psychotherapy podcast

Understanding Placebo

On this week’s episode of the Psychiatry and Psychotherapy podcast, I interview Mark Ard, M.D., a third year psychiatry resident at Loma Linda University. On the state level, he works towards developing means of access to care, in-patient psychiatric care, affordability of care, and further access to mental health.

Mark is also the person who encouraged me to start pursuing weight training through Starting Strength, which we will link in this article.


Understanding Placebo

David Puder, M.D., Mikyla Cho, Mark Ard, M.D.

What is placebo?

The original meaning of the word placebo is, “I will please.” That statement comes from a time when doctors didn’t have our modern code of ethics, and they would prescribe whatever would make the person feel better. They probably had the best intentions, but they also would have known that whatever they were prescribing might not have been a real medication for the symptoms the patient was experiencing.

Doctors, even then, knew that suggestion was powerful, sometimes more powerful than the medicine they were prescribing.

Laypeople who hear the word “placebo” automatically think of sugar pills. They may think only that it’s something a doctor gives to placate and make people feel better when they aren’t getting the active medication. Placebos have long been used as a comparison arm for clinical trials. Usually it is in the form of an inert sugar pill or sham-procedure. Researchers can observe a psychobiological response known as the placebo effect.

But when thinking about the word “placebo,” we must think of the entire effect of it, and it is perhaps better termed “the meaning effect.” As I discussed in last week’s episode of the podcast, the meaning we give something creates belief, and belief is a potent change mechanism, even when it comes to our physical health. It is especially potent when it comes to mental health.

The placebo effect encompasses the therapeutic alliance, expectations, natural healing of the body and mind, and the environment of therapy. It involves the power of suggestion, mood, and the beliefs behind even one positive or negative interaction with a doctor. It also, as we will see, involves studies involving heavy-hitting medication.

When there is an increased ritual, there is an increased placebo effect. During a hospital stay, the surgery preparation, meetings with doctors, nurses and therapists can have an incredibly therapeutic effect on a patient. It is possible to see biological mechanisms triggered by psychosocial context and attribute it to a placebo effect.

What is the power of suggestion, the meaning effect, placebo effect, and how do we use it or avoid it in our practices and when testing new medical treatments?

Why do we study placebo?

We study placebos because we need to understand how meaning works, how belief works, and on the other side, if a medicine actually works.

As doctors, we need to be able to read studies critically, with an eye for placebo. We need to see what actually works and what the study was controlling the treatment group to. We also need to know if there parts of the treatment that are working only because of the placebo effect, and if so, how do we use that to heal people.

How does the placebo effect work?

The efficacy of the placebo goes up because of the expectation and meaning we give to placebo.

In one study, half of the patients got the actual medication, half got the placebo. In the same study, in another group, 25% of the patients got the placebo, and 75% of them got the actual medication. In both of these studies, the participants were told the percentage chance they would get the real medication. In the study where only 25% of patients received the placebo, more people experienced positive changes from the treatment, whether they received the placebo or not. Most people believed, because of hearing the percentages, that they would probably get the medicine. That belief increased the placebo effect.

In groups with lower percentages receiving the actual medication, the response is lower, even with real medication.

Researchers think placebo effect works because of expectation and classical conditioning mechanisms. Such understanding may be an oversimplification of a very complex phenomenon but it provides a useful framework. Expectation is how much the patient believes in the therapy. Higher expectation leads to hope and positive outlook, which results in better outcomes. Exactly how this works is still under investigation. There are multiple theories as to the underlying mechanism, but overall, we can say that there is a bidirectional interaction between expectations and emotions, and we respond better when expectations are high and our mood is good.

Classical conditioning contributes to the placebo effect by modulating conscious expectation and non-conscious learning. The white coat effect is a classic example of how our body responds to a conditioned stimulus. Also, when a patient feels better after taking a pill, it becomes a conditioned stimulus, and the body may respond positively even after taking a placebo medication because of its conditioned response.

Expectation can be shaped by many factors. Broadly, these factors can be grouped into patient effect, clinician effect and study design effect. Patient effect refers to patient characteristics such as beliefs, values, cultures, and the meanings associated with the illness and the treatment.

In a study of IBS patients, Vase et al found that expected pain levels and desire for pain relief accounted for up to 81% in the variance in visceral pain intensity. There is also a greater dopamine release in patients who had higher expectation. (De la Fuente-Fernández). Conversely, pessimists were more likely to have negative side effects (when compared to optimists’ responses) when told a placebo would make them feel bad.(Geers)

How a patient interprets and generates meaning in a given treatment condition is widely variable and difficult to control for. A similarity in demographic characteristics would not account for all of them. Direct-to-consumer (DTC) advertising of antidepressants is an example of how a society can shape one’s view and expectation of the illness and the treatment. The promotion of antidepressants inherently depends on the biological model of depression. By simplifying depression as serotonin deficiency, antidepressants were promoted as a simple solution to a complicated problem. These advertisements are designed to convey that “psychopharmaceuticals have an obvious, objective, and scientific relationship to the symptoms they are supposed to treat”(Greenslit, 2012). The reality is more complex and difficult to understand than the advertising, but the narrative is believed and shapes decision making.   

An interaction with a clinician can shape the expectation of outcomes as well, especially if there is a strong alliance. Warmth, empathy, duration of interaction, and communication of positive expectation may significantly affect clinical outcome (Kaptchuk).  

One article (Verhulst et al., 2013) deconstructed the correlation between the medical alliance and placebo. The placebo effect encompasses the beliefs, values, and expectations that patients have about a treatment. We can help shape a patient’s belief and expectations by giving realistic illustrations of the treatment, which are more valuable than false hopes; this is the medical alliance that we as healthcare providers can utilize. Part of the medical alliance is the idea of concordance between the physician and patient. There is both narrative concordance, the shared understanding of the patient’s condition, and the relational concordance, the shared relationship structured based on scripts, boundaries, and interactional rules. Ultimately, by utilizing the idea of concordance and a strong alliance with the patient we can influence how they view a treatment and better the outcomes via the placebo effect.

Study design can also change expectation. Having a higher chance of being assigned to the treatment group and having a choice (Rose 2012) increases the expectation. The degree to which placebo resembles the treatment is another important consideration, because unblinding can lead to decreased expectation. (Some studies utilize active placebo to make unblinding more difficult.) In pharmacological studies, active placebo usually contains some real medication that contains some of the expected side effects to imitate the expected treatment.  

The mechanisms that control placebo effect:

  • Opioid system

This system bolsters a lot of the evidence for pain relievers—you have more of a placebo effect on the patient if they know they're getting the medication than if it’s snuck into an IV. The opioid system in the brain begins to work as a pain reliever before any actual medication sets in, if it’s even administered.

  • Dopamine system

Dopamine signaling is involved in expectation and response. Our brains will respond as if something is happening if it believes it will happen. This pathway is also involved in habit formation and novelty seeking. The brain lights up in the same way to a placebo as it does to an active intervention. There is a fascinating link between dopamine deficiency and Parkinson’s disease; placebos can induce dopamine release, leading to improvement in Parkinson’s disease motor dysfunction.

In another study, people were told they were getting either a cheap medication or an expensive medication. Even though they both received placebos, the group who was told they were getting the more expensive medication experienced a greater placebo effect.

Even the color of medication can affect a person’s response. Brand names can affect a person’s response. A person who is told they are receiving an anti anxiety medication will calm down, even if it’s a placebo.

  • Prefrontal cortex

The third “system” is prefrontal cortex, which is involved in associations and meaning. This is also one of the main areas involved in improvement of depression (Murray, 2013).


What is the effect of placebos on the medical profession?

Is placebo testing accurate?

Some industries fail to examine things with an accurate and rigorous placebo. For example, in a recent study on Botox used for depression, ¾ of the subjects knew if they had received the placebo or not (Finzi & Rosenthal, 2014). Some studies also neglected that placebos can actually change brain chemistry, and activate or deactivate different areas of the brain.

We often think that the patient who is administered a placebo, in taking the medication, thinks it is real and thus the whole placebo response is merely from taking the pill. But in those results we neglect the human factors that come into play when a person meets with a psychiatrist that is doing the patient interview, and how it could be the therapeutic alliance and feeling cared for that influences outcomes and spontaneous remission of symptoms.

For the medical field to determine that it’s not only the placebo effect taking place, that the medicine or treatment actually works, many factors come into play.


Discussing negative side effects with patients

How do you talk about medication as a doctor without scaring the patients with a side effect list? Studies show that by listing side effects, people are more likely to experience the side effects.

I usually discuss the side effects with patients if they occur in more than 1% of patients or if the side effect is life threatening. Also, if the patient feels like they need to stop the medication, I tell them to call or email me. Even knowing they can reach out of they are experiencing problems gives patients a sense of peace, and could decrease negative placebo effects of the medicine, and increase positive effects of it.

In medical education at large, there seems to be a loss of the science of connection and a focus on medicine rather than being able to emotionally connect to people, and mental health is part of the human experience.


Therapy and the placebo effect

Placebo and psychiatry have an interesting and complicated relationship—both are concerned with the mind-body connection. Using placebo in psychiatriatric research is, therefore, more challenging. It is more difficult to tease out the true effect of a treatment since mental illnesses have significant psychosocial components.

Higher therapeutic alliance, higher empathy, and higher interpersonal skills all have better outcomes. Beyond the model of therapy, each therapist’s kind of connection to their patients deeply affects a patient's’ response.

The value of the therapeutic alliance can be as powerful as medication, and also bolster the effectiveness as the medication itself.

In their paper Wampold, Frost, and Yulish (2016) reviewed the history of how placebo was used in randomized control trials for testing the efficacy of psychotherapies. They found that when poorly designed placebo therapies were used as controls, the psychotherapy treatment group had superior results. It is difficult to have a truly controlled placebo. For example, it can be obvious whether a therapy is a placebo or a true psychotherapy and the providers administering the treatments would also know which was the true treatment. People have advocated that different psychotherapies are beneficial because of their common factors such as the therapeutic alliance, discussing expectations, and instilling hope. These and other factors common to the variety of psychotherapies can also be found in the placebo effect, which facilitates the argument that placebo psychotherapies are not inert. Therefore when we look at studies that compare psychotherapies to a placebo therapy, we must be aware that the comparisons may not be completely accurate.

In therapy practice there are no effective placebos to be given to compare, so effect size with therapy is very different than effect size with medication vs placebo. A broader and more nuanced understanding of the placebo effect is important in two ways. First, it allows a clinician to critically evaluate studies that compare the treatment with placebo. Placebo should be evaluated within the framework of mental illnesses. Secondly, understanding placebo allows a clinician to maximize the clinical outcome by focusing on factors such as alliance. Placebo teaches us about the complexity of the mind body connection, and calls for a more integrated approach in treating mental illnesses.

The effect size in double blind studies, however, does not tell the whole story of the effectiveness of the psychiatric relationship, because it does not take into account the part of the placebo response that actually came from a psychiatrist’s relationship with the patient.

Even since the beginning of psychopharmacology, in the 1940’s, placebo effect has increased. In part, I believe that’s because we’ve reduced mental illness to a few symptoms and then say those can be helped or fixed by a pill. For example, there is commonly believed language around depression that says it’s a serotonin deficiency. So, patients take medicines to boost their serotonin (SSRI medication). That is not the only thing going on in depression, and it’s not necessarily true. So SSRI medications have a large placebo effect.

