Marianne asks “how can I get off klonopin’’

A woman named Marianne messaged me wanting to know how to get off of Klonopin, which is a benzodiazepine, or benzo for short. She has been taking them regularly for more than twenty years, which is a very long time to be on a benzo. That will certainly complicate things. Before I go into how to stop taking benzos, I want to tell you what they are and what they do. 

What are they?

Benzos are medications designed to treat anxiety, panic disorders, seizures, muscle tension, and insomnia. Some of the most commonly prescribed benzos include: Xanax (alprazolam), Klonopin (clonazepam),Valium (diazepam), Restoril (temazepam),
Librium (chlordiazepoxide), and Ativan (lorazepam). A 2013 survey found that Xanax and its generic form alprazolam is one of the most prescribed psychiatric drugs in the United States, with approximately 50 million prescriptions written that year. Unfortunately, this class of drug is also highly abused. Another 2013 survey found that 1.7 million Americans aged 12 and older were considered current abusers of tranquilizer medications like benzos. When abused, benzos produce a high in addition to the calm and relaxed sensations individuals feel when they take them. 

How do they work?

Benzos increase the levels of a chemical in the brain called GABA. Meaningless trivia: GABA stands for gamma amino-butyric acid. GABA works as a kind of naturally occurring tranquilizer, and it calms down the nerve firings related to stress and the stress reaction. Benzos also work to enhance levels of dopamine in the brain. Dopamine is the feel good chemical, the chemical messenger involved in reward and pleasure in the brain. In simple terms, benzos slow down nerve activity in the brain and central nervous system, which decreases stress and its physical and emotional side effects.  

Why can using them be problematic?

Benzos have multiple side effects that are both physical and psychological in nature, and these can cause harm with both short-term  and extended usage. Some potential short-term side effects of benzos include, but are not limited to: drowsiness, mental confusion, trouble concentrating, short-term memory loss, blurred vision, slurred speech, lack of motor control, slow breathing, and muscle weakness. Long-term use of benzos also causes all of the above, but can also cause changes to the brain as well as mental health symptoms like mood swings, hallucinations, and depression. Fortunately, some of the changes made by benzos to the different regions of the brain after prolonged use may be reversible after being free from benzos for an extended period of time. On the scarier flip side of that coin, benzos may in fact predispose you to memory and cognitive disorders like dementia and Alzheimer’s. They’re many studies currently focusing on these predispositions. A recent study published by the British Medical Journal (BMJ) found a definitive link between benzo usage and Alzheimer’s disease. People taking benzos for more than six months had an 84% higher risk of developing Alzheimer’s dementia, versus those who didn’t take benzos. Long-acting benzos like Valium were more likely to increase these risks than shorter-acting benzos like Ativan or Xanax. Further, they found that these changes may not be reversible, and that the risk increased with age. Speaking of age, there are increased concerns in the elderly population when it comes to benzo usage. Benzos are increasingly being prescribed to the elderly population, many of which are used long-term, which increases the potential for cognitive and memory deficits. As people age, metabolism slows down. Since benzos are stored in fat cells, they remain active in an older person’s body for longer than in a younger person’s body, which increases the drug effects and risks due to the higher drug concentrations, like falls and car accidents. For all of these reasons, benzos should be used with caution in the elderly population. 

A big problem with taking benzos for an extended period is tolerance and dependency. Benzos are widely considered to be highly addictive. Remember that benzos work by increasing GABA and dopamine in the central nervous system, calming and pleasing the brain, giving it the feel goods. After even just a few weeks of taking benzos regularly, the brain may learn to expect the regular dose of benzos and stop working to produce these feel good chemicals on its own without them. Your brain figures, “why do the work if it’s done for me?” You really can’t blame the brain for that! It has become dependent on the benzo. But as you continue to use benzos, you develop higher and higher tolerance, meaning that it takes more and more of the drug to produce the regular desired effect. This tolerance and dependence stuff really ticks off your brain. It’s screaming “why aren’t these pills working anymore?!” The answer is that it has become dependent and tolerant, so it needs more. Just to prove its point, it makes you feel anxious, restless, and irritable as it screams “gimme gimme more more more!!!” The problem is that the body is metabolizing the benzo more quickly, essentially causing withdrawl symptoms, and a higher dose is needed. The longer you’re on a benzo, the more you’ll need. It’s a vicious cycle and it’s sometimes tough to manage clinically. 

