubled the serum level of the Lamictal that had just been rapidly increased leading to extremely high serum levels and the serious rash.  It had also been noted that Lamictal seemed to be very effective in stabilizing moods.  The FDA [Federal Drug Administration] only allowed Lamictal to be used for moods after very extensive testing on thousands of people with the development of a titration protocol that insured that it would be tolerated without a serious rash.  It has since been prescribed and found to be safe and effective.  It is prescribed for mood swings after they have been partially stabilized and is helpful in preventing the swing into depression that plagues people with mood swings about 80% of the time.  

I began noticing that people who had been struggling with the impact of untreated attention deficit hyperactivity disorder [ADHD] were often irritable and reacted to minor situations with frustration.  This frequently continued even after their concentration and attention was improved with medication.  Then someone that I was treating who was experiencing the irritability and reactivity was prescribed Lamictal for headaches and the irritability and reactivity were significantly reduced and were elimiinated with a further titration of the dose of Lamictal.  I then began prescribing Lamictal and found it to be effective in treating the irritability and reactivity.  I would suggest that the Lamictal be continued for a year and then discontinued and there would be no return of those symptoms. I have also found that if I slowly increase the dose, Lamictal is tolerated well. Occasionally someone will develop a small rash on their arm or face and this seems related to the body adjusting to the medication and is not an allergic response.  I will reduce the dose and have a slower increase in dose and the rash goes away and does not reappear.  [The brain's need to adjust to the presence of the medication and then the absence of it is a topic for another blog].

To summarize, I have found that Lamictal is a safe and effective medication to help reduce the irritability and reactivity that can occur because of the stress of untreated ADHD.  I have wondered if these symptoms are related to the brain's attempt to reduce the demands for concentration and focusing by causing people to remove themselves from interacting with others because of the irritability and reactivity that they experience when interacting with others.  It seems to me that interacting with people requires a considerable amount of focusing and attention. What do you think?

LISTENING, REALLY LISTENING...WHY IS THIS SO IMPORTANT?

Over and over recently I have seen how listening can reduce stress in our lives and help us to be more confident.  So, how can listening help reduce stress and improve our confidence?  My initial awareness of the significance of listening came when some of my patients talked about trying to help their friends deal with grief.  My patients felt bad that all they could do was listen to their friends. When we discussed their friends response to being listened to, it seemed to be positive. Another patient indicated that when she responded emotionally to her friend who was experiencing grief and said that she knew what her friend was experiencing, her friend became angry.  We then wondered if listening was really being empathic and saying how you feel or that you understand, is not empathic but really being sympathetic.  So sympathy seems to be more about the person who is trying to console the other and actually may separate themselves from the one they are trying to console.

Maybe listening is really like meditation, like being present with ourselves and the person we are listening to. if listening is a way to be empathic then does that mean that being empathic is like being present with someone [and with ourselves]?

Another benefit associated with listening without our own agenda is that when we do this our brains seem to be working optimally as we realize that we remember everything that we are hearing and then we are able to respond without worrying or feelling stressed.  

So, does that mean that listening to others and ourselves is like being present with others [and ourselves] and is a very good way to us our brains?

"INSIDE OUT" GETS IT RIGHT!

I recently saw the movie "Inside Out" with my wife and two of our friends.  The mother of a 9 year old that I treat had recommended that I see the movie.  

The movie is about the feelings that a 11 year old girl named Riley has as she leaves behind her home in Minnesota and moves to San Francisco.  Her feelings are depicted by characters identified as sadness; anger; joy; fear; and disgust. Joy takes charge and attempts to keep Riley feeling happy.  Joy feels that she must contain and limit sadness so sadness doesn't infect the other feelings with sadness. Over the course of the movie it becomes clear to Joy that Riley needs her sad feelings to help her to cope with the move from Minnesota to San Francisco.  When she is able to feel her sadness, Riley is able to share her feelings with her parents about missing Minnesota.  This allows Riley to let go of her missing Minnesota and start to have feelings about San Francisco.  Dacher Keltner and Paul Ekman were hired as consultants for the movie and their piece on the op-ed page of the New York Times on July 5, 2015 indicated that they were disappointed that sadness was portrayed as limited and contained.  However, I think that the movie does a good job portraying what happens when we hold our feelings in and often then we are stuck not being able to let go of our worries and not able to move on.  When we hold our feelings in, our brains interpret this as a problem and then focus on trying to solve this problem.  We are therefore stuck and not able to let go of the worries.

Sadness is important as are all our emotions are.  To deny them or hold them in and not show them requires a lot of work from our brain and this occupies our brain and blocks us from experiencing our feelings and moving on with our life.  

It is also important to note that happiness was not one of the emotions that Riley was experiencing.  So, may be it is possible to feel sadness or any other emotion and still be happy.  What do you think?