Further, different psychiatrists will have different effectiveness with patients (McKay, 2006). The authors analyzed data from the Treatment of Depression Collaborative Research Program (TDCRP) that compared imipramine hydrochloride with clinical management vs. placebo with clinical management and found that 7% to 9% of outcome variabilities depended on the psychiatrist providing the treatment. When using BDI, the results were statistically significant (p < 0.05) and when using the HAM-D the results were marginally significant (p = 0.053). Therefore the authors concluded that the psychiatrist effect was at least equal to or greater than the treatment effects. The effectiveness of a psychiatrist is also critical in proving optimal treatment.  


Non-therapeutic medical fields and doctor-patient relationships

Even the awareness that the placebo effect exists should make medical workers understand that we need to consider people’s outside lives, not just the psychopharmacological effects of the medication. If little things have a placebo effect, and that is directly related to meaning and belief, what are the patients experiencing outside of the medical office that is influencing them?

Conclusion

Our brains were made to create meaning out of things, and this meaning can change the very nature of the brain. When we understand placebo we become better guides to our patients, steering them away from things that don’t do anything, and towards things like having a connected relationship with a caring person, which can be the treatment itself. We also look not only at how powerful a medication was compared to the placebo, but also if the patients thought they were taking the real medication or not. We also learn that belief is powerful and can understand how people get swayed into cults and taking things which have been proven to only be harmful.  

Perinatal Mood and Anxiety Disorders

In this podcast and article Dr. Kelly Rivinius, a licensed clinical psychologist who helps women suffering from PMAD, gives her insights about PMAD, its risk factors, prevention, and her own experience with perinatal OCD and anxiety.

David Puder, M.D. and Kelly Rivinius, Psy.D. have no conflicts of interest to report.  


Article the accompanies this episode go: here

Therapeutic Alliance Part 2: Meaning and Viktor Frankl’s Logotherapy

Episode CME activity objectives:

  • In the context of a therapeutic alliance, apply the information given in this episode to help draw out meaning in others.

  • Identify who Viktor Frankl was and how his work and legacy have shaped how we understand and utilize meaning in psychiatry.

  • Define psychic determinism.

  • Recognize that meaning is idiosyncratic and unique to each individual.

  • Recognize the multitude of ways people can find meaning in their lives and the various ways they can express and convey this.

  • Summarize the various studies listed in this episode that have shown how meaning and the creation of meaning can have a positive impact.

David Puder, M.D. has no conflicts of interest to report.  

Link to sign up for CME go: here

Member Login to do CME activity go: here


In this week’s episode of the podcast, I’m going to be emphasizing the meaning that I, as a therapist, can help draw out of other people’s experience through a therapeutic alliance.

David Puder, M.D., Kristen Bishop, Brooke Haubenstricker, Mikyla Cho

In the celebrated book Man’s Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners’ small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together.

“The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity—even under the most difficult circumstances—to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal.” - Viktor Frankl

“We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” - Viktor Frankl

Frankl argued that the ultimate human drive is the “will to meaning,” which could be described as the meaning to be found in the present and in the future. For example, I have had patients who are suicidal, yet they would not kill themselves, despite part of them desiring death, because they would not get to see their grandkids grow up. The meaning of the future moments and being able to help their grandkids in some small way empowers them to keep going to treatment.

People’s meaning keeps them going, even when other drives, like sex or desire for power, are completely gone. In this way, Frankl noted, “Focus on the future, that is on the meaning to be fulfilled by the patient in his future…I speak of a will to meaning in contrast to the pleasure principle (or, as we could speak also term it, the will to pleasure) on which Freudian psychoanalysis is centered, as well as in contrast to the will to power on which Adlerian psychology, using the term ‘striving for superiority,’ is focused.”

This idea led to the beginning of a new type of therapy—logotherapy.

Helping a patient find meaning

Being unable to find personal meaning in our lives can lead to depression, hopelessness, anxiety, and suicidality. As a physician, I see this often, and I try to help my patients find meaning in their lives. However, the approach I have learned from Dr. Tarr (my mentor), and from my studies, is different than the normal approach of just asking people, “What is your purpose?” or, “What is your vision for the future?” The technique I use is based on another principle called “psychic determinism,” which means that everything has meaning. There is nothing that a person says, no flash of emotion, no change in body posture that is meaningless.

When you believe this, you view the patients’ words differently. The meaning may not be readily apparent; it may be expressed in primary process mentations and have an unconscious-type meaning like dreams, which may be difficult to understand. Suffice to know at this point that the mindset we have when we approach people is that everything they say has meaning; every sequence of thoughts that they say is deep and valuable.

We start from small moments of meaning that are coming from their words, their body language, their microexpressions, your experience of them in the moment, and we take those small moments of meaningfulness and start to verbalize what we find meaningful. Listening to our patients and helping them to understand the hidden meaning in their lives, even in the midst of work or difficult times, can help them withstand trauma, stress, and hardships.

No rambling is random

Sometimes patients will talk for awhile, changing subjects rapidly, and we may think it is random, but it isn’t. Even when schizophrenic patients talk, there is meaning behind what they’re saying. When we allow for free association, we can derive a sense of meaning from the commonalities in topics that come up.

For example, a patient might be talking about how they are angry at their significant other, then immediately report that when they were young their mother would often yell at their father, and their father would cower in his room in silence. How is their current anger related to how they felt as a child watching this drama? How might the two be linked? What about the microexpression of disgust that flashed as they reported both topics.  

As you look deeper, the meaning becomes more evident. In this particular situation, the disgust or revulsion they experience recollecting their father’s cowardice magnified the disgust they felt toward their significant other. Understanding the link and the uncovered meaning helped them tolerate the intensity of that negative feeling, and helped them develop new meanings about their current and past experiences.

Even hallucinations and delusions generated by some mental illnesses have meaning. When I’ve given patients antipsychotics and they’ve adapted to the medicine, we explored their hallucinations and they were able to see why they wanted to believe in an alternate reality—it gave them a sense of power or control, or related to a deep underlying fear in some way. As we developed meaning in their real lives, they felt more comfortable in their actual reality.

When we sincerely believe that everything the patients say has meaning, the patients themselves feel meaningful. Ascribing meaning enhances the patient’s esteem tremendously and makes them feel safe enough to continue to freely associate. Incredible progress can be made with patients in this way.

To get people to free associate, you need to reduce the shame enough to get people to feel safe enough to be able to share their uncensored thoughts and feelings.

Empathize with the meaning

“Men are not moved by events but by their interpretations.” - Stoic Epictetus

Relationships can allow for deeper understanding and meaning to develop in life. To strengthen our relationship with our patients, we must understand what they’re saying and then empathize with that meaning.

We often think in the context of our own lives, and as therapists or physicians we need to allow people to be the experts of their own lives. A word or phrase may mean something completely different to our patients than it does to us, so we must ask the patients to help us understand their interpretations and the meanings they assign to the events they’ve experienced. It is important that the patient communicates their meanings and that assumptions aren’t made. Misunderstandings can cause feelings of isolation, leading to strains or ruptures in the relationship. If this happens, try to reconnect, as this conveys respect.

Try to deeply connect with the patient emotionally through empathy and listening. Listen to what is said, what is not said, and what makes the patient defensive. We can listen to the rhythm, the sound, their vocal cadence, and watch their face for emotional cues.

Even if we believe the patient isn’t entitled to the emotions they are experiencing, we have to search for the meaning they’ve assigned to their pain. That meaning is what we can empathize with, no matter the circumstance. When we empathize, we can join them in their distress or enjoyment, and we can develop a deeper therapeutic alliance that is patient-centered and emotion-centered.  

“To feel with a patient and share distress and hopelessness and mistrust of the future, is therapy. You are an observer in taking history, but you’re a participant as a therapist. To share together, is therapy.” - Dr. Tarr

Meaning develops emotional endurance

People who have chronic pain who believe they are enduring it for a deeper meaning report feeling far less physical pain compared to those who do not report a deeper meaning. Even in birthing units, women report the highest amount of pain, but also often the highest amount of satisfaction. The child being born gives meaning to the pain, and this meaning is so powerful that some women choose to endure the pain instead of accepting medication.

Help patients find meaning in their symptoms. Most symptoms are adaptive, even eating disorders, cutting, and other harmful behaviors. These things have helped people cope with the realities of their lives in some way. We don’t want them to judge their symptoms, but we want them to identify what the meaning behind them.

To really connect with a patient, we must convey to them through our words and actions that they mean something to us, and that we empathize with the meanings they’ve assigned to their lives.

Here are a few phrases I like to use that convey to the patient that I want to connect with them:

  • “What we are talking about together is meaningful.”

  • “We want to make sure we are understanding each other.”

  • “I think I know what you mean. Please tell me if ______ is what you meant. I want to make sure I am understanding you and that we are in tune with each other.”

  • “If you feel I misunderstood you, please tell me right away so we can clear it up as soon as possible.”

  • “We will know together, find out together…”

  • “Could you give an example, elaborate on that, I want to be sure I understand what you are sharing with me.”

  • “I can understand in part how that interaction would make you feel that way.”

Logotherapy, created by Viktor Frankl, helps patients understand and develop meaning in their lives.

Viktor Frankl’s book not only chronicles how the principles of logotherapy helped Frankl survive the Holocaust, it also recounts his observations of how others used meaning to retain their human dignity during times of great suffering. So what is this “logotherapy” that helped people survive?

Essentially, logotherapy is a meaning-centered approach to psychotherapy. Frankl first published his ideas on logotherapy in 1938, and it is now known as the “Third Viennese School of Psychotherapy.”

The Viktor Frankl Institute lists the three principles that are the basis for logotherapy:

  1. Freedom of will

  2. Will to meaning

  3. Meaning in life

The core tenants can also be elaborated in another way, as done by the Viktor Frankl Institute of Logotherapy in Texas:

  1. Life has meaning in all circumstances, even the most miserable ones.

  2. Our main motivation for living is our will to find meaning in life.

  3. We have freedom to find meaning in what we do, and what we experience, or at least in the stand we take when faced with a situation of unchangeable suffering.

Frankl noted that there are a variety of ways in which we can find meaning, such as by our actions, our experiences, our relationships, and our attitude toward suffering. Indeed, logotherapy has been utilized to help treat a variety of psychiatric illnesses, such as anxiety, depression, obsessive-compulsive disorder, and even schizophrenia. Currently, there are several logotherapy institutes around the world in Africa, Asia, Europe, and North America that focus on educating the public about logotherapy and applying it to find meaning in people’s lives.

Here are some studies about logotherapy:

  • One study (May, 2010) found psychological safety and psychological meaningfulness was significantly related to engagement in work. 73% of the variance in engagement in work was able to be explained, with 62% coming from meaningfulness and 42% coming from psychological safety.

  • One study (Mahdizadeh, 2016) of patients after heart surgery found that those receiving logotherapy had improvement in mood. Additionally, this study found that logotherapy did not change the physical capabilities of the patient post surgery. However in the patients who had little to no symptom relief and continued limitation of functions post-op, it still showed an improvement in mood 6 months after the study was completed.

  • Another study (Robatmili, 2014) had the logotherapy group work on describing what was meaningful, setting goals, and then had the group facilitate each other moving towards their goals. In this treatment group, the “meaning of life” scores increased and depression scores decreased. Discovering and pursuing meaning is facilitated by helping through the following steps: (a) establishing the therapeutic relationship; (b) increasing insight regarding identity, values, and goals; (c) reframing meaninglessness and depression; (d) discovering meaning within the meaninglessness and depression; and (e) pursuing the fulfillment of meaning.

  • Once you have some positive attributes, you find other positive attributes—like a snowball effect of developing positive meaning in life. One study (Zhang, 2018) showed this after surveying 1,000 elderly people in Hong Kong. There was a higher level of meaning associated with happiness, health status, and decreased healthcare utilization.