The most severe form of physical harm caused by benzos is overdose. This occurs when a person takes too much of the drug at once and overloads the brain and body. The Centers for Disease Control and Prevention (CDC) cites drug overdose as the number one cause of injury death in the United States. A 2013 survey reported that nearly 7,000 people died from a benzo overdose in that year. Since benzos are tranquilizers and sedatives, they depress the central nervous system, lowering heart rate, core body temperature, blood pressure, and respiration. Generally, in the case of an overdose, these vital life functions simply get too low.  

When combining other drugs with benzos, obviously the risk of overdose or other negative outcome increases exponentially. But mixing benzos with alcohol is a special case, deserving of a strong warning as it is life-threatening. BENZOS + ALCOHOL = DEAD. One of the most common and successful unintentional and intentional suicide acts in my patient population is mixing benzos with alcohol. The combo is lethal, plain and simple. The body actually forgets to breathe. People pass out and just never wake up. If you’re reading this and you take benzos with alcohol and you’re thinking that you don’t know what the big deal is, you do it all the time and have never had a problem, then my response to you is that you’re living on borrowed time, and I strongly suggest you stop one of the two, the booze or the benzos, take your pick. 

What about withdrawl from benzos?

Benzo withdrawal can be notoriously difficult. It is actually about the hardest group of drugs to get off of. The level of difficulty is based on what benzo you’ve been taking, how much you’ve been taking, and how long you’ve been taking it. Obviously, if you’ve been on benzos for 25 years, it’s not going to be a walk in the park. To be honest, it’s going to be a rough road. Sorry Marianne. But it can be done. The first and most important thing is that you should never just stop benzos on your own, as it can be very dangerous and can include long or multiple grand mal seizures. Withdrawal from benzos should be done slowly through medical detox with a professional. It is best done with an addiction specialist like myself, because a specialist has the most current knowledge and experience. This is the safest way to purge the drugs from the brain and body while decreasing and managing withdrawal symptoms and drug cravings. As for the symptoms of withdrawl, these can include mood swings, short-term memory loss, seizure, nausea, vomiting, diarrhea, depression, suppressed appetite, hallucinations, and cognitive difficulties. Stopping benzos after dependency may also lead to a rebound effect. This is a sort of overexcitement of the nerves that have been suppressed for so long by the benzos, and symptoms can include an elevated heart rate, blood pressure, and body temperature. There may also be a return of the issues that lead you to take the benzos in the first place, insomnia, anxiety, and panic symptoms, and they can possibly be even worse than before. 

I’m sure that just about everyone currently taking benzos is thinking “I’m NEVER stopping!” right about now. It is not easy to do, but there is a way to manage all of this, to come off of the benzo and deal with all of the physical and cognitive aspects of withdrawl. I do it everyday. I set up a tapering schedule to lessen the specific benzo dosage over time, sometimes over a period of months. I will also often add or switch to a long acting benzo, which can be very helpful. I use several drugs to deal with the withdrawl symptoms: clonidine for tremor and high blood pressure, neurontin for pain and to help prevent seizures, anti-psychotic like seroquel for sleep, and an anti-depressant for depression, thank you Captain Obvious. The drug regimen varies from patient to patient. I also utilize psychotherapy to help work out the psychological kinks associated with withdrawl and rebound effect symptoms. Another trick I strongly recommend to many of my patients, not just those withdrawing from alcohol or any drugs, is transcranial magnetic stimulation or TMS. This is a non-invasive procedure done in the office that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and anxiety, and I’ve found that it seems to calm the nerves and offer relief to some people in withdrawl. Electrodes are placed on the forehead and behind the ears and painless stimuli are passed into certain regions of the brain for 40 minutes in each daily session for about a month. Many patients say it’s the best 40 minutes of their day.

I’d like to wish Marianne good luck. Please feel free to call me at the office at 561-842-9950 if you have any questions. 

