Sunday, August 29, 2010

Sleep Apnea and Death Wish

Is sleep apnea an ultimate expression of Death Wish?
Yes, yes, I know scientists have shown its causes, beyond a shadow of doubt, to be physical, psychology therefore has no place in its etiology. Pulmonary scientists have shown that sleep apnea is merely a lack of muscle tone which occurs in apnea folks more strongly than normals, and this factor, along with overgrowth of soft tissues in the airway passage, explains the pathophysiology of Apnea. Why do I want to complicate the matter by bringing in such a funny concept as Death Wish into the equation?
And why would anyone have death wish in the first place? Don't we want to live forever, and what makes me think that this most primary of instincts - to cling tenaciously to dear life - is abandoned in sleep?
But I have a nagging feeling that sleep apnea which is closest thing to death perhaps may be a premature expression of the wish to die and to be free of the rigmarole of life.
In "Beyond the Pleasure Principle" Freud put forward the view that the ultimate purpose of all living organism is to die. Our drives/instincts are conservative in nature and their aim is to restore an earlier state. As soon as life arose - the first drive - it sought to undo the act and strove to restore the earlier inorganic state. It was the bombardment with a fresh trauma and creation of a fresh drive that prevented life from reaching its goal of death in a linear fashion. With addition of each fresh trauma and fresh drive, life became more and more complicated, with each drive seeking death in its own unique way. It is the cross-purposes of these different drives in their endeavor to reach death [eternal peace] which produces the clamor of life.
Sleep is a state of partial death. The real aim of sleep is to die completely. To do absolutely nothing. To give up all our tensions. But we cannot do that. Some basic activity, like the activities of respiration, circulation and temperature must still go on, while the rest of us lies there practically dead.
Yet, when life if hard and the tensions through the day high, in sleep the wish to give up all tensions completely, including breathing and heart activity, to give up the ghost entirely, becomes tempting.
It is this wholesale abandonment of tensions - the stressed man throwing off the yoke of all the cares and worries of the day - that is reflected in the drop in the tone of respiratory muscles. In milder cases in the form of snoring and in extreme cases as sleep apnea. Obesity and hypertension, themselves a reflection of unmanageable stresses of life, act as contributory factors.
Now it is a matter of everyday observation that when we are having a difficult time during the day we sleep poorly and we snore. There is a definite correlation between the loudness of a person's snoring and the stress he is having in his life. So perhaps all these factors obesity, hypertension, snoring and sleep apnea are end points of a person's inability to deal with the tensions of life.

Now do I have anything clinical to bolster such a hypothesis? Do I have dreams that show that in sleep we seek to be free of life's tension and wish for death?

Well, the theme of taking a journey -symbolizing the journey of life - and recoiling from it in horror is perhaps the most frequent dream of humans. And this typical dream, in all its variations, after interpretation, show in it, the two contrary wishes: to die and to cling on to life. The prototypical manifest content is generally framed in imageries such as taking a plane journey and being late for it and missing the flight or trying to reach one's childhood home but never quite making there, getting lost on the side roads, or taking a train journey but getting left behind on the platform or in a very interesting twist a patient of mine, a retired man in his Eighties, would dream of seeing himself back at work and working like a dog. The distress of having reached the end of one's life transposed to distress at having to once again live the drudgery of factory work.
Do I have dreams of a person who actually has Sleep apnea which can support the hypothesis?
One of my patient does have sleep apnea and it was very instructive as to how his dreams changed once he was put on C-pap machine and his apnea got treated.
And what was the change?
During his apnea day his dreams were very vivid and real. In fact they were so real that he would feel that he could actually bring back things from his dream to real life. Pieces of candy, a slice of pie, a mug of coffee; they would appear so real in the dream that he would have a feeling that all he had to do was to grab them and bring them out of his dream into the waking world.
There were other intense dreams as well. Dreams about his family when he was young, romping with his brothers in the countryside - he grew up in rural area, about being on a vacation in a resort hotel, gambling in casino.
Yes, there were dreams of falling off a bridge or drowning in water (fantasy of rebirth) and these pointed to the symbolic representation of death. But majority of dreams were of being intensely alive.
Now such dreams of being intensely alive contradicts the assumption that a common factor produces sleep apnea and the wish to take refuge in death away from life's tensions. In fact the apnea was accompanies by just the very opposite wishes - to be intensely alive. Is there anyway out of the difficulty?
Perhaps there is.
When the patient was asked about the affect accompanying the dreams of playing blackjack in casino and about romping with his brothers in the countryside, he admitted that while the visual pictures were those of enjoyment, the emotions accompanying them were unmistakably those of anxiety and distress.
So those dreams were not so much celebration of life as a denial of death and the dream was showing that "Oh no, you are not dying but you are in casino having time of your life. Or you are about to get a piece of the pie or you are once again a child and having fun with your brothers." So here we see the familiar element of wish fulfillment trying to reverse the fear of death by showing just its opposite - living life to the fullest. However, the wish fulfillment fails to reverse the distress/fear of death perhaps because it was fueled by the real situation of death - the actual apnea - and emotionally the patient continued to experience distress despite the visual imagery being that of enjoyment.
One last point. Since dreams of taking one's last journey and dying -and its denial by showing oneself busily engaged with life - are so universally present regardless whether the dreamer has sleep apnea or not, one must assume that whenever life frustrates us we dream of abandoning this world [and being reborn] and only when this wish becomes pathologically strong does it make a move from a purely psychic process to a psychosomatic one and gives rise to the disorder of Sleep Apnea.