  • Another study (Mahdizadeh, 2016) showed that when educational interventions based on the main concepts of logothearpy were made, it lead to an improvement of the patient’s quality of life after CABG surgery in persons over the age of 35 (specifically, scores in QOL were improved psychologically).

  • In one study (Mosalanejad, 2013), an infertile experimental group that used logotherapy showed significant decreased psychological stress scores.

  • One case review (Southwick, 2006) looked at adding a meaning-based intervention into the treatment of chronic combat-related PTSD showed positive enhancement of outcome when combine with traditional therapies and medications.

  • A study of women with breast cancer (Mohabbat-Bahar, 2014) showed logotherapy to be helpful at reducing anxiety.  

  • I also discussed a study (Thomas, 2014) regarding how structured sessions helped cancer patients improve their sense of meaning in life.  

  • A qualitative interview study on nursing home residents (Drageset, 2017) found that meaning could be found in physical and mental well-being, belonging and recognition, personally treasured activities, and spiritual closeness and connectedness.  This present study also showed a link between well-being of patients’ hope for an improved state of health and are in accordance with previous studies showing significant associations between meaning, hope and well-being among older people in nursing homes.

  • Finally, a study (Leveen, 2017) explored how poetry can be used to increase a sense of meaning in physicians caring for patients.    

Conclusion:

By focusing on what is said by our patients and those we care about and by believing that everything that is said has meaning, we can increase our connectedness with them.  We can also slowly find the deeper sources of meaning and purpose which can help make sense of suffering and physical and emotional pain.






Psychiatric Approach to Delirium with Dr. Timothy Lee

This week on the podcast, I am joined by Dr. Timothy Lee, the Loma Linda residency program director and the head of medical consult and liaison services. One of his specialities is delirium, so this week we will be discussing both hypoactive and hyperactive delirium.  

What is delirium?

Delirium is an acute change in a person’s sensorium (the perception of one’s environment or understanding of one’s situation). It can include confusion about their orientation, cognition or mental thinking.

With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family, or non-psychiatric medical staff, might be concerned that the patient is experiencing something like schizophrenia.

Hyperactive delirium symptoms in patients:

  • Waxing and waning—it comes and goes

  • Issues with concentration

  • Pulling out medical lines

  • Yelling profanities

  • Throwing things

  • Agitated

  • Responding to things in the room that aren’t there

  • Not acting like themselves

Hypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they do not express their confusion verbally or physically.

Hypoactive delirium symptoms:

  • Slower movement

  • Softer speech

  • Slower responses

  • Withdrawn

  • Not eating as much

Often, nurses and physicians can miss the fact that the patient has the typical confusion that denotes delirium because the patient is quieter, so it doesn’t come to the attention of the medical team or psychiatrist consult service.

Delirium can even be confused for depression. One Mayo Clinic study showed that when consulting a doctor about their depression, 67% of the time, the patient ended up having delirium.

Why does delirium happen?

Often we see it happen, even to relatively healthy people, in physically stressful situations—post surgery, during an acute illness, or even just being stuck in the hospital for a few days. This does not mean it is indicative of a sudden onset of a long term mental illness, such as schizophrenia.

To consider what can cause delirium, I like to think systematically from the top of the body and work my way down. This is by no means exhaustive, but it can be helpful.

Many things can cause delirium. I like to think about starting at the top of the body and going down, as a way to not miss the cause. Here are a few we would consider as we go down the body:

  • Stroke—check strength in both arms and legs, have the patient smile

  • Hypertensive emergency

  • Infection or meningitis

  • Physical trauma—concussion, head injury with initial loss of consciousness, then after regaining consciousness they can have delirium

  • Brain bleeding

  • Medications that affect the brain, such as ones that produce anticholinergic side effects. (They suppress acetylcholine, causing brain imbalances and confusion. Anti-allergy medicines, pain medications, and some psychiatric medications are anticholinergic.)

  • Circulatory issues

  • Thyroid imbalances or parathyroid hormones

  • Cancer

  • Heart attack

  • Traumatic injury to the heart

  • Aspiration pneumonia

  • Lung infection

  • Lung cancer

  • Viral pneumonia

  • Pancreatic inflammation

  • Urinary tract infections in women

  • Liver cirrhosis

  • Hepatitis

  • Gallbladder inflammation

  • Low bilirubin

  • Hepatic encephalopathy

How do we identify delirium in a patient?

Asking certain questions to the patient and/or medical team and family can help us understand if the patient is experiencing delirium. Often, a patient experiencing delirium will still know where they are, what they are doing, and who they are. The main test to really determine if it’s delirium is the “clock drawing” where we ask the patient to draw a clock with the hands showing 11:10.

Here are some questions and tasks we ask the patient to answer and perform to test for delirium:

  • Does the person know who they are?

  • Does the person know where they are?

  • In what detail does the person understand where they are?

  • Does the person know the date?

  • Can they orient to the situation? Do they know why they are there and the circumstances that led to them being in the hospital?

  • We might ask the patient to repeat back a few words for us.

  • We will ask them later if they remember the three words we asked previously.

  • We test for concentration, like asking the days of the week in reverse order.

  • We try to assess their visual and spatial ability.

  • We might ask them to draw a clock to look for spacing, impairments, or difficulties.  

Some tests that are common to determine delirium are:

  • The Mini Mental Status Exam (MMSE)

  • The Montreal Cognitive Assessment

How to help

It is important, if the patient has loved ones with them, to educate the family about delirium, because both hypoactive and hyperactive delirium can be terrifying to watch.

When it comes to giving medications, it’s important to follow a few rules, Dr. Lee says. Giving medications with anticholinergic side effects can make the patient more agitated. When prescribing meds, be careful not to switch from a hyperactive delirium presentation to a hypoactive delirium presentation by just sedating the patient but maintaining confusion. Medications like benzodiazepine, barbiturates, sedatives and pain medications (beyond what is needed for pain) can all cause worsening of delirium.

If the confusion is from an infection, an antibiotic should eventually help the cause of the delirium, however it may take a few days for the confusion to improve after the cause is eliminated.  At times antipsychotic medications are used to help the delirium and reduce the time needed to stay in the hospital.

Even after the cause of the delirium is gone, and the delirium seems to have improved very quickly, a person may still have lingering cognitive issues. It’s important to be conservative in terms of how quickly you taper them off of the antipsychotic medication used to treat the delirium.





Ketamine and Psychedelics with Dr. Michael Cummings

Blog by David Puder, M.D., Mark Ard, M.D., Mikyla Cho,

On this week’s episode of the podcast, I interview Dr. Cummings, a reputable psychopharmacologist, about ketamine. We talk about psychedelics, the research behind it, both the positives and the negatives. We will look at how it is or is not helpful in psychiatric treatments.

(Disclaimer: There are no conflicts of interest to report. Neither Dr. Puder or Cummings is affiliated with any companies in favor of ketamine and other drug companies.)

Ketamine

Although ketamine has recently become a medication of great interest in psychiatry, it actually is a fairly old medication. It was first synthesized in 1962 and began human trials for anesthesia in 1964. It was finally approved by the FDA as a dissociative anesthetic in 1970.

What has piqued interest in psychiatry is that infusion of a smaller dose of ketamine produces a rapid response in terms of reversal of depressed mood, suicidality, and some treatment-resistant depressed patients.

The literature is rich (in one sense) as the most recent consensus statement (Sanacora, 2017) looked at seven randomized controlled trials, all of which support a robust antidepressant response and anti-suicide response. The difficulty with those trials is the majority of them lasted only one week. A few of the later trials lasted two to three weeks with two to three infusions per week. So, what’s lacking at this point is adequate data regarding long term treatment response and data about transitions to more traditional antidepressant treatments.

This area is of great interest, largely because of the limitations of our current antidepressants. In the STAR D antidepressant trials, 48.6% of people got a 50% reduction in depressive signs and symptoms with the first antidepressant, whereas only 37% of depressed patients achieved remission with the first medication.

Limitations of ketamine in Psychiatry

People receive low-dose infusions of ketamine for depression and suicidality, and there seems to be short term response to this, though the long term effects have not been measured.

The decrease in depression and suicidality is typically robust, but short lived. There is a fairly rapid decay of the antidepressant response following infusion. The infusions are done over 40 minutes. About thirty percent of the patients will become fairly unresponsive to light verbal stimulation. They then recover, but within a few days their mood will begin to deteriorate.

The study comparing 2 days/week to 3 days/week showed fairly equivalent effectiveness of ketamine for the several weeks it was studied. The other limitation of ketamine in terms of an ongoing treatment for depression is like all NMDA antagonists, these drugs are psychotomimetic and cause dissociation. They can induce psychotic signs and symptoms, and those do begin to become more prevalent with repeated infusions.

Currently adverse effects are known for chronic abusers, and can include cognition problems and bladder issues and we don’t have adequate data telling us how long it would be safe to continue ketamine infusions and how to make a transition from ketamine to a more stable, longer lasting treatment.

Ketamine and Dissociative States

Those who described their experiences during the ketamine infusion note a loss of sense of personal boundaries and a sense of union with the universe. There are fairly dramatic changes in their thinking.

Ketamine inhibits the brain’s primary activating receptor, the N-methyl-D-aspartatic receptor, blocking the effects of glutamate, which transiently enhances plasticity.  Ketamine blocks presymptic inhibitor interneurons, blocking glutamate, leading to more glutamate overall in the brain. This “glutamate surge” leads is what is thought to lead to a rapid release of BDNF which is a growth factor for the brain.  This may be responsible for the short term improvement in depressive symptoms.

People also use ketamine as a recreational drug because of its ability to induce a dissociative state. It has been a drug of abuse for a number of years since its introduction in the 1970s. It goes by “Special K,” and a number of other names. Many people abuse it after drinking and at raves. If they take a high enough dose, they can lose their ability to hear and see and become stuck in a “frozen state.”

It can produce delirium, which can be either stuporous or agitated. The related drug, phencyclidine (PCP, aka angel dust), causes more severe dissociation and psychosis. However, the effect of ketamine and phencyclidine are in the same direction and by the same mechanism.

People refer to Ketamine’s dissociative state as the “K Hole,” when one can’t move and experiences this depersonalization. Ketamine is sometimes used as a “date rape drug” because the person can be in a very vulnerable state.

Ketamine dosage

  • Ketamine dosage given for depression is at 0.5 mg/kg, which results in a plasma concentration of approximately 70-200 ng/mL.

  • Ketamine dosage given for anesthesia results in plasma concentrations of 2000-3000 ng/mL.

  • Doses people use at raves or for anesthesia are about an order of magnitude higher than those used for infusion for treatment of depression.

  • Peak plasma concentration with antidepressant infusions of ketamine are about 200 ng/mL. For recreational or ICU anesthesia purposes, it is closer to 2000 ng/mL.

Side effects/risks of ketamine infusion

When people are recovering from the antidepressant infusion, there is still a risk. They may become agitated, confused, or hallucinate, which is why one of the recommendations for treatment centers using ketamine is that they have adequate expertise in controlling psychomotor agitation and confusion if those things occur.

During ketamine infusion, about one-third of patients also exhibit a fairly pronounced sympathetic arousal during the initial portion of the infusion.

  • About 30% of patients achieve a heart rate of 110 and a blood pressure of approximately 180/100. (Sanacora, 2017)

  • One of the recommendations for ketamine infusion centers is that they take a good cardiac history and be sure that the person can tolerate exercise. Additionally, the drug should be administered by someone who is ACLS certified and has access to a crash cart.

  • For cats recovering from surgery (Jasani, 2015) on ketamine use for animals), it is helpful and ideal to put them in a quiet environment. The same is true for humans. Patients should be put in a quiet, safe environment so that one does not induce an agitated delirium because the patient is responsive to the environment, but their interpretation of that environment may not be based on reality and can produce an agitated response.