To everyone else: If you can avoid ever having to take benzos, I strongly suggest that you do. If you’re currently taking them, give some serious thought to finding an alternative medication. I can help with that. For more information and stories about benzos, other drugs, and the process of medical detox, check out my book Tales from the Couch on Amazon.com.

How To Manage Stress

Rather than just introducing you to today’s topic, I want to play a little game of ‘Who am I?’ I’ll give you ten clues and let’s see if you can guess who I am. And no looking down below and cheating!

1. Everyone has me, either intermittently or constantly.

2. I am an unwelcome guest.

3. Some people deal with me better than others do.

4. I keep lots of people up at night.

5. I make some people physically ill.

6. I can shrink your brain. 

7. Some people take drugs to deal with me.

8. I can make some people binge, purge, or starve themselves.

9. I can cause a whole host of medical problems.

10. I have a good side, but nobody ever gives me credit for it!

Last clue: 

I am defined as “a physical, mental, or emotional factor that causes bodily or mental tension.”

So who am I? 

I am STRESS! 

I see so many stressed out people every day that I thought I’d do a little educational primer on stress.

Stress is a normal psychological and physical reaction to life’s everyday demands. A small amount of stress can be good. Positive stress is officially called eustress, and it can motivate you to perform well. But multiple challenges throughout the day such as sitting in traffic, meeting deadlines, managing children, and paying bills can push you beyond your ability to cope.

What’s going on in your brain when you feel stress? Your brain comes hard-wired with an alarm system for your protection. When your brain perceives a threat or a stressor, it signals your body to release a burst of hormones, especially cortisol, that increase your heart rate and raise your blood pressure. This is part of the fight or flight mechanism. But once the threat or stressor is gone, your body is meant to return to a normal, relaxed state. Unfortunately,some people’s alarm systems rarely shut off, causing chronic stress. When chronic stress is experienced, the body makes more cortisol than it has a chance to release. This has been shown to kill brain cells and even reduce the size of the brain. Chronic stress has a shrinking effect on the prefrontal cortex, the area of the brain responsible for memory and learning. So it’s very important to find effective ways to deal with stress. Stress management gives you a range of tools to reset your brain’s alarm system. Without managing stress, your body might always be on high alert, and over time, this can lead to serious health problems and contribute to mental disorders such as anxiety, depression and post-traumatic stress disorder. So don’t wait until stress damages your health, relationships, or quality of life…start practicing some stress management techniques. 

To help combat the negative effects of stress and anxiety, here are five tips to help manage stress in your daily life…

1. Follow a Regular Sleep Routine
It may seem like simple advice, but often the simplest advice is the best advice. Following a regular sleep routine can help you decompress, recharge, and rejuvenate your body and mind after a stressful day. Try going to bed at the same time every night and aim for 7 to 8 hours of sleep. Resist the urge to stay up late watching TV. In fact, avoid screen time altogether before bed, including tablets and smart phones. Studies have proven that reading on a backlit device before bed interrupts the body’s natural process of falling asleep. These devices also impact how sleepy and alert you are the following day.

2. Use Exercise to Combat Stress
Exercising regularly can have an enormous impact on how your body deals with stress, and it is one of the most recommended ways doctors instruct patients to reduce stress. The endorphins released while exercising can help improve your overall health, reduce stress levels, regulate sleep pattern, and improve mood. The key to exercising is to choose something that you truly enjoy. Whether it’s going for a walk, taking an exercise class at the gym, going for a swim, or lifting weights, exercise keeps us healthy. Make sure to mix up your exercise routine to prevent boredom and stay motivated. 

3. Learn How to Meditate
One of the simplest ways to help alleviate stress is to practice deep breathing and meditation. There’s no secret to this, and you don’t have to chant and burn incense or any of that. It’s just about finding a quiet space without distractions. It only takes a few minutes every day, either before bed or first thing in the morning. Breathe in through your nose, letting your abdomen expand. Hold your breath for a count of three, then breathe out slowly through your mouth. Repeat this three times. Focus on your breathing and your heart beat to prevent thinking about everything that you need to do. If doing it in the morning allows stressful thoughts of the upcoming day to intrude, try it at night. Deep breathing is especially important when your stress levels are high. Aim for meditating for at least 15 to 20 minutes, but if you’re feeling pressured during the day, a quick 5-minute meditation session can help you chill out.