Saturday, August 28, 2010

A quartet of psychosomatic symptoms and their obsessional neurotic roots

In his "Notes on a case of Obsessional Neurosis" Freud remarks how Obsessional Neurosis is a rich and rewarding field of inquiry, and how many closely associated patterns of symptoms exist in this illness that would be worth inquiring into. The most famous constellation of this kind is Freud's delineation of a regular association between parsimony, obstinacy and orderliness, all components of anal eroticism

I have been struck by the following four psychosomatic symptoms that seem to occur together in quite a few of my obsessive patients.

Migraine headaches
Stomach pains and cramps
Insomnia
Panic Attacks with fear of leaving familiar surroundings.


Underlying these symptoms, on careful observation one finds a surfeit of undischarged aggression. The patient who cannot discharge the aggression by normal means does so by taking it out on himself; by creating the suffering in his own body. I will give two such cases where I could make some headway into their psychopathology.

A 26-year-old very attractive girl suffered from horrendous headaches, inability to sleep despite massive doses of benzodiazepines, stomach pains at the thought of leaving the house, throwing up and diarrhea at the slightest bad news, and Panic attacks that would leave her exhausted.
She had highly charged destructive thoughts towards men which she struggled against with all her might. The struggle was reflected in her feeling a constant tension in her head which would quite frequently escalate into frank migraine headaches. She was so ashamed of her evil thoughts towards men, which were connected with the possibility of their being unfaithful, that she had married inter-racially, thinking that a black man would not be unfaithful to her, valuing her highly for being white.

On exploration of her insomnia it was found that she slept in a fetal position in one corner of the bed as if she was anticipating somebody attacking her. She had to go through obsessive rituals like checking and rechecking windows and doorknobs to fall asleep and even then it would take her a long time. The insomnia was connected with her fear of dreaming rather having nightmares. The nightmares were 'anxiety dreams' in which young girls were abducted and tortured and raped and subjected to extreme sexual humiliation. The immediate source of it was watching a cable channel where real life stories of little girls getting abducted by sexual perverts was the staple, but its deeper roots were her unresolved attachment to her father from the oedipal phase. The guilt over her love for her father was handled by regression to anal erotic (obsessional) level marked by fantasies of getting beaten, tortured and killed by a rapist.

The reaction to this desire to abjectly submit herself to men and be beaten and humiliated by them found expression in a great [coexisting] hostility towards them. It was this hostility which caused the panic attacks at the thought of leaving the house. The actual thought of leaving the house and be exposed to strangers whom one may solicit or who may abduct one and then subject one to act out the sexually humiliating fantasies caused churning of the stomach and diarrhea.

The second case is of an adolescent boy who also suffered from migraine headaches, insomnia, stomach cramps and pains, a great urgency to defecate when stressed, but not frank diarrhea, panic attacks and inability to leave the house. Added to this quartet were attention problems, hyperactivity, and motor tics. Motor tics were predominantly around the eyes but also posed difficulty in swallowing that emerged as complex motor movements through the upper torso of his body. He was capable of suppressing these motor manifestations of aggression by actively concentrating upon them, but it would leave him exhausted and give him migraine headaches. The headaches were always there as low lying muscle tension becoming frank migraines if there was parental conflict or if he had to do some trying activity like taking a test. He also had inflammation of the sinuses causing sinus headaches, also probably a manifestation of the same psychosomatic pathology.

