"I DON'T CARE AND I DON'T CARE THAT I DON'T CARE."

Recently one of my patients came in and announced that "I don't care and I don't care that I don't care."  She said that she realized this just the day before.  She reflected on this and indicated that it was a relief not to care.  She feels less stressed and yet still feels responsible for others and realizes that she takes care of others better than she takes care of herself.  She believes that "not caring" is helping her to feel less stress and take better care of herself.  

So, what is this "not caring?"  I am treating this person for severe PTSD symptoms that include paranoid thinking, frequent flashbacks and dissociative symptoms.  One of the treatment goals has been to not feel a need to react to the past and also to no longer fear past traumatic experiences, recognizing that they have no power anymore. The growing success not reacting to the past seems to have led to being able to "not care" about things from the past, and "not care" about things that are happening now or that might happen in the future.  It is like a weight has been lifted as worries about the past and fears about the future have lessoned. There is a calm more of the time now and it is easier to be around people. A feeling of responsibility for others is still a problem but is also more contained than before. It is also easier to focus on self care.

My wish for the universe is that all living things can learn to "not care" what happens, so that they can experience the joys of living, without being distracted by "caring."

Confusing? Imagine that you don't care and don't care that you don't care, and see what happens.  

MOOD SWITCHING WITH ANTIDEPRESSANT USE

Diagnosing bipolar depression vs unipolar depression [major depression] remains difficult.  So why be concerned?  Well, there is building evidence that taking antidepressants and having a mood swing to a manic or hypomanic mood is associated with a poorer prognosis that includes more depressive mood swings [rapid cycling?], not responding as well to mood stabilizing medications, increased risk for substance abuse, more disability, and more mortality from suicide or from medical illnesses.  Also, there is a statistically higher risk of switching moods with antidepressant use in adolescents compared to adults. One explanation is that the adults are more likely to have their bipolar illness diagnosed.  There is also evidence that there are more mood swings to mania or hypomania associated with antidepressant use than those that switch spontaneously.  This could reflect how difficult it is to distinguish bipolar depression from unipolar or major depression.  In the past this switching was considered a side-effect of antidepressants and not indicative of bipolar illness.  This apparent resistance to diagnosing bipolar illness may represent the prevalence of irritability with major depression, the worse prognosis of bipolar illness, and the difficulty lifting a stable bipolar depressed mood with mood stabilizing medications.  

So, what to do?  There are a number of factors that are associated with an increased risk for switching moods on antidepressants.  These include: a family history of bipolar illness or psychosis; onset of symptoms before age 25; number of depressive episodes within several years; cyclothymic, and irritability symptoms; past post partum mood disorder symptoms; depression with psychomotor retardation, hyersomnia and increased appetite [pointing toward Bipolar Type II diagnosis]; history of excitation on mood elevating medications [basically antidepressants]; current agitated and dysphoric symptoms; possible comorbid substance abuse; and treatment with a tricyclic antidepressant or venlafaxine or duloxetine [any antidepressant known to significantly elevate more than one neurotransmitter].

After taking into consideration the above, I have found that if someone's moods are cycling it is often possible to stabilize moods, with mood stabilizing medications, without having to use antidepressants. However, if someone has symptoms suggesting bipolar depression and yet is stable [stuck] in a depressed mood, I will treat briefly with an antidepressant [often escitalopram due to quicker response] and then begin tapering it and discontinuing it after a couple of weeks of improved mood.  If the taper or discontinuation leads to return of depressive symptoms then I reinstate the antidepressant at the previous dose and then the taper and/or discontinuation is tried a couple of weeks later.  At some point I have found it is possible to stop the antidepressant and the improved mood is maintained.  Meanwhile, I have initiated a mood stabilizing medication that then will hopefully hold the improved mood.    

PLACEBO EFFECTS AND TREATMENT RESPONSES

There has been a lot written recently about the placebo effect and how it shows that medications are ineffective because they are not more effective than placebo.  In these studies, the placebo response is often in the 30-50% range as is the response to the active treatment being studied. Placebo controlled studies are ones where if we were in the study, we would not know whether we were getting the actual treatment or are receiving everything but the active component of the treatment. Thus, we would think we were getting the treatment but we would not be.  Thus, the placebo response is the response to the belief that we are getting the treatment.  In medication studies, the treatment would be the medication.  It is quite amazing to me that believing that we are getting medication can lead to a benefit as if we wer getting the treatment. This response only occurs if we believe that we are getting the medication.

I have often heard people say that if there is a placebo response close to the response to the actual treatment [medication in this case] that the treatment is not effective.  Studies have repeatedly shown that responses to treatment are improved considerably if medication is combined with different forms of therapy and I wonder if this would also help the placebo responders to improve their outcomes. Another important fact to be aware of is the limitations of studies that involve larger numbers of people as the statistical analyses show correlations but not causations.  Also, the studies are short duration and often do not generalize to real life experience with the medications.  In fact, the placebo controlled randomized studies identify potentially useful medications that then are prescribed by your doctor and you then become part of the larger study determining the effectiveness of the medication.  This is very important as it requires more time and dosing adjustments to fine tune the use of medications to determine how effective they are.  There are two problems that prevent this from occuring.  First, it takes time with each person to assess their response to medication and to help them to determine how they are responding.  Unfortunately, it is not common for physicians to take the time that is needed. Second, there is no mechanism to feedback information about how you responded or are responding to the medication in order to update the research.  Thus, there is no way to update research with your experiences and then decisions about treatment remain limited to the initial, time limited studies.  This is another reason that treatments [like medications] are considered to be ineffective.