4. Take Care of Your Skin
It may not seem like skin care and stress prevention are linked, but they are. Have you ever noticed that your skin is more prone to break out when you’re stressed out? How many times have you gotten up for work all stressed out about a presentation and looked in the mirror only to see a big zit on your nose? For crying out loud…why the heck is that?!!? How does your skin know you have a big presentation? Well, stress causes a chemical response that makes your skin more sensitive. And as we discussed, your body produces more cortisol when stressed, which causes your sebaceous glands to produce more oil. More oil means oily skin that is prone to acne. So it’s important not to neglect your skin care routine, especially when you’re stressed out. This goes for both guys and girls. You may be exhausted at night and want to go straight to bed, but taking an extra few minutes to wash your face and remove daily dirt and any facial products or makeup you’ve worn during the day will make a world of difference. And if you’re prone to oily or dry skin, always choose skin care products that are specifically designed for your skin type. Your skin will thank you for it by surprising you with big red zits less often. 

5. Ask For Help When You Need it
Asking for help may not always be easy, but when you need a shoulder to cry on or someone to listen, it can help put things into perspective.  Seeking support from family and friends or a professional isn’t a sign of weakness. In fact, it takes courage to admit you need help. Many patients that I see for the first time have been needlessly suffering for so long. I feel terrible for them. There is no reason not to seek help for any ailment affecting your health, especially your mental health. Patients who wait until they start to develop multiple physical and psychiatric issues before seeking help have a much harder time recovering than those who seek help sooner. Remember that friends and family are great support, but if you develop any signs of anxiety or depression or other mental health issues, get help from a licensed mental health professional immediately. In my experience, some patients may need medication, but some do not, they find relief through simple talk therapy with me. It’s very much an individualized assessment. While not a replacement for professional help, you can also look for online support groups for stress management. You’re not the only person who’s ever dealt with a specific stressful situation, so why not discover how other people managed their stress and overcame a potentially frustrating situation.

Hopefully after reading this you have a better understanding of what stress is, how it can impact your physical and mental health, and what you can do to start dealing with it effectively to minimize its role in your life. If you feel you need help, call my office for an appointment. I can help you. For more mental health topics and stories, check out my book Tales from the Couch, available on Amazon.com or for purchase in my Palm Beach office. 

How To Sleep Better At Night

Slumber, shuteye, repose, siesta, snooze…Sometimes we have a love-hate relationship with it…we love it when it’s good and curse it when it’s bad, but we all need it. Whatever you call it, one complaint I hear from patients day in and day out is that they have difficulty sleeping. It’s so prevalent that I want to discuss how to  get better sleep. In my 30 years of practice, I’ve compiled a list of 14 things in no specific order that you can do that should have you snoozing at night night in no time. 

Rule 1: Bright light during the day.  Your body has to have bright light during the day; sunshine is best, but even sitting in a bright room, like by a window, is helpful. Bright light tells your brain that it is day time, time to be awake. Darkness or the absence of bright light tells the brain it is night time, time to sleep. If you’re in a dark room all day, you probably won’t sleep well at night. So remember, in the day time, bright light is right. 

Rule 2: Limit blue light. What is blue light? Blue light is what is emitted from your computer, laptop, and smartphone. The more blue light you are exposed to, especially at night, the more disruption you’ll have in sleep, as it disrupts circadian rhythm. Lots of people climb into bed with their cell phone or iPad, and that’s the worst thing to do. You should avoid looking at bright screens beginning two to three hours before bed. There are apps you can install on your phone that filter out the blue light. There’s also something called “F. Lux” that you can put on your computer or iPad which will block out the blue light. You never hear about it, but blue light exposure, especially at night, is a major factor in hindering sleep. 