Mechanism of action

In many cases of treatment-resistant depression, it is necessary to alter the plasticity of the brain to get a response. Ketamine, perhaps via the blockade of glutamate at NMDA receptors, and perhaps via downstream mechanisms from that, seems to do this.

This correlates to some extent with how we know antidepressants and electroconvulsive therapy works. They have looked at CT scans for what is important in gaining a response, and for decades, it was thought that it was the seizure. Now, it may actually be the postictal neuronal suppression period that accounts for the therapeutic benefit because that is associated with turning on rapid response genes.

One small study looked at simply exposing people repeatedly to isoflurane, an anesthetic agent, causing repeated neuronal suppression. They also received an antidepressant response from that. So it may be that turning neurons off transiently can be beneficial in terms of resetting them at the DNA level and making them more plastic. Ketamine may not be the only anesthetic agent that alters longer term functioning of neural circuits.

Ketamine Clinics

Although ketamine has become popular, the major risk is not that the drug may not have psychiatric utility, but that we are still fairly early on in using it. The risk is that the use will outrun the data we have available to guide us. This may already be happening, as evidenced by the surge of new ketamine clinics.

Often, the clinics are started by anesthesiologists, and there is no clear psychiatric evaluation that may precede patients starting ketamine.

Currently, the data we have now essentially points to ketamine as treatment for major depression, refractory to other treatments. In many ketamine clinics, they’re using it to treat all complaints, but the data on this ranges from slim to none at all.

There may be a lucrative pull toward these clinics as they are usually cash pay since insurances don’t currently cover this.

Advice to Those Considering Ketamine Clinics

One should first get a very careful psychiatric evaluation, including a diagnosis of their mental disorder and a careful review of their treatment history to be sure that they have received optimal treatment in terms of established long term treatment options.

If one does decide to pursue ketamine treatment, then they should work with a psychiatrist who is well-versed in not only using ketamine, but is also knowledgeable in using other means to address depression, such as more traditional antidepressant medications and psychotherapies (especially day treatment programs).

Other Concerns with Ketamine

According to existing literature, ketamine is not a cure all for major depression. It may help “jolt” a brain that has become resistant to treatment into being more plastic and transiently being less depressed, but it is not a cure for the underlying condition.

Another concern is that we don’t know what the patient will be like after long-term treatment with ketamine. Will they have had a full recovery? Experience persistent issues or treatment complications?  Cognitive issues? Bladder issues?

Ketamine may be most helpful for patients who have failed multiple treatment modalities, such as full doses of antidepressants or even ECT. It may provide a means to enhance treatment response to get the person out of the immediate danger of severe depression and suicidality. However, at this point it is not a standalone treatment.


Ketamine and Psychotherapy

If ketamine is a dissociative drug, it might be best to have the person off of ketamine before starting psychotherapy so that their brain is fully functional. The psychotherapy would need to follow after the person’s dissociation has dissipated.  The half life of the parent compound of ketamine is about 2.5 to 3 hours. The active metabolite (norketamine or N-desmethylketamine) is up to 12 hours.

By the time the person is 60 hours post-infusion, the ketamine is gone. It is unlikely that there are prolonged dissociative effects, at least not with one, two, or three exposures. However, there is no data stating just exactly how many exposures to ketamine is considered safe in terms of avoiding a more protracted delirium.  

Final Thoughts on Ketamine

This is still a new frontier that will most likely be revisited as newer and larger studies are done. Ketamine is promising in that it does suggest that if we can discover more useful and somewhat more gentle NMDA antagonists, we may discover a new avenue into treating more resistant depressive illnesses.

Psychedelics

History of Psychedelics

Psychedelics are illegal is most areas of the world. Because of a few studies and their ability to alter mental states, they are a gaining interest in some areas of psychiatry.

They have been used for millennia in some Native American and other indigenous populations. Historically, they have been used primarily in terms of religious rituals, often under the guidance of a shaman or medicine man helping to guide an individual in respect to life issues. Traditionally, they were often used only once or very sparingly as a support to what were ritual-based psychotherapies. The interest in psychiatry is if these would facilitate some form of psychotherapy while using the psychedelics.  

All of these drugs, such as psilocybin, LSD, and ayahuasca, are all essentially very potent 5-HT2A serotonin agonists, with many of them also being agonists at other serotonin receptors.  

They produce a state similar to ketamine.

      • The person has an alteration of their sense of self, a loss of boundaries.

      • They have a sense of being in touch with the universe.

      • They become much more influenceable under those circumstances.

Of course, like ketamine, psychedelics have also been prone to being drugs of abuse like the psychedelic area of the late 1960s. Studies (Kalasinsky, 2014; Palamar, 2016) of people who have used street ecstasy have found that the drug was often mixed with other chemicals, such as methamphetamines and bath salts, making it very different than what could potentially be given at a pharmaceutical grade.

Psychedelics dosage

Psychedelics in high doses

Much has to do with the dosing and concentration that is present when abused, which are often both very high. These drugs can cause permanent changes. For example, LSD can induce a persistent hallucinosis that’s essentially the result of a permanent change in receptor status that usually occurred with repeated, very high dose exposures.

Psychedelics in modest doses

Frankly at this point, we don’t know very easily how to separate the benefits and risks of these drugs. Although used as they were traditionally, there were often very limited exposures and very controlled environments. This suggests that these drugs should perhaps be used with caution for therapeutic benefits.

Studies about Psychedelics (Rafael, 2018 for most recent review)

  • Psychedelics have shown benefits in a variety of open label, small studies, and lack adequate control group of mostly short duration for everything from depression, to anxiety, and to even inhibiting the use of substances like alcohol.

  • Psilocybin has been studied in decreasing depression in cancer patients

  • Patients will take the medication or placebo, wear an eye covering, and listen to some light music while lying down on the hospital bed. If patients do undergo an experience of some sort, there is a person in the room they can talk to.

Most studies typically report a positive primary result, but are limited by their very small samples and lack an adequate control group. Therefore, much of our data is still very early on with respect to the hallucinogens and their possible benefits.

In contrast, the wealth of data from traditional cultures that have used these substances for millennia shows that when these drugs are used in a very controlled, limited manner, they do not seem to induce ongoing mental disorders.

Research is still at an early stage and may open new routes for treatment by modulation of serotonin receptors in ways that we haven’t approached before. It may turn out that hallucinogens themselves may or may not be the right agents to use in the long run. But, this may point to a new approach to altering brain plasticity to enhancing treatment.

Study designs and placebos affect study results.

Some studies use saline or sugar pills as placebo, and patients are likely to know they have not received the treatment in those cases. A good placebo produces some degree of change and level of consciousness. For example, an infused benzodiazepine might be a possibility.

A normal saline infusion or an oral sugar pill would not produce an adequately blinded study since both hallucinogens and ketamine produce a fairly rapid effect that anyone being exposed to the drug would be aware of.

Another example is a study that used botox for depression (Finzi, 2014). 75% of the Patients knew if they have actually received the botox or just an injection of normal saline since the effects on the muscle were so different. These studies would then become suspect because particularly in treating mood disorders, the placebo response rate is typically fairly high, often around 30-40%. Therefore, studies really do need to blind both the participants and the researchers by giving an active comparative placebo.

The Hawthorne effect can bias the study because if you expect something to happen, you tend to see it, whether it actually exists or not. However, the results of a study can change once it becomes a multi-site study.

Open label studies have a higher rate of positive findings than those of randomized controlled trials.

  • In an open label trial, the patient and the prescriber of the treatment both know what the patient is receiving and consequently, they can be biased by their beliefs.

  • If you compare open label studies to studies in which neither the patient or the prescriber knows what the patient got, the rate of positive results is about twice in the open trials than what it is in the controlled trial.

    • We can fool ourselves into seeing something that wasn’t actually there about half the time.

Final Thoughts

Longer trials of up to six months should be done for ketamine research to address several questions.

  • How often can a patient receive treatment?

  • What are the long-term effects?

  • What is the point at which one should stop because of any long-term effects on a person’s brain?

  • How do we transition from ketamine infusion to alternative treatments?

  • Does ketamine ultimately make the person more responsive to other pharmacologic interventions or psychotherapeutic interventions?

Psychedelics also still need to be studied more extensively.

  • We need to understand more fully what is happening in the brain as a result of very potent stimulation of 5-HT receptors.

  • Perhaps we can use that as a jumping off point to look for other means to modulate or encourage treatment response using those receptor systems.

We do not know enough about ketamine and psychedelics to be able to tell if they will have positive long term effects on mental health and be useful to psychiatry. These topics will need to be revisited as more research is done.

dos Santos, R. G., Bouso, J. C., Alcázar-Córcoles, M. Á., & Hallak, J. E. (2018). Efficacy, tolerability, and safety of serotonergic psychedelics for the management of mood, anxiety and substance use disorders: a systematic review of systematic reviews. Expert review of clinical pharmacology, (just-accepted).

Finzi, E., Kels, L., Axelowitz, J., Shaver, B., Eberlein, C., Krueger, T. H., & Wollmer, M. A. (2018). Botulinum toxin therapy of bipolar depression: A case series. Journal of psychiatric research, 104, 55-57.

Kalasinsky, Kathryn S., John Hugel, and Stephen J. Kish. "Use of MDA (the" love drug") and methamphetamine in Toronto by unsuspecting users of ecstasy (MDMA)." Journal of Forensic Science 49.5 (2004): JFS2003401-7.

Palamar, Joseph J., et al. "Detection of “bath salts” and other novel psychoactive substances in hair samples of ecstasy/MDMA/“Molly” users." Drug and alcohol dependence 161 (2016): 200-205.

Sanacora, G., Frye, M. A., McDonald, W., Mathew, S. J., Turner, M. S., Schatzberg, A. F., ... & Nemeroff, C. B. (2017). A consensus statement on the use of ketamine in the treatment of mood disorders. JAMA psychiatry, 74(4), 399-405.



What is psychodynamic theory?

On this week’s episode of the podcast, I interviewed Allison Maxwell-Johnson, a social worker and PhD student of clinical social work. I refer patients to her regularly for psychoanalysis, and she has had a wonderful impact on their mental health journey.



Psychodynamic therapy is a form of talk therapy where the practitioner work focuses on the patient’s emotion, fantasies, dreams, unconscious drives and wishes, early and current life relationships, and the relationship that is forming between the patient and therapist.  

The history of psychodynamic therapy

Sigmund Freud is known as the father of psychodynamic therapy. He practiced in the late 1800’s and early 1900’s. Some psychiatrists and therapists think that Freud has been debunked because he is a controversial figure. But my colleague, Allison Maxwell, and I, think his impact on furthering the mental health field has been positive.

Historically, people with borderline personality disorder, somatic disorder and post traumatic stress disorder (PTSD) were all grouped under the title of “hysteria.” A few hundred years ago, these people would have been killed as witches, put in asylums, and there wasn’t much ability to, or interest in, digging into their psyche. There was certainly no warmth or empathy given to them.

Freud began to grapple with those deeper, tougher issues, claiming it wasn’t just a medical disorder. He gave empathy, and a level of connectedness to his patients that hadn’t been done before. As the first psychoanalyst, he was a pioneer in his field, and he figured out that having an emotionally connected relationship with his patients (he would even have is patients over for dinner and go for walks with them) could actually heal the patient.

Affect

Affect is something therapists need to pay attention to when it comes to each individual patient. It’s about noting the facial and emotional state of the person. Is the patient emotionally flat or expressive? Are they depressed or happy? Are they peaceful or agitated?

