MANAGING STRESS IN OUR LIVES

Sunday
Jun092013

EARLY MENARCHE [START OF MENSTRUAL PERIODS] AND DEPRESSION

C. Joinson, Ph.D. et al, report in the June 2013 issue of the Journal of the American Academy of Child and Adolescent Psychiatry on their longitudinal study of the impact of early menarche and the development of depressive symptoms.  They found that early menarche was correlated with increased depressive symptoms in 13 and 14 year old females but not for 16.5, 18 and 19 year old females.  Depressive symptoms increase over the course of adolescence for females but the increase is more rapid in early adolescence and this is two fold [100 %] increase.  They defined early menarche as menstrual periods beginning before menarche represents 15.5% of the sample. 

Unfortunately, earlier menarche seems on the rise. This means that there are more and more adolescent girls who are at risk for having depression at an earlier age and this predicts more depressive episodes, with a significant impact on their lives, including an inceased risk for suicide. 

What to do? Stop using hormones in producing food? Stop exposing pregnant women and young children to endocrine altering chemicals? Early identification and treatment of depressive symptoms?  Your ideas?

Sunday
Jun092013

BEING BULLIED IN CHILDHOOD AND SELF-HARM BEHAVIOR AS AN ADOLESCENT

Earlier, I wrote about the impact of being bullied and being a bully, ten years later.  One study showed that children who were bullied were at significantly inreased risk for anxiety and depressive disorders while males were also more likely to be suicidal and girls to have agoraphobia [fear of public spaces and crowds]. The bullies had an increased risk of antisocial personality disorder.  I felt that the bullied children were also at increased risk for post traumatic stress disorder.

Another study by S.T. Lereya, Ph.D., et al, in the June, 2013 issue of the Journal of the Academy of Child and Adolescent Psychiatry reported on the impact of being bullied in childhood on adolescent self-harm [cutting and suicidal] behavior. They controlled for a number of other variables that also can lead to self-harm behavior and found that about 20% of the total self-harm behavior was caused by the bullying.  This is a very large effect from the bullying. 

It is a critical problem, especially as children [and adolescents] very often suffer in silence and do not tell their parents or teachers.  They also tend to  hold their feelings in so it is not easy to detect depressive symptoms.  Frequently they will complain of a number of different nonspecific symptoms that include headaches, stomach aches, backaches, dizziness, sleep problems and they may resist going to school and be withdrawn. When they do tell an adult they often feel that it doesn't help as they expect the adult to get the bullies to stop.  It would seem that a focus on helping the victims of bullies to cope with this stress so that they are no longer feeling overwelmed and can ignore the bullies more successfully.  Another focus, of course, would be to stop bullying from occuring in the first place.  Zero tolerance for violence or the threat of violence, so why not zeo tolerance for bullying?  I wonder if educating children and adolescents on the impact of bullying and the different forms it takes and then how to resist being part of bullying, wouldn't help reduce bullying significantly.  I am interested in your thoughts about how to prevent or at least reduce significantly, the bullying of our children and adolescents. 

Of course, it happens with adults, too.

Monday
May272013

BIPOLAR DISORDER, TYPE II...WHY IT IS IMPORTANT

Bipolar II disorder [I will refer to this as BP2 for rest of blog] made the news when it was reported that the actress Catherine Zeta-Jones was given this diagnosis.  Most people are aware of bipolar I disorder [BP1] yet BP2 is more prevalent and has significant levels of morbidity [the impact of the illness on one's life] and mortality [it can lead to suicide].  Also, and very importantly, BP2 is often misdiagnosed as frequently people with BP2 initially present to general medical settings and not psychiatric settings where they are likely to be diagnosed with a major depression and treated with antidepressants.  This happens in psychiatric settings as well.

BP2 is diagnosed if someone has had one or more major depressive episodes [MDEs] with at least one hypomanic episode.  In contrast, someone with BP1 has had at least one manic episode and usually one or more MDEs.  Differentiating BP1 from BP2 requires being able to determine if there has been a manic episode vs only hypomanic episodes.  Manic episodes involve periods of persistent and abnormally elevated, expansive or irrirtable mood  lasting at least one week.  Change in mood must be accompanied by at least three of the following if mood is elevated and at least four if mood is irritable. These include: 1. inflated self-esteem or grandiosity, 2. decreased need for sleep, 3. more talkative than usual, 4. flight of ideas or the subjective experience that thoughts are racing, 5. distractibility, 6. increase in goal-directed activity or psychomotor agitation [very restless and anxious], and 7. excessive involvement in potentially dangerous activities.  The manic mood causes impairment in functioning. Hypomanic episodes involve a period of persistently elevated, expansive or irritable mood, lasting for at least four days and it is clearly different from the person's typical depressed mood. The hypomanic mood is accompanied with the same list of possible symptoms as for manic epsiodes and must be clearly a change in functioning and observable to others but not to level of impairment. 