Rule 3: Captain Obvious here with a newsflash. Caffeine will keep you up at night. Don’t think you’re going to have coffee or tea after dinner or before bed and expect to sleep. And if you’re drinking sodas, coffee, or iced tea all day, it’ll still disrupt your sleep. I tell patients to limit caffeine consumption to under 250 – 300mg a day. As a guide, an 8oz cup of coffee has about 100mg caffeine, the same amount of tea has 24mg, a 12oz can of soda has 34mg, and those gnarly energy shots have 200mg of caffeine! I strongly advise against consuming caffeine after lunch if you plan on a bedtime between 10pm and midnight.  

Rule 4: No naps! Boo! Hiss! Why is it that as kids, just the word nap sent us into a tizzy tantrum, but as adults we love naps? If anyone has an answer, please let me know. Anyway, as satisfying as it is, napping disrupts your sleep-wake cycle, temporarily resetting it to where you’re not likely to be able to go to bed between 10pm and midnight. Bummer. 

Rule 5: Melatonin. I recommend 2 to 4mg of melatonin at bedtime; it really seems to help a lot of my patients. I do find that some patients get daytime hangover from it though, so you’ll have to see where you fall on that one. But it’s definitely worth a shot if you’re suffering from insomnia. 

Rule 6: Get up at the same time every day, and go to bed at the same time every day. Yeah, it’s kind of a drag not sleeping in on weekends, but a sleep routine can make a big difference in your relationship with Mr. Sandman. You can’t regulate when you’ll fall asleep, but you can regulate when you wake up. So set your alarm and get up at the same time every day, no matter how tired you are. Don’t nap and go to sleep between 10pm and midnight, and you should fall asleep. If sleep still eludes you, stick to the same plan, and you should surely sleep the second night. You can’t decide when you’ll fall asleep at night, but you can regulate your sleep-wake cycle by deciding when you wake up. Stick to setting your alarm for the same time every day, and hopefully your brain will get the idea. 

Rule 7: I recommend taking a glycine or magnesium supplement at night as well as L-theanine and lavender. They don’t make lavender teas, pillow sprays, lotions, and sachets for nothing. I have heard from people that swear by lavender as part of their wind down routine before bed. You can find these supplements on Amazon.com. Shameless plug: handily enough, you can also find my book, Tales from the Couch for sale there too. Check it out. 

Rule 8: This is the Mac Daddy, numero uno, absolute, not-to-be-broken rule. Alcohol. If you consume alcohol before sleep, you will not sleep. Why? As the body metabolizes the alcohol, it goes into a withdrawl-like reaction and disrupts sleep. I know what you’re thinking. You’re thinking that a little nightcap helps you sleep. Wrong. Some people will tell you differently, but trust me…alcohol and sleep do not play well together. 

Rule 9: A comfortable bedroom. Your bedroom should be an oasis of calm serenity. There should be no office or desk in the bedroom. It should be uncluttered. Anything not conducive to sleep should be out. Make sure it’s dark and quiet at bedtime. The weight of multiple blankets can help sleep. You can even purchase weighted blankets expressly for this purpose. The weight is comforting and relaxing to the body. 

Rule 10: This sort of goes hand in hand with #9 above. Try a low temperature in the bedroom. I personally make sure my bedroom is at 70 degrees. The blankets from rule number 9 come into play here too. There’s something very comforting about burrowing under fluffy blankets to go to sleep. I mean, they’re called comforters for a good reason. 

Rule 10: No eating late at night. People seem to mostly make terrible food choices at night, all in the name of snacks…chips, candies, baked goods. Sugary foods are especially bad. When you eat, the body goes into digestive mode, not sleep mode; it is very interfering to sleep. Sugars especially are no bueno. Evening or night snacking is one of the worst things you can do If you want to sleep.  

Rule 11: Relax and clear your mind. There’s an older pop song that has a lyric, Free your mind and the rest will follow. It’s true. We all have problems and stresses throughout the day, and they seem to pop up when your head hits the pillow. You have to come to some resolution on how you’re going to handle the problems in your life and put them to bed so that you can put the rest of you to bed.  

Rule 12: Spend money on a comfortable quality mattress. You’re going to spend a third of your life in your bed. Just suck it up and spend the money on the mattress. Don’t cheap out. Another place to spend money is on good linens. Few things are as inviting as a comfortable mattress covered in minimum 1,000 thread count all-cotton sheets. If you’ve never had nice linens, try them.You can pick them up on a white sale or online. You can thank me later. 