TF-CBT [TRAUMA FOCUSED COGNITIVE BEHAVIORAL THERAPY] FOR CHILDREN WHO HAVE BEEN AFFECTED BY SEXUAL ABUSE OR OTHER TRAUMATIC EXPERIENCES

It has become very clear how damaging chronic stress is for our bodies and our minds.  It is also becoming clearer how many children are traumatized by different types of events and suffer from chronic stress.  TF-CBT was developed to specifically treat symptoms of chronic stress [Post Traumatic Stress Disorder (PTSD)].  This has been adapted for use with children and recent studies have demonstrated it's effectiveness.  To review some of these studies you can go to: The California Evidence-Based Clearinghouse For Child Welfare (2011) at http-//www.cebc4cw.org; or SAMHSA Model Programs: National Registry of Evidence-Based Programs and Practices at http://ncrepp.samhsa.gov. There have also been studies showing benefit for children who have witnessed violence, see Cohen, Mannarin, & Lyengar, 2011 and also benefiting parents. Children who have experienced abuse often experience: feelings of guilt for what they see as their role in the abuse; anger toward their parents for not knowing about the abuse and for not protecting them; feelings of being powerless; feeling that they are "damaged goods"; and fears that they will be treated differently because of the abuse. They also may demonstrate negative behaviors, have other mental health problems such as depression and have PTSD symptoms that include: intrusive and traumatic thoughts of the abuse; avoidance of reminders of the abuse; emotional numbing; irritability; trouble with sleep and concentration; and physical and emotional hyperarousal with sudden and more extreme emotional reactions than is indicated for different situations. 

Benefits of TF-CBT for abused children include: reduced symptoms of PTSD and depression and also reduced behavioral problems while providing support and positive coping skills for non-offending parents.  TF-CBT components are described using the word PRACTICE.  P = psychoeducation and parenting skills. R = relaxation techniques. A= affective expression and regulation.  C= cognitive coping and processing.  T= trauma narrative and processing.  I= in vivo exposure.  C= conjoint parent and child sessions.  E= enhancing personal safety and future growth.   The therapy involves individual and parent and child sessions.  In our hospital based treatment program at the Copestone Child and Adolescent Inpatient Programs at Mission Hospital, we have found that a group therapy focus can more rapidly help children and adolescents to feel less stressed about their problems and to learn positive coping skills as they support each other in talking about their problems and learning better coping skills. 

Hopefully, more children who have been abused will be identified and referred to therapists who have been trained in TF-CBT.  It is important to note that some children or adolescents who have been running away, cutting themselves or are actively suicidal should be stabilized first using DBT [dialectical behavioral therapy] before TF-CBT is used.  For more information on TF-CBT you can go to the Child Welfare Information Gateway at http://www.childwelfare.gov/pubs/trauma.

WHY MUST TREATMENT BE INDIVIDUALIZED?

I have previously written about the fact that we are not statistics and that any one individual may not fit where most people [statistically about 68%] can be grouped when making diagnostic and treatment decisions.  It is clear that 32% of people fall outside one standard deviation from the mean and may not fit diagnoses or treatments based on studies that use statistical analyses [they almost all do].  In addition, the accuracy of these studies depends on the diagnostic symptoms or treatment responses being causally related to the results.  Statistics show that things are correlated and the studies need to not have other factors that are not part of the study influencing the outcome.  The other factors are often called factors and they are either controlled for or not.  Studies can control for age, sex, socioeconmic status, etc. and yet there are many other factors in humans that are hard to identify and very hard to control for.  So, studies might show statistical evidence that the treatment works but it might be only correlated and not causally connected to the outcome.  

Wow, that's confusing. However, it does seem to lend support to the idea that we must make the diagnosis or treatment fit each of us specifically.  This is obviously harder than lumping all people into one group and diagnosing or treating them the same way until it doesn't seem to work or doesn't work as well as we [you or me] had hoped.  Unfortunately, even trying to do things this way is a problem as it requires knowing each person and their specific responses to determine if the treatment is working.  It takes time and skill to listen and support someone so that they participate in figuring out if something is working or not.  

I have found that I must not only listen and clarify a person's response to a  treatment, but must also help that person identify other factors that influence their response.  Some of these factors can then be treated so they do not interfere or confuse the response to the treatment being evaluated.  Also, each of us must be willing to give the treatment a try and willing to work with their physician, psychologist, therapist, etc. in order for the treatment to have a chance to be helpful.  Part of this involves identifying the way the person experiences their symptoms and also how they experience improvements.  All of this is unique to the person.  

We are all unique and we must be helped with this in mind.