We focus on their emotional state and try to lean in to understand what a patient is feeling during a session. As the doctor or therapist, what is the emotional reaction you're having to the patient, in the moment? Analyze the situation—both your feelings and theirs. Ask them for clarification on their feelings, then ask yourself how you can use that information to understand and connect with the patient emotionally.

There are multiple emotions going on which can be conflicting. We need to ask ourselves if we can empathize with the distress that is in the room.  

It’s not only about intellectually understanding what’s happening with a patient, or diagnosis. It’s about understanding how to create an emotional connection and help someone.

Transference

A therapist applies the principle of transference when we pay attention to the emotional state the patient has towards them. If the therapist reminds them of their abusive father, and they react emotionally, it’s a classic transference situation.

Understanding transference can help a therapist remain empathic and curious, even when a patient is angry at them. Transference can be seen in their complete reaction towards you, both from their past, and how you are interacting with them.  

Countertransference

As therapists, we are also humans. We will have reactions to the patients we work with.  Countertransference is the complete reaction we have towards our patients, both coming from how the patient reminds us of people from our past, and our reaction towards the things that the patient is uniquely doing.

The unconscious exists both in our patients and in us. If we can keep countertransference in our awareness as therapists, we can try to understand what is happening interpersonally—why we do or don’t like our patient, and why we feel angry or upset with our patients.

As therapists, we should not react to our patients out of direct emotion, but understand that countertransference is happening, and be curious about the meanings behind our feelings, and their feelings towards us.

Studies that show psychodynamic theory works:

  • For the curious, read this article by Jonathan Shedler, “The Efficacy of Psychodynamic Psychotherapy” PDF

Mentalization-based therapy

Mentalization therapy is an emotion-focused therapy for people with borderline personality disorder. It helps them question whether they are accurately mentalizing, or understanding, their own experiences and their therapists emotional experiences. The positive effect of mentalization-based therapy is measurable. It has a mean effect size of 1-2, meaning it is 1-2 standard deviations from the control group—it works.

People who were in and out of psychiatric hospitals with suicide attempts, after mentalization therapy, can have great success in achieving a normal life.

  • Study on Mentalization based therapy with 8 year follow up: PDF

Transference Based Therapy:

  • Article on transference focus therapy increasing a patient’s narrative coherence and reflective function: PDF

In conclusion

As therapists, including psychodynamic principles can help us connect with our patients. It will protect us from burnout, and give our patients the chance to feel emotionally connected with someone, in a corrective and healing way. It can be incredibly rewarding, rather than draining, when we feel connected, and our patients usually express gratitude as they heal.



Therapeutic Alliance Part 1

What is a therapeutic alliance?

The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership.

Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye.  

It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives.

The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor.

Why do we care?

We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine.  

Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates.

What builds a therapeutic alliance?

Research shows there are a few things that grow therapeutic alliance:

Expertness

  • Facilitating a greater level of understanding

  • When residents are worried they are an imposter, I tell them that humility is good, but realize that you have experience that most will never have, medical school, being highly educated, being around vast different ways of thinking and reflecting on the world...

Consistency

  • Structuring your office to run on time.

  • Being consistent to respond to refill request, lab results, or patient’s questions.

Non-verbal gestures

  • Eye contact

  • Leaning forward

  • Mirroring of emotion occurs naturally when people pay attention to emotion

Maintenance of the therapeutic frame

  • A dual relationship (eg, dating) breaks down therapeutic alliance. Patients will test the frame. It can be helpful to say, "There will be positive and negative feelings between us and what will be safe is to talk about them."

Empathy, attunement, positive regard

  • Patient: “Therapist is both understanding and affirming."

  • Patient: “Therapist adopts supportive stance.

  • Patient: “Therapist is sensitive to patient’s feelings, attuned to patient, empathic.”

  • Research has found that for beginning therapists, setting and maintaining treatment goals is harder

  • Research has shown that strength of therapeutic bond is not associated with level of training

  • Therapist should appear alert, relaxed and confident rather than bored, distracted and tired

Foundational concepts of the therapeutic alliance

Our profession gives us a privileged glimpse into the human heart and mind. Each patient is idiosyncratic, unique, precious. Each patient has unique strengths which we should place focus on.  Some therapists can be in a hurry to find out what's wrong, but we should also want to find out what's right with our patients.

Our own feelings, as therapists, about the session are not intrusions but clues. If you are experiencing boredom, perhaps you are not understanding the main point the patient is trying to explain. Be curious for what you are missing. If you start feeling something different than you did at the beginning of the encounter, notice it. Try to empathize for the patient with what changed.

Our goal is for the patient to feel understood, heard, accepted, felt. To be understood is to be accepted.

A strong alliance will provide a "Corrective Emotional Experience"  (Franz Alexander), which means past relational pain and difficulties are worked out in a new relationship. When your subjectivity (your feelings, thoughts, goals) come into contact with the patient's subjectivity, a unique "intersubjective relationship" is formed from your mutual influencing of each other. A new dyad (2 coming together) is formed by looking at new meanings, understandings and connectedness. As a therapist, you are a “participant observer” as you observe the patient’s behavior and also become a “significant other” in their life through your interactions (Harry Stack Sullivan).

Here are some things to consider on a first encounter with a patient:

The patient will feel: examined, fear being seen as crazy, fear of not being liked, discouraged, hopeless, helplessness, needy, fear you are a mind reader, or even fear that you sleep with your patients.

In developing this relationship, it’s important to understand they can formulate defenses that are adaptive. Try to empathize with that underlying emotion. Starting with what's an adaptive response and solves something, looking for what’s maladaptive does not.

The patient may question your competence. They might say you look very young to be a doctor. The appropriate response would be to dig down and see why they are feeling what they are feeling. Say something like,"Perhaps you were looking for someone who looks older; of course you’re entitled to worry about how competent I am and how much I may be able to help you."

Therapists are always worried about being ineffectual. It's very natural to feel like an impostor in our position. It’s also normal to feel—when someone's angry at us, our mirror neurons lead us to be angry back.

Always face the patient, without desks between you, lean slightly forward, give appropriate eye contact, and do not do excessive note taking (you should be observing at least 90% of the time). Ideally, a clock is positioned behind the patient which can easily be seen by you without making obvious movements.

On Listening: An Active Process

Connection is non-verbal, and is equally as important as verbal communication, sometimes more so.

  • Omissions (what is not said) in the patient's stories and memories are important.

  • Point out common patterns you hear.

  • If every time you say something to the patient he says "no, that's not it" then point out that to the patient.  

  • Be aware when asking "why" questions, you are likely going to arouse the same defensive emotional reactions that occurred when the patient as a child was asked "why did you do that?" by the parent.  At times, "why" can communicate disapproval. For example you ask, "Why do you feel that?" And they say, "I DON'T KNOW! Are not you the doctor!"

  • Dr. Tarr has some good advice on nonverbal communication: "I participate. I respond. I react to my patient and to his verbal and nonverbal communications.  At the same time I observe what's going on, what the patient is saying and what he is not saying. I am particularly attuned to evidences of anxiety, to what I am feeling and thinking, and where, if anywhere, the interchanges are going. I am wondering how best to formulate for this particular patient what I observe that may help him feel understood and responded to."

  • Observe that defenses (sublimation, reaction formation, intellectualization), although they reduce anxiety, may misrepresent reality.  

  • Assume an attitude of "reverie," like a good maternal object, receiving toxic stuff from patients and then giving it back to them in a detoxified form (Wilfred Bion).

  • Create a "holding" place for patients in which patients have a transitional or play space (Donald Winnicott).

  • Listen in a way that notes what the patient is trying to say about your relationship.

    • Patient: "I feel lonely even when I am with people."  Doctor: "Do you feel lonely here with me now?" Patient: "No, I feel you understand me somewhat."  Doctor: "I want to know if there are any times where you feel more lonely in our sessions, it will help me to understand what is going on between us."

  • Listen to their moment to moment change in emotions.

    • Try to enter a bit into their feeling, be present with them, mirror the emotion/feeling, use their own words, ask them to find their own words.

    • If you don’t get why they are sad, then stay with it, ask them more questions, have them deepen your understanding of it.

    • Once they feel you truly understand the effect will change. When people feel heard, deeply understood, it is pleasurable.  

    • Shame- patient looks down

      • “I can understand why talking about this must be difficult.”

      • Perhaps as you talk about this you feel…”

      • Try to find the adaptive function: “I hear switching to a new doctor is hard, I think that is a common experience, I think it is adaptive to be hesitant at first in what you share, we are just meeting."

    • Anger/Frustration:

      • “Would you say that as you mentioned this you feel frustrated.”

      • Find the adaptive function: “your anger here seemed to have the goal to protect you and your family”  “your anger likely kept you alive!"

    • Sadness

      • “Perhaps you are feeling sad as you say this?”

      • Find the adaptive function: “it makes sense that you feel sad here, I think crying and feeling sad shows how much you valued your dad and therefore the loss hurts that much more."

    • Disgust

      • “I am wondering if you feel disgusted by this?”

      • “I hear you feel disgusted…” (ask with a questioning tone).

      • Find the adaptive function: “Feeling disgusted by how your sisters turned on you and cast you out of the family makes sense, it sickens you to see the level of their resentment and bitterness."

    • Fear

      • “I hear a deep concern or perhaps fear regarding this.”

      • “Might there be a deep concern or perhaps fear regarding this?”

      • Find the adaptive function: “After your traumatic event, it makes sense that you would no longer want to put yourself in that situation, it sounds like you are trying to protect yourself."

Listen to the patient’s goals, purposes, aspirations, fears, hopes, values, meanings.

How do you create and maintain a working alliance:

Be sensitive to empathic strains and prevent them from developing into empathic ruptures.  

Ask for feedback. Reflect on the "we" aspect of the encounter. If the intervention/participation failed to have the desired result then look at what went wrong with the communication.  

  • “As we were talking together when did you really feel we were on the same page?”  
  • “When did you feel we were understanding each other?”

  • “When did you feel we were communicating meaningfully?”  

  • “When were you feeling disappointed?”

  • “When did you fell I was not responding enough?”  

  • “When did you feel frustrated, misunderstood, or impatient?”

Be able to define and predict interpersonal conflicts that may cause a disruption of the shared empathic relationship. Set the groundwork for openness.

For example:  

Doctor: "Tell me about your past psychiatrist?  “What worked and what were your disappointments with your past psychiatrist?"

Patient: "He was kind of a jerk."  

Doctor: "Can you tell me more about that?"  

Patient: "He always would just stare at this computer, and often answered his pager during sessions."  

Doctor: "Thank you for sharing that, I will stop typing and finish this later, I hope that if you ever have any feedback for me you will know that I will want to hear it, even if it is negative, and will appreciate knowing your experience of things."

Patient: “Ooo I was not talking about you.”

Doctor: “Ok, nevertheless it is a good reminder to not be focused on the computer, but if you are bothered by things or frustrated it will be helpful to know.”

The therapeutic alliance is an incredibly powerful relationship, and if it is managed with care, it can affect positive change in a patient’s life.

In future episodes on therapeutic alliance I will dig deeper into specifics of it, and pull upon the depth of my mentorship from Dr. John Tarr.

How to Treat Emotional Trauma

This week on the podcast I spoke with fellow therapist, Randy Stinnett Psy. D, about how trauma works, and how we can help our patients overcome it.  

What is trauma?

Emotional trauma comes from stress that is overwhelms a person’s neurological system. Some stress can be good and formative, or it can be bad and get stuck in the brain, causing someone deep emotional pain.