Rule 13: No exercising late at night.  When you exercise late at night, you raise blood pressure and heart rate, which will hype up the body, which is the antithesis of what you want when it’s time to sleep.  

Rule 14: No liquids prior to sleeping. No rocket science here. If you put liquids in, you’re going to need to get liquids out. In other words, you’re going to have to get up in the middle of the night to pee. And you’re probably going to stub your toe. Not good. 

This is my handy dandy guide on the do’s and don’ts when it comes to sleep. Anything is better than counting sheep. I don’t know who came up with that, but I would like to inform them that I have never in 30 years heard of it working. I’ve never before wanted people to fall asleep as a result of reading something I wrote, so this is a first! I hope you’ve learned some things here that will put you out like a light.

Warning Signs Of Bipolar

As a psychiatrist practicing in Palm Beach Florida, I come across a lot of bipolar patients.  What are the warning signs of bipolar disorder? How can you recognize if someone you love or even yourself has bipolar disorder? You can’t get through an hour television program without at least 2 commercials for bipolar medications, so I thought it would be a good idea to talk about it. 

First, what is bipolar? Bipolar disorder is a mental health disorder more commonly found in women that can cause dramatic changes in mood and energy levels. The term bipolar refers to the two poles of the disorder, the extremes of mood. Those two extremes of mood are mania and depression. The symptoms of bipolar can affect a person’s daily life severely as their mood can range from feelings of elation and high energy to depression. There are two types of bipolar, type 1 and type 2. Type 1 is more serious and disruptive than type 2, which can also be called hypomania. 

Bipolar is sort of the Jekyl and Hyde of psychiatric disorders, with cycling of mania and depression. Manic episodes and depressive episodes have very specific signs and symptoms associated with them.

When someone is manic, they do not just feel very happy. They feel euphoric. Key features of mania include, but are not limited to:

– irritability 

– having a lot of energy
– feeling able to achieve anything
– having difficulty sleeping
– using rapid speech that jumps between topics.
– inability to follow through with ideas or tasks

– feeling agitated, jumpy, or wired
– engaging in risky behaviors, such as reckless sex, spending a lot of money, dangerous driving, or unwise consumption of alcohol and other substances
– believing that they are more important than others or have important connections
– exhibiting anger, aggression, or violence if others challenge their views or behavior
– in severe cases, mania can involve psychosis, with hallucinations that can cause them to see, hear, or feel things that are not there.

People in a manic state may also  have delusions and distorted thinking that cause them to believe that certain things are true when they are not. While I have many patients that get delusions of grandeur, I have one patient that comes to mind. Her name is Felicia. Felicia is a 32-year-old receptionist. She was diagnosed with bipolar type 1 when she was 25, which happens to be the typical age of diagnosis. Felicia is on two medications for her bipolar with mixed results. She still cycles occasionally to a manic state. Sometimes that’s a clue that she may not be compliant with her meds. Like many bipolar people, Felicia loves loves loves her manic state. When Felicia is manic, she is on top of the world. Her house is pristinely clean, the meals she makes for her family are total gourmet, and her appearance is perfect. Sounds great, right? You may be thinking ‘Where’s the downside, Dr. A?’ Well, in this manic state, Felicia absolutely positively believes that she is descended from “the true” royalty. She believes that the father of the current Queen of England, the previous King George VI, actually stole the monarchy and the crown from her father. As a result, she believes that she should be the rightful current monarch. In reality, her father is a semi-retired urban planner living just outside of Topeka Kansas. Regardless, when Felicia is super manic, she will relay this story with a voice full of indignation and a perfectly straight face. She will tell anyone this story, so people think she’s totally nuts. 