Another very important distinction must be made between BP2 and Major Depressive Disorders [MDD] as they do not involve any hypomanic episodes, while BP2 involves MDEs and hypomanic episodes.  If someone presents with an MDE, the only way to determine if they have BP2 is to find out if they have had any hypomanic episodes in the past.  This can be difficult as often people do not consider hypomanic episodes as problematic or pathologic and may not recall them even with direct questioning.  This is one reason that it can take over ten years to correctly diagnosis BP2.  I have treated people who have had seven different trials of antidepressants with an initial improvement and then worsening of their moods only to try another antidepressant.  This can lead to a lot of suffering and risk of suicidal behavior.  

So, how common is BP2? Lifetime prevalence rates in the US = 1.1%.  It often is associated with panic disorder, substance use disorders and ADHD.  Importantly, the depressive episodes for BP 2 compared to those for MDD were associated with more suicidal thoughts, hypersomnolence [increased sleeping] and higher rates of agitation. BP2 moods are also more seasonally influenced [more depression in later fall and winter].

Therefore, while there are some things that distinguish BP2 depression from MDE depression, the diagnosis still rests on identifying hypomanic episodes.  Be alert for these in anyone you know who has had a MDE as early treatment can make a big difference in quality of life for those with BP2.  

Sunday
May192013

ANXIETY IN NANOSECONDS, WHAT CAN YOU DO?

Over the past several months I have helped a number of people who have had traumatic experiences that keep bothering them even after they are no longer exposed to the traumatic situation[s].  They report becoming very anxious very rapidly when anything reminds them of the traumatic events.  They often have develped a number of good coping skills but they are always having to use them after the anxiety has been triggered.  In trying to understand this, I recalled reading a study that found that the amygdala can respond in nanoseconds when our brains feel that something overwelming may occur.  In other words, the brain continually scans our environment and our reactions looking for potential danger.  If we have been trauatized in the past, our brains will frequently see the possibility of danger and will trigger the amygdala very rapidly.  A nanosecond is one millionth of a second!

I have found that treating the anxiety after it has been triggered can reduce the intensity of the anxiety but not lower the frequency of it.   The problem with treating the anxiety before it occurs is that the medication to reduce the anxiety needs to be present all the time and be well tolerated in between times when there is not anxiety symptoms but also be able to contain the anxiety so the amygdala is not triggered.  I have had success with low doses of atypical antipsychotic medications with monitoring for metabolic side-effects.  I do not know yet how long these medications will need to be taken.

Sunday
May192013

AFTER BEING BULLIED, IT STILL HURTS TEN YEARS LATER

The most recent AACAP News summarized an article by Copeland, etal., in JAMA Psychiatry 20:1-8 that looked at children and adolescents who were bullied or the bullies 10 years later.  This was a follow-up from the Great Smoky Mountain Epidemiological study that was done in wesern North Carolina.  They found that both those who were bullied and those who did the bullying continued to suffer.  Those who had been bullied were still at high risk for several anxiety disorders and depression.  In addition, suicidal impulses were very increased in males who had been bullied and agoraphobia was very increased in females who had been bullied.  For those who had done the bullying, the only increased risk for any psychiatric disorder was for antisocial personality disorder.  

It is important to also mention that the increased risk for psychiatric disorders was related to the bullying and not to genetic or other environmental factors.  This points out the serious consequences of being bullied and also the consequences for the bullies as well.  It is possible that the continuing suffering is related to the development of Post Traumatic Stress Disorders [PTSD] and ongoing symptoms related to the PTSD.  The PTSD is treatable and yet must be recognized as PTSD to help the treatment to be successful. I have treated a number of children and adolescents in the hospital who developed suicidal behavior related to their being bullied.  

I hope that increasing awareness of the severe consequences of bullying will help efforts to stop bullying and treat it as a serious problem that often leads to longterm suffering.  We have zero tolerance for threats of violence in our school systems.  Maybe it is time to have zero tolerance for bullying as well.