Think of climbing Mount Everest. Some people choose to do that, and it’s easily one of the most stressful situations you can put yourself in on purpose. That’s good stress if you have trained for years and are ready for it. If someone forced you to climb Mount Everest, it would register in the brain as a trauma.

Trauma is too big for the mind, brain, and nervous system to assimilate. It’s a memory, or experience, that gets stuck because the person believed it would result in their death, or at least serious injury.

The brain has several mechanisms to keep something stuck so that the person will remember it, and try to avoid getting hurt in the same way in the future. It is a survival instinct.

People commonly demonstrate symptoms of trauma when they’ve:

 

  • Experienced a sexual violation

  • Seen violence

  • Experienced violence or abuse

  • Been neglected—experienced the absence of something that they should have had.

  • Been in near death experiences like car accidents or war

People who have PTSD, or post traumatic stress disorder, have experienced a soul-level of brokenness, and even talking about the event, or having a memory of it, can bring it back with the same force that occured in the actual accident. They often have recurring nightmares, or repetitive symptoms that continue long after the event.

Typical PTSD symptoms alternate between chronic shut down and fight and flight

  • Fight and flight symptoms are:

    • Sweating, nightmares, flashbacks, anger, rage, panic, hypervigilance, tense muscles, painful knotted gut

  • Shut down symptoms are:

    • Dissociation, freezing, emotional detachment, voice trembling, difficulty getting words out, numbness, apathy, fear, helplessness, dizzy, empty, nausea

  • Moments in connection mode look like:

    • curiosity, exploration, relaxed and full breathing, feeling grounded, true smiles

 

Body movement and trauma

We’ve all heard the reference to Pavlov’s dogs—the bell rings and the dogs salivate because they know it is dinnertime. Pavlov discovered many more things than that dogs drool. Once, his lab was flooded with freezing water that nearly filled the cages of the dogs. When they were finally able to get the dogs free, the dogs interacted differently with the world around them. They seemed hopeless.

Humans work the same way.

PTSD rates were 16% for survivors of 911, and 33% for survivors of Hurricane Katrina. Why? Traumatologists speculate it was because during 911, survivors were running away from the catastrophe to save their lives. In Katrina, the victims were airlifted out and placed in gyms, for sometimes months at a time. Those in lower socioeconomic levels had no money, no home, and nowhere to go—they were trapped.

The body is designed to move away from danger, but if the body can’t move, trauma can set in.

 

Attachment based trauma

Having a negative attachment with parents often sets people up for later traumas in life to be a bigger assault on the nervous system and psychological functioning, than it would have been as a standalone event.

Patients who experience unhealthy attachments often struggle with emotional regulation and boundaries.  

Many people, as children, were not heard and mirrored in their emotions and experiences. When they discussed their problems with their parent, and it was met with disdain or shut down, the patient has most likely developed the idea that they have no voice. The stress was not contained and thus all the raw emotion is still there and unprocessed. This leads something to continue to be traumatic in the brain.  

This follows the same pattern as polyvagal theory. When we are in connection mode, we are open hearted and happy. When we feel stress, or lack of connection, our sympathetic nervous system kicks in and we switch into fight or flight mode. If that disconnection continues, our parathetic nervous system takes over and we go into full-on shutdown. When children are repeatedly ignored or abused, they switch in and out of shutdown mode, causing trauma.

Polyvagal theory and attachment theory, and how they affect children (and adults too), are demonstrated best in the Still Face Experiment video (link to prior article I wrote on that experiment).

Attachment trauma is repeated trauma. It can occur in childhood, or any other time throughout our lives within relationships.

 

Notes to therapists on dealing with PTSD

Studies show that having an emotionally connected therapist, while someone is reprocessing their traumatic memories, can help heal the emotional damage of those memories.

Displaying emotional stability

Patients often superimpose all of their abusers onto their therapists. As therapists, we need to realize this, and stay steady during the entire course of therapy. Remaining calm, safe and empathic is one of the most healing things we can do for them.

It is a way of being, not just an action, or a reaction, towards our patients.

Receiving feedback

As therapists, it’s important to be able to receive feedback from our patients about what is working for them without it being an adversarial situation.

We must respond in a way that allows the patient to have their own voice. First, validate their emotional experience of the patient. Next, thank them for being honest with you. Ask for the whole story behind their feedback.

I am not saying this as some sort of technique, but rather this should come out of the belief that 1) their emotional experience is valid and needs a voice 2) it takes courage to voice any feedback and this is important for their growth and success.

When these things are truly believed, we are empathizing and thanking them, out of the core of our being, and not just as a technique.  

Where they were expecting rejection, you end up validating their experience. Finally, ask them how it feels, in the moment, to be heard and to be able to safely express their opinion. Allow them to experience a felt difference between you and their abusers. This provides a corrective emotional experience!

Know when to limit the stress

Understanding the different nervous system’s functions will help you know when enough is enough for your patient.

Study the symptoms of the activation of the somatic, autonomic, sympathetic, and parasympathetic nervous systems. This is imperative, and if you cannot slowly uncover the stressful situations in a way that the patient can manage it without engaging shutdown mode, you will end up doing more damage than good.

Emotional connection

One psychiatry resident asked my mentor, Dr. John D Tarr, if it was better to keep inpatient people at an emotional distance, so the patient would not get attached and want to continue to stay in the hospital. My mentor responded that we always want to be connected to our patients, to be empathic. When we feel they are getting attached and don’t want to leave, we need to open up that dialogue to how we can help them experience connection outside of the hospital.

Studies show that patients who feel connected to their doctor are more engaged in treatment—they go to therapy, take their medications, and continue their mental health journey.

Trauma-based memories are different from normal memories, like knowing what you ate for breakfast this morning. Trauma-based memory has a sensory aspect to it. They are stored in a different part of the brain than where we function for our daily, normal connection mode.

As therapists, when we access those memories with patients, the patient begins to switch to a different part of their mind, and demonstrate symptoms of trauma physically. They may tremble, sweat, and sometimes even their voice changes—it can be hard to get the words out, they whisper, they sound child-like.

To understand how people respond to trauma, we have to know that emotions have primacy, or first dibs, on our reactions. Our brain deems them more important than our executive functioning—our ability to reason and plan our lives’ daily tasks.  

If the patient is open to it and we have established a good, trusted attachment and connection, we will talk about their traumatic memories. If we do not have a connection in that way, I will not explore deep traumatic memories with them. It is more important to build a safe, secure relationship first.

Trauma gets stuck in the non-analytical parts of the brain—our emotions, creativity, experiences, art. It’s image-based, somatic (physical body), it’s non-verbal. Parts of the left hemisphere of the brain deals with logic, reasoning and language. To integrate this part of the brain, the patient will have to access the emotional parts and then put words to their experiences.   

In that conversation, these are some of the questions I will ask:

  • What did you see?

  • What did you feel emotionally?

  • What did your body experience?

  • What do you believe about yourself as a result?

Allow for freedom

Also, when we require our patients to do anything, even to stay for the whole hour of therapy if they do not want to, we are reinforcing the trapped feeling. Keep an open dialogue about what your patient is feeling throughout the therapy session.

If the patient is suicidal with a plan and intent, they likely need a safe place to get through the intense time. I will tell them, “My goal is to not keep you here indefinitely. We will come up with a plan to get you out of here, and for you to be healthy.”

In general, try to give your patients, especially the PTSD ones, choices. Create boundaries and give guidance, but allow them to have freedom in their choices.

Summary  

In this first discussion with Dr. Stinnett, I wanted to highlight some introductory understanding on trauma.  We discussed how trauma is stored differently in the brain and how the polyvagal theory is connected with this journey.  We highlighted the importance of emotion, connection and feedback. Please leave comments below on your thoughts regarding this blog and podcast!  

 

Setting Boundaries in Relationships

This episode can be found on iTunes podcast, Sitcher, Overcast and Google Play.  

What are boundaries?

When we refer to boundaries, we are talking about emotional walls that are healthy. Boundaries are meant to keep us in relationship with the people that we love.

Think of them as your property lines around your house. You know where your lines are, where your property ends and your neighbors begins. Therefore you know what you are supposed to take care of and what your neighbor is supposed to take care of.

A boundary defines our self. Within ourselves, our “property” consists of our physical body, our desires, our intellect, and our ability to make decisions. It gives us a sense of defining what is “me” and what is “not me.”

We are not supposed to take on too much of other people’s emotional experiences. When I was a newly practicing psychiatrist, I didn’t know that, and I felt depressed after meeting with a depressed patient. It is possible to have an understanding of what is happening in someone’s emotional world, but not take it on yourself.

There is a psychological principle that is common among people who struggle with having good boundaries with others. It’s called “siding with the aggressor.” For example, if someone grows up in a home where the father is constantly displaying angry behavior, a child might learn to develop a sense of humor if he or she learns that will diffuse the situation. Rather than running away from, or fighting back, these people joined with the aggressors, paying attention to them, calming them, helping them.

Early on in childhood, people who side with the aggressor understand how to make others happy. This continues into adulthood and is formative in new relationships in how the person would choose to interact with others.

I don’t think of it as a weakness, I think of it almost as a superpower—these people are incredibly skilled interpersonally when they get older. They know how to react to others, how to make others happy, and how to make angry people calm down. They are great peacemakers, therapists, and psychiatrists. It was an adaptive feature for them in childhood.

But as they grow into adulthood, they need to learn to choose when to use this superpower, or when to have a boundary.

My wife, Lindsay, first began learning about boundaries when she was experiencing burnout as a young, working woman. She never said no, always went above and beyond the requirements of her job. And at the end of the night, she was exhausted. After awhile, she started to become upset—upset at herself, and even a her situation.

Within the Big 5 personality types test, Lindsay scores high in Trait Agreeableness. People who are high in that trait value relationships, are empathic and helpful. They will do things they don’t want to, merely to maintain their relationships. Women typically test higher in the trait than men.

I see many women come into my practice who have high markers of agreeableness—they haven’t found (or been able to express) their boundaries. They have issues with chronic pain, problems with expressing anger, either within themselves, or towards others.  

It’s also common that these people have no idea that their “helpfulness” is causing them huge amounts of physical pain. People who are caretakers, who feel looped in to being someone’s source for happiness, life, wellbeing, often get looped into these types of situations if they don’t have a strong sense of self. Obviously, many people are caretakers for their relatives. I’m not talking about being a nice person versus being selfish, or being a caretaker versus letting someone you love be alone.

I’m talking about the emotional position of your heart during those situations. Are you able to say no when you need to? Are you asking for help when you need to? Are you taking time for yourself? Are you in pain? What is your emotional state when someone calls and asks for help? Do you check in with yourself before you say yes?

How do you know when you need to start establishing boundaries?

Typically, with people who have no boundaries, the resentment will build and build, and they will do something drastic to relieve their pain—cut off the relationship, quit caretaking altogether, stop being friends with the person, get a divorce. Or the resentment will build up in their body, causing either depression (as the anger is turned inward) or body pain (as the body carries the burden).

The truth is though, that when someone with no boundaries says yes, it might be ingenuine. They are saying yes out of guilt and obligation, not out of a true desire to say yes.

When we do things out of obligation or compulsion, we lose passion for that task, and begin to build resentment. If we aren’t making the choice to say yes, we are thus protecting our ability to say yes to our passions, joys and desires.

Good fences make good neighbors

As you’re setting up your “fence,” you want to keep the bad out, but it will also keep the good in.

When we talk to people about boundaries, they are often scared of beginning to say no.

When you learn to say no, and you begin to make new friendships with people, you will tend to set higher standards for how you want to be treated during those relationships.

How to set up healthy boundaries

  1. Look at the people you have a hard time saying “no” to. Is it your boss? Someone in authority? Someone who is a family member?