A person in a manic state may not realize that their behavior is unusual, but others may notice a change in behavior. Some people may see the person’s outlook as eccentric or sociable and fun-loving, while others may find it unusual or bizarre. The individual may not realize that they are acting inappropriately or be aware of the potential consequences of their behavior. In some cases, they may need help in staying safe when they are completely out of touch with reality. Bipolar type 1 patients can be some of the most dangerous patients in my practice, as they can be violent, prone to rage and acting out on that rage. They are chaotic. If you have an untreated or ineffectively treated bipolar 1 person in the household, you will know. One big problem is that patients enjoy the manic state of their disorder. They feel such increased energy and euphoria that they are prone to stop taking their meds. Once that happens, all hell breaks loose. 

But eventually, that mania will cycle into deep depression with all of the symptoms that go with it, and may end with suicidal thoughts or acts. Key features of depressive episodes may include, but are not limited to:

– feeling down or sad
– having very little energy
– having trouble sleeping or sleeping a lot more than usual
– thinking of death or suicide
– forgetting things
– feeling tired
– losing enjoyment in daily activities
– having a flatness of emotion that may show in the person’s facial expression
– In very severe cases, a person may experience psychosis or a catatonic depression, in which they are unable to move, talk, or take any action.

Bipolar type 2, also called hypomania, is a disorder which is sort of like type 1-light. It features episodes of depression and hypomania. Symptoms of hypomania are similar to those of mania, but the behaviors are less extreme, and people can often function well in their daily life. But if a person does not address the signs of hypomania, it can progress into the more severe form of the condition at a later time. I see type 2 patients more often in my practice, and I see them as generally being much calmer than type 1 patients. They do not get as violent, do not hear voices, do not have hallucinations, and are not disorganized in their speech or behavior. However, they are usually irritable. They talk quickly. They have trouble sleeping. They have trouble concentrating. They have trouble getting things done. They have relationship issues. They have trouble sleeping. These periods of hypomania can last anywhere between minutes to days to weeks.

So what can be done for a patient suffering from bipolar disorder, whether type 1 or 2? There are multiple drugs which can be used to balance the patient. I find my go-to drug would be lamotrigine, as it is minimal in its side effect profile, is mood stabilizing, does not put on weight, does not make you drowsy, and does not have many drug interactions. There are other drugs which can be used,  oxcarbazepine and divalproex, which are antiseizure mood stabilizers. These have some effectiveness and have various side effect profiles. In some cases, antipsychotic drugs like lurasidone are useful. Many times I put patients on at least two drugs, one to treat mania and one to treat depression. I can prescribe all the drugs in the world, but they won’t do any good if patients are non-compliant in taking them. So the biggest and most important key feature in treating bipolar is having a relationship with the patient and making sure they are compliant with medicine, because the manic state is so enjoyable to them that they may choose non-compliance. That’s really the biggest barrier to treatment. I always explain to my manic patients that while they may like the mania, they will have to pay the piper, because guess what? Next they’ll be hopelessly depressed and unable to get out of bed.

In my practice, I see many female patients with mood disorders. The way I approach treatment is to find the best tolerated drug. This may not be the best drug on the market, but may be the best drug for that patient because it is better tolerated and has a better side effect profile for that patient. If the drugs cause weight gain, make them drowsy, or cause sexual dysfunction, they won’t take them. And who would blame them? So I work very hard to explore all available pharmaceutical treatment options for each patient as an individual. The goal is to have a drug regimen which is the least invasive in that person’s life and to combine that with psychotherapy. Because bipolar disorder is a lifelong disease, treatment should also be lifelong. If you suspect that you have bipolar or a loved one has bipolar, contact a physician for referral to a mental health professional like myself. For more information, check out my book, Tales from the Couch, available on Amazon.com. 

Post-traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a severe anxiety disorder that can develop after exposure to any event that results in-psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one’s own or someone else’s physical, sexual, or psychological integrity, overwhelming the individual’s ability to cope. As an effect of psychological trauma, PTSD is less frequent and more enduring than the more commonly seen acute stress response. Diagnostic symptoms for PTSD include re-experiencing the original trauma(s) through flashbacks or nightmares, avoidance of stimuli associated with the trauma, and increasedarousal – such as difficulty falling or staying asleep, anger, and hypervigilance. Formal diagnostic criteria (both DSM-IV-TR and ICD-10) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.

Agoraphobia (Without History of Panic Disorder)

Agoraphobia Without a History of Panic Disorder is an anxiety disorder characterized by extreme fear of experiencing panic symptoms, of panic attacks.

Agoraphobia typically develops as a result of having panic disorder. In a small minority of cases, however, agoraphobia can develop by itself without being triggered by the onset of panic attacks. Historically, there has been debate over whether Agoraphobia Without Panic genuinely existed, or whether it was simply a manifestation of other disorders such as Panic Disorder, General anxiety disorder, Avoidant personality disorder and Social Phobia. Said one researcher: “out of 41 agoraphobics seen (at a clinic) during a period of 1 year, only 1 fit the diagnosis of agoraphobia without panic attacks, and even this particular classification was questionable…Do not expect to see too many agoraphobics without panic” (Barlow & Waddell, 1985) . In spite of this earlier skepticism, current thinking is that Agoraphobia Without Panic Disorder is indeed a valid, unique illness which has gone largely unnoticed, since its sufferers are far less likely to seek clinical treatment.

Agoraphobia

Not to be confused with agraphobia, agoraphobia is a condition where the sufferer becomes anxious in environments that are unfamiliar or where he or she perceives that they have little control. Triggers for this anxiety may include wide open spaces, crowds (social anxiety), or traveling (even short distances). Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a panic attack and appearing distraught in public. This is also sometimes called ‘social agoraphobia’ which may be a type of social anxiety disorder also sometimes called “social phobia”.

Not all agoraphobia is social in nature, however. Some agoraphobics have a fear of open spaces. Agoraphobia is also a defined as “a fear, sometimes terrifying, by those who have experienced one or more panic attacks”. In these cases, the sufferer is fearful of a particular place because they have experienced a panic attack at the same location in a previous time. Fearing the onset of another panic attack, the sufferer is fearful or even avoids the location. Some refuse to leave their home even in medical emergencies because the fear of being outside of their comfort area is too great.

The sufferer can sometimes go to great lengths to avoid the locations where they have experienced the onset of a panic attack. Agoraphobia, as described in this manner, is actually a symptom professionals check for when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post traumatic stress disorder can also cause agoraphobia, basically any irrational fear that keeps one from going outside can cause the syndrome.

It is not uncommon for agoraphobics to also suffer from temporary separation anxiety disorder when certain other individuals of the household depart from the residence temporarily, such as a parent or spouse, or when the agoraphobic is left home alone. Such temporary conditions can result in an increase in anxiety or a panic attack.

Another common associative disorder of agoraphobia is necrophobia, the fear of death. The anxiety level of agoraphobics often increases when dwelling upon the idea of eventually dying, which they consciously or unconsciously associate with being the ultimate separation from their mortal emotional comfort and safety zones and loved ones, even for those who may otherwise spiritually believe in some form of divine afterlife existence.

Gender differences

Agoraphobia occurs about twice as commonly among women as it does in men. The gender difference may be attributable to several factors: social-cultural traditions that encourage, or permit, the greater expression of avoidant coping strategies by women (including dependent and helpless behaviors); women perhaps being more likely to seek help and therefore be diagnosed; men being more likely to abuse alcohol in reaction to anxiety and be diagnosed as an alcoholic. Research has not yet produced a single clear explanation for the gender difference in agoraphobia.

Causes and contributing factors

Although the exact causes of agoraphobia are currently unknown, some clinicians who have treated or attempted to treat agoraphobia offer plausible hypotheses. The condition has been linked to the presence of other anxiety disorders, a stressful environment or substance abuse. Chronic use of tranquilizers and sleeping pills such as benzodiazepines has been linked to onset of agoraphobia. In 10 patients who had developed agoraphobia during benzodiazepine dependence, symptoms abated within the first year of assisted withdrawal.

Research has uncovered a linkage between agoraphobia and difficulties with spatial orientation. Individuals without agoraphobia are able to maintain balance by combining information from their vestibular system, their visual system and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse (as in wide open spaces) or overwhelming (as in crowds). Likewise, they may be confused by sloping or irregular surfaces. In a virtual reality study, agoraphobics showed impaired processing of changing audiovisual data in comparison with healthy subjects.