  2. What do you fear losing from them if you say no? Is it love? Respect? Provision? For a boundary-less person, being a pacifier has some advantage. Maybe you were the peacekeeper in your house growing up. Maybe you weren’t allowed to say no. Maybe abuse was involved. Or maybe you were simply a sensitive, sweet child who heard repetitively that it was a good thing to be kind and helpful. Whatever the case, there is some sort of relational reward to say yes, and to keep the peace. Pay attention to what you’re getting out of saying yes to that person.

  3. Become aware of body sensations you're having when you think of setting boundaries, of saying no to someone. Do you feel tightness in your chest? Numbness in your hands? Is your heart racing? Do you have anxiety?

  4. Have a pre-programmed response for when someone asks you for something. Lindsay likes to say, “Can I get back to you later with an answer?” It allows her to take off the social pressure of saying yes immediately, and be able to respond with a truthful answer later on.

  5. Before you say yes to anything, think about your ultimate goals and boundaries. We all have a purpose, we are all unique. If we spend all of our time doing only what other people want us to do, we won’t accomplish our goals. When we start to focus on ourselves more, we can see where the opportunities to say yes, or no, will take us, and we can see if they line up with our ultimate goals.

  6. Have safe people in your life, so that when you don’t have the strength to say no or speak up, you can talk to them. You can ask for help. It could be a therapist or just someone you can feel safe with. Lindsay has a group of women she has talked to once a week for 12 years. On that phone call, they discuss what they are dealing with and how they are growing.

  7. Have conversations with your current friends where you set boundaries. I go on walks with people all of the time. I often ask if we can switch topics on the way back. Normally I would be the listener the whole walk, but with my new boundary, it lets me also talk about something that’s going on in my life. People are always responsive when I ask for this, and it’s always positive. People who are higher empathy have a harder time asking for what they need.

  8. Throughout our lives, we have new possibilities for relationships every day. We can take care with adding those who are good, positive, safe people, who will understand our “no” and will allow us to uphold our new boundaries. When you’re looking for new, good friends, look for people who are full of grace. They are also full of truth—they are kind and open, but also honest.

Parenting and boundaries

Children are difficult to have boundaries with. It can be because we love them and want to give them the world, because we know they aren’t fully emotionally developed, or because we want to ease some of our own exhaustion by giving in!

One key to holding our boundaries when our kids throw temper tantrums is to respond to tears with empathy, not just say “yes” to ease our discomfort. If we resonate with them, it will help both us and them. For example, if your child is screaming and crying about leaving the park early, try saying, “I know it must feel hard for you to leave something that is so fun. We will come back again. Nevertheless right now, it’s time to go. At home, you have toys too and can play with them.” This offers empathy, hope and it keeps a boundary.

If we give in and let them stay, we are teaching them a bad habit. We should never set a boundary that we aren’t willing to follow through on. It helped Lindsay and I to remember the statistic that even giving in to 1 out of every 8 tantrums taught the child that tantrums worked, and they would win. It reinforced their negative behavior.

If we make them leave and don’t care that they are upset, we aren’t recognizing their emotions and are being unempathic.

Letting children feel stress, and being empathic and reassuring when they’ve completed the task, is more helpful for them as they grow. If you step in every time and relieve the stress (such as not making them go to school when they don’t want to), you’re not preparing them for adulthood.

Keep your boundaries, and express empathy.

Boundaries in romantic relationships

Dating is hard work. There are several boundaries to navigate during dating. When you have talks about boundaries in dating, if they don’t respond appropriately, you definitely need to evaluate whether you want to continue dating them or not.

Be honest and open right from the start.

Physical boundaries

This is a hot topic in society today—consent, verbal consent, being able to talk and have conversations. Many of my patients do not want to follow through with physical relationships with people, but they have a hard time saying the actual word “no” when they are in the moment. Define what you want and don’t want, long before you get into another relationship. If someone does not respect your “no” that should be a deal breaker.

Spiritual boundaries

Define what you want and don’t want, what you believe spiritually. What are your worldview deal breakers? Defining your deal breakers and writing them down, and asking your friends to help keep you accountable, is important.

If you are Muslim, Jewish, or Christian, make sure that you know what you want in a partner, and that you aren’t letting go of boundaries that will one day matter to you again, just so you can date someone.

Conversational boundaries

Part of dating now is “ghosting,” or shutting down communications when you don’t want to have real conversations about how you’re experiencing someone. I believe this has developed unhealthy communication patterns in society.

When Lindsay and I were dating, she almost broke up with me because I demonstrated some anxious behaviors during our dinners together. I would shake my leg, or eat three loaves of bread in ten minutes! She nearly ended it without telling me why—she just thought I was odd.

But when she talked to her friends, they urged her to communicate how she was experiencing me. When she told me what she was feeling, and I told her I was behaving that way becuase I was nervous—I was so into her! She was pleasantly surprised and we continued dating. Now, we have been married for 6 years and have two children together.

When you’re dating, make it a point to not shut down just because you’re having a negative experience of someone (if that experience isn’t too bad, of course). Try communicating to the person what you’re feeling. This will go a long way in setting up the relationship (and changing your personal habits) to developing positive communication patterns.

Dealing with relationships and change

People view consistency as a positive. That means that as humans, we are wired to strive for create an equilibrium in our relationships. And agreeable, boundary-less people strive for consistency in behavior more than others.

When someone that didn’t have boundaries starts saying “no,” the people in their lives start to sit up and notice what they would deem “inconsistency.” The first time you say you cannot help with that thing you’ve helped with every week, they may be nice about it. But the second and third time, they’ll start to say that sentence we all fear…”you’ve changed…”

When you grow in your boundaries, there will be people who don’t like them. They will shame you, yell at you, push every button that they can to get you to comply in the way that you used to.

Understand that by saying no, you may not be as helpful in relationships, volunteer organizations, or work situations as you used to be.

But, by saying no, you will also free up your time to be able to accomplish what only you can accomplish in your life. Saying no to trivial things that are daily time-vampires will free you up to do the things you are passionate about. That passion will grow, your freedom will grow, and you’ll be able to really start to feel in control of your own life and schedule again. People will respect you.

 

The History and Nuances of Bipolar Illness

Below is a detailed review of the podcast episode, with most of the content that Dr. Michael Cummings and I (Dr. Puder) discussed.  Special thanks to Arvy Wuysang (MS4) for his work in the initial transcription and organization.

The history & nuances of bipolar illness

Bipolar Illness was first discovered by Emil Kraepelin, who was also the first to describe schizophrenia in the 19th century.

Kraepelin noticed another major mental illness in which people had episodic disturbances of mood. He saw either elevation of mood and increased energy, along with a decreased need for sleep, and often impulsive or psychotically related behaviors.

Then, the same patient would experience the opposite, sleeping through the day, demonstrating lowered energy and depression.  These patients were noted to have normal function in-between these episodes. 

Nuances of the bipolar illness diagnosis

The Diagnostic Statistical Manual of Mental Disorders (DSM) identifies bipolar illness primarily by the presence of at least one episode of mood elevation to help distinguish it from unipolar or major depressive disorder.

Here are some defining symptoms:

  • Patients are fairly normal between episodes.
  • When they’re manic, their mood elevates their lack of sleep. They will sleep four to five hours at first, later progresses to no sleep at all on a nightly basis.

  • Every true manic episode will end in three places: hospitalization of some type, jail, or death.

  • Initial peak is in the 20s and 30s. Although, people suspect that many individuals who become bipolar don’t initially declare themselves.

  • They often present with a series of recurrent depressive episodes and then, at some point, they exhibit a period of mood elevation meeting the criteria for either hypomania or mania, which earns them the diagnostic label of bipolar mood disorder.  

  • There are two types. Type I, in which the person has fully evolved to mania or mood elevation and fully evolved episodes of depression. Type II, in which the person may have a milder form of mood elevation but still has fully evolved periods of depression.

  • Grandiosity is a major part of mania. Although historically some people with bipolar illness have often been incredibly productive during episodes of mood elevation, before they become disorganized or psychotic.

  • There is often impaired judgment during manic episodes. For example, someone who is manic will propose to 5 different girls, max out multiple credit cards, buy extra houses/cars/boats, etc.

Bipolar and the limbic system

Underlying pathophysiology is centered around the limbic system. Involves the temporal lobes and and structures which swings upward into the mamillary bodies into the anterior cingulate gyrus, which then projects forward into the frontal lobe. That circuit goes through periods of hypo-activity or depression in people who are bipolar. They have depressed metabolic rates of the system upto 30 to 40 % below normal. During periods of mood elevation, there is an increase in metabolic activity and instability in that limbic circuit. The mood is an element of that, but the person’s overall activity, sleep-wake cycle, circadian rhythms, along with all the things related to the functioning of the limbic system are disturbed in bipolar illness.

 Bipolar illness and sleep patterns

There are some models of the illness that suggest that perhaps the core of the pathophysiology of bipolar illness is an abnormally regulated biological clock.

In most of us, the nerve cells, the neurons that make up the biological clock, are very tightly linked to each other in terms of their operation. They literally form two pacemakers or oscillators in a very small structure that sits right on top of the optic chiasm called the supraoptic nucleus.

Normally all of our circadian rhythms are regulated by this master clock. In healthy people, it’s very difficult to get the two oscillators to separate from each other. In bipolar people, those oscillators drift apart relatively easily. Something as simple as loss of sleep during the latter half of the night will cause them to diverge from each other.

When that begins to happen, the overall functioning of the limbic system begins to oscillate in an unstable manner.

People have looked at things like disturbed sleep as being a very common precipitous of a mood episode. If somebody has a difficult day or disturbing event, and they’re genetically vulnerable to being bipolar, they may not sleep well at night, and the next night they may not need to sleep as much. The night after that, they really don’t sleep, and then their mood begins to elevate and another episode is initiated.

Genetic markers of bipolar illness.

Bipolar is typically passed on genetically, and can be linked with other similar markers of illness. Around 100 genetic markers have been linked to bipolar illness.

They overlap with schizophrenia in part, but not entirely. People with bipolar illness have a much more normal brain in terms of development then do people with schizophrenia. But, there appears to be an inherent defect in the operation of the limbic system elements with these periodic repeating of overactivity and underactivity, plausibly related to the core biological clock.

Mood stabilizers have an effect in terms of decreasing and stabilizing the activity of the limbic system. They tend to push that clock back toward being phase-linked or operating together as a single oscillator, rather than as divergent oscillators.  

Mood Stabilizers

History of Lithium

The very first mood stabilizer discovered was lithium. It was very popular in the 19th century for the treatment of gout because it decreases uric acid crystals.

In the 1940s, a psychiatrist named John Cade (1912-1980) served in World War II and was a prisoner of war for three years. After the war, he worked in a repatriation hospital in Australia and became fascinated with bipolar illness. At the time, he looked at the earlier history and thought that uric acid somehow caused bipolar illness. That turned out to be a wrong hypothesis. But, it led him to use lithium urate, a soluble form of uric acid, in hamsters, to see what would happen. The hamsters got lethargic and sleepy upon administration.

He decided to give his lithium compound to ten patients—six of them were bipolar, four of them were schizophrenic. They all became less agitated, though the schizophrenics didn’t change all that much. However, all of the bipolar patients’ moods stabilized.  

It’s amazing how he didn’t kill any of these patients in spite of giving them gigantic doses of lithium. His initial dose was 1300 mg, three times a day. Most of the patients got ill with that. If you give somebody too much lithium, they develop nausea, tremor, and diarrhea. You can make them very seriously ill with lithium because it has a very narrow therapeutic index. The distance between therapeutic and toxic is not very far. Optimal dose for most patients 0.6 - 1.0 mmol/L. Toxicity usually begins at about 1.5 mmol/L, serious toxicity begins at about 2.0 mmol/L.

At Loma Linda and at patton State Hospital, most patients start at 900 mg at night, obtain a plasma concentration five to seven days later, and then adjust the dose.

Dosing lithium

Lithium should never be given in divided doses.

The kidneys is spared by having a long trough period between lithium doses, so it is best to give it at bedtime.

Lithium tends to decrease urine concentrating capacity. Almost everyone who takes lithium, their urine output will increase by about 20%, and their water intake will correspondingly increase by about 20% to compensate. There are a few people who get much more severe diabetes insipidus, an insensitivity to anti-diuretic hormone in the kidney.

Over the course of many years, about 5% of people who take lithium will develop mild to moderate degrees of renal failure or insufficiency. That risk is minimized by keeping the lithium level < 1.0 meq/L and also by giving Lithium only once a day.  

Lithium and suicidality

It’s clear that lithium reduces suicidality, which may be a product of its ability to inhibit impulsivity. Suicide rates are substantially lower when people take lithium.

In the healthy population, when they’ve done studies in areas with very low concentrations of lithium in the groundwater, rates of suicide and rates of homicide are lower in areas with lithium in the groundwater compared to areas that don’t have lithium in the groundwater.

The amount of lithium that people are getting from the groundwater would be roughly the equivalent of taking 3 milligrams of lithium a day. This means that in the healthy non-bipolar non-mood disordered brain, it doesn’t take very much lithium to make people somewhat less violent.

When would you take someone off Lithium?

    • The best measure for lithium is to measure the eGFR (estimated glomerular filtration rate). If the eGFR declines to 50 or less, the person should not take lithium.

    • The other common adverse effect that lithium has is to make the person hypothyroid.

      • Lithium tends to decrease the synthesis and secretion of thyroid hormone. The good news is that if it makes somebody hypothyroid, we can easily replace the thyroid hormone with Levothyroxine, a synthetic analogue of the hormone. Frankly, your body doesn’t care whether you get your thyroid hormone from your thyroid gland or from a tablet.

    • Dermatologic side effects

      • Psoriasis is a contraindication to lithium use. It will greatly worsen psoriasis.

      • If the person is prone to cystic acne, lithium will typically cause a worsening of cystic acne.

      • One of the effects of lithium is to increase oil secretion in the skin. That can lead to both increased psoriatic plaques and cystic acne.

History of other mood stabilizers

The reason we have other treatments for bipolar illness, is largely the result of the work of Robert Post.

Post was a psychiatrist who worked at NIMH and was doing an unrelated experiment. He was looking at kindling, or increased sensitivity of the limbic system, by putting electrodes into mouse temporal lobes and giving them a one second electrical stimulus once a day.

Initially, when you do that, nothing happens.

But about day two or three, the mouse will have a complex partial seizure, a temporal lobe seizure. If you keep doing it pretty soon the mouse will start having spontaneous seizures. Robert Post looked at that and thought that the nerve cells of the limbic system can become more and more sensitive, more and more hyperactive, less and less well-controlled. He thought that he could block that effect, in terms of seizures, with anticonvulsants. He then, made a leap in logic, thought that perhaps mood episodes are acting like electrical stimulus causing kindling in the limbic system for people with recurrent mood episodes, like in bipolar patients.

He decided to treat some bipolar patients with an anti-epileptic.

The first medicine he used was Carbamazepine (Tegretol). Tegretol is a very difficult drug to use because it induces its own metabolism, so the level keeps falling. It also is fairly toxic with respect to the bone marrow. So, you have to watch out for loss of white cells, red cells, platelets.

He fairly soon turned to another anti-epileptic, valproic acid, which is a branched-chain fatty acid. He found that it was also effective in treating bipolar illness. Turned out that compared to lithium, valproic acid was more effective if the person was a rapid-cycling bipolar patient having more than four episodes a year. (Although lithium remain superior if the person is a classic type I bipolar patient.)

In young women in general, valproic acid it can be problematic because it can cause Polycystic Ovary Disease.

  • In pregnancy, it causes not only a risk of neural tube defects such as spina bifida, it also decreases the intellectual capacity of the offspring by about 10 IQ points, and roughly doubles the risk of autism in the offspring. It also causes hirsutism and weight gain.

Psychiatry has pretty much examined every anti-epileptic introduced since to see if it had mood stabilizing properties.

Lamotrigine (Lamictal) for example, does treat bipolar depression and does stabilize mood cycling, but has almost no benefit with respect to mood elevation. In fact, Lamotrigine as a monotherapy may actually cause switches into mania in some patients.

People have looked at Topiramate and found that it may have some prophylactic capability but doesn’t seem very effective at all if the person is already manic or depressed. If their mood is already stable, and you’re just trying to decrease the cycling, it may have some benefit.

Lamictal, used as a mood stabilizer, may have gotten more use than it should because although it does have antidepressant properties in bipolar illness, it is certainly not a benign drug.

People were initially attracted to it because there’s not a lot of laboratory monitoring involved. The plasma concentrations of lamotrigine don’t correlate very well with its efficacy because it is very rapidly cleared from the blood compartment and taken into tissue. It’s easy to administer and when you’re not using it for seizures, usually can be dosed all at bedtime.

It does carry a risk of Stevens-Johnson Syndrome, which is severe malignant rash, and which the person winds up looking like a burn victim because their skin literally dies and falls off.

It also can cause lymphohistiocytosis, which is a similar autoimmune process, but involving the blood vessels and internal organs. Luckily, that is rare, but it's also typically a life threatening response to the drug

The risk of the side effects above are increased by titrating the drug to rapidly. They discovered the side effects when they were using the drug initially for seizures. They were often increasing the dose by a hundred milligrams a day starting at 100 mg, and by day four, the person was on 400 milligrams. They found a 9% increased rate of malignant rash. If you slow down and don’t go faster than around 25 to 50 milligrams a week in the titration, the risk is reduced, but it’s still not zero. It’s probably less than one half of 1%, but it is a caution.

The other caution with the drug of course in bipolar patients is it sometimes is not a very good monotherapy because it doesn’t provide any protection against mood elevation. It seems to be effective in treating the depressed phase of the illness, but not the manic or hypomanic phase.

Oxcarbazepine has flunked multiple trials as a mood stabilizer. Oxcarbazepine differs from Carbamazepine in only one bond. In carbamazepine the bond between carbons 10 and 11 is an epoxide bond, while in oxcarbazepine that same bond is an ester bond.

It appears, however, that the mood stabilizing properties of carbamazepine result from the epoxide metabolite, and of course oxcarbamazepine does not produce that metabolite.

Oxcarbazepine can, in some individuals, reduce impulsivity, which seems to be a truism across the anti-epileptic drugs, but it’s not an effective bipolar treatment.

There was only one study looking at it in forensic settings for impulsive or violent patients. It was a self-funded single investigator study and it’s been the only study that was ever produced, never replicated. It was suspicious in that the patients were all outpatients, self-recruited via newspaper ad. It’s database even for impulsivity and so forth is pretty limited. It does have some application in that regard, but it is not as good as people hoped.

People became enamored with it simply because it was easier to use than carbamazepine, which isn’t to say that it’s benign. It induces hepatic enzymes, it causes dangerous hyponatremia in about 2.5% of the people who take it.

There haven’t been any really good studies identifying it as an anxiolytic. Like most anti-epileptics, it can be sedating and somewhat calming, but you could get the same effect from literally any of the anti-epileptic drugs, probably safer would be gabapentin.  

Antipsychotic use as mood stabilizer

Some of the second generation antipsychotics have also shown mood stabilizing properties, albeit as an addon to a primary or classic mood stabilizer. This include drugs like Aripiprazole, Brexpiprazole, Cariprazine, Olanzapine, and Quetiapine. Quetiapine in particular is effective in treating bipolar depression, as is Lurasidone.

Antidepressants as mood stabilizers

Do not give an antidepressant to a bipolar depressed patient!

There are now a host of studies suggesting that antidepressants offer little or no benefit with respect to depression in bipolar illness. It serves only to increase the rate of mood cycling and to risk a switch into mania.

Cognitive side effects of mood stabilizers

Lithium typically causes cognitive impairment only if the plasma concentration is too high, in which case it can cause decreased brain function all the way up to coma if the concentration is high enough. However, lithium used at therapeutic concentrations actually is neurotrophic.

It’s been used now in some demented patients with modest results. MRI scans will show a thickening of the cortex if you put somebody on lithium.

In contrast to lithium, antiepileptic drugs almost universally tend to dull cognitive performance. For example, one of the tip-offs that you’re giving the person too much topiramate is they start to lose the ability to find nouns, they become anomic.

Barbiturate and Benzodiazepine use in bipolar illness

Barbiturates were introduced in 1903. At that time, they were essentially the only psychiatric medication available. They treated literally everything that involved mood elevation or agitation with a barbiturate.

In the middle ages, individuals that seemed to have manic episodes as we understand it today, were considered witches. They were given doses of sedation that would bring a normal person down. These manic individuals, however, would not be sedated with those doses.

This is described in the book The Witches’ Hammer. Most of these tests were designed so that if you were the accused, you most likely won’t pass them. For example, one of the tests was being tied up and thrown into a mill pond. If you drowned, you were concluded not to be a witch, but of course you were dead. If you manage to float and you survived, you were concluded to have done so via witchcraft, in which case they retrieved you from the water and subsequently burned you.

Frankly, psychiatry has come a long way!

Importance of sleep hygiene in bipolar illness

One of the most important things to teach bipolar patients is to emphasize the importance of sleep hygiene.  They should go to bed at the same time every night. It’s dangerous for them to casually stay up to watch tv or a movie etc. That may be a setup for them to have the next episode of mood disturbance.

If they’re having difficulty sleeping, this is a group in which long term use of one of the Z drugs may be appropriate.

Dr. Cummings’ personal favorite in that group is Eszopiclone (Lunesta), because it has a longer half-life. It’s half-life is around 4-6 hours, so it’s long enough that the person will actually stay asleep. It also has a broad dose range, 1 mg - 8 mg at night.

It’s been used to treat primary insomnia in some individuals for up to decades without development of complete tolerance, or resulting in any withdrawal syndrome if the medication is stopped.

Education for bipolar patients

Patients and families need to realize that the more episodes of illness they have, the more resistant to treatment the illness will become, and the less responsive the illness will become to medications. This idea goes back to Robert Post’s study on kindling.

Additionally, when people have more episodes, the cycle tends to become progressively shorter. If they were initially having an episode every two or three years, it may suddenly occur every year, to having multiple episodes for a year.

One of the major costs for both families and individuals who are bipolar is that severe depression or severe mania is incredibly disruptive to the individual’s life. It can destroy their marriage, their job, and cause large setbacks.

I (Dr. Puder) will bring patient's families in, get them on board with a plan to identify early symptoms such as decreased sleep, increased energy, and change in physical activity.  I want the family to keep in close contact with me if these things are developing, and I will alway get them in within the week.  

Role of psychotherapy in bipolar illness

    • For many bipolar patients, the common pathway into a mood episode is an environmental stressor that causes sleep disturbance, which then sets off the instability that they have innately in their internal clock, and then they’re off into a mood episode. Teaching the person good sleep hygiene, teaching them to be better able to cope with stressors is crucial.

    • Psychotherapy can also train them to become more self aware, so that they may be able to spot earlier changes in their mood and recognize an impending episode sooner. This allows them to seek for intervention before things get out of hand.

    • Focus on developing healthy habits like exercise and healthy diet.  

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