The boy was insightful enough to figure out that his attention problems were connected with death wishes towards his parents. In classrooms, instead of listening to his teachers, he would be struggling mightily to prevent the death of his parents by doing some day dreaming or some complex mathematical activity designeded to ward off the evil that was to befall his parents. This animistic thinking also found expression in some compulsive motor movements like having to tap the door or other objects a fixed number of times, generally three, symbolizing his mother, father and himself.

Additional symptoms that confirmed he was struggling against his death wishes towards his father were his castration fears that his hair needed cutting, or his shirt was not trendy enough or marked by defects, or he smelled, or he had body deformities which would subject him to ridicule in public. These are all manifestations of a hypochondriacal and social displacement of castration anxiety. He would take a long time to groom which was displacement/regression of his castration anxiety escalating to an anal-erotic phase.

His great rage towards his father was a reaction to his fear of getting castrated by him for his sexual proclivities towards his mother arising from the oedipal phase, but now buried in the unconscious. He also reacted at the thought of leaving the house with panic and churning of stomach. The panic was at the thought of humiliating himself with strangers by abjectly submitting himself to them. This was a passive dissimulating reaction to hide his desire to murder them, a displacement of the murderous rage towards the father on to strangers.

Friday, August 20, 2010

The Madness of Multi-axial Diagnostic System in Psychiatry

About eight months ago I had a site-visit by a Behavioral Management Company (BMC) contracted by a Medicaid HMO to keep down service costs. In other words, this company is contracted to find ways to minimize a patient's visit to doctors and other medical activities. Ostensibly it's contracted to perform the above tasks, but in practice it is to cut down medical consumption across the board whether for good or for greed. The purpose of this particular site visit was to use a little fear mongering because I did not fit their mold.

It is very unusual in the world of psychiatry to include psychotherapy as part of patient treatment. Today's standard practice is for the psychiatrist to quickly make some monolithic diagnosis such as Major Depression or Schizophrenia or Bipolar Disorder, write a few prescriptions, and hand over the patient to a social worker or psychologist to then tinker with their mind. A psychiatrist's role is limited.

I find something drastically wrong with this picture. In such a system the psychiatrist is unlikely to allow any patient who comes his way to escape without putting him on at least one medication. If the patient does not respond to the first medication, in all likelihood the psychiatrist will keep adding more and more medications until the patient, if not healed, is at least completely out of it. I do my own psychotherapy with my patients and do not split my patient's treatment with therapists. I manage not only their medications, but their psychological world as well.

The BMC was not happy with such a state of affairs. They were not unhappy that I was getting good results. They were not unhappy because I was prescribing medications very sparingly (which alone saves them tons of money). They were not unhappy because I rarely admit patients (which again saves tons of money). They were not unhappy because my patients are not unhappy with my psychotherapy or my medication management. They were not unhappy because Medicaid was not saving money by my doing both aspects of treatment: medications and therapy.
So, what was making this BMC so unhappy?

The BMC was unhappy because my patients were happy seeing me and almost all of them wanted to avail themselves to the full 20 sessions allotted annually by Medicaid. The BMC prefer to utilize therapists who are so poorly trained and are so stinking bad that people would rather commit suicide than have a psychologist see them beyond a few sessions.

The BMC had decided that as a psychiatrist I was not authorized to bill for psychotherapy; I could only bill code 90862 (medication management) which reimburses $27.00. I could not bill code 90806 that pays $54.00 for a full session. The BMC stated that code is reserved for psychologists and social workers. When I offered the services to do psychotherapy, bill code 90806 and throw in the medication management for free, I was told there is no such thing as a psychiatrist doing psychotherapy without tinkering with the patient's medications and for that I would have to bill code 90807 to receive $32.00 because the BMC does not think psychiatrists are capable of doing psychotherapy. When I stated I would take this issue to the Mental Health Board and to the American Psychiatric Association they decided to do another site visit in an attempt to scare the bejeezus out of me.

The social worker who visited to review my charts was pleasant and was astonished that most of my records were primarily analyses of patients' dreams. She was very impressed with that. She had seen nothing like it in her entire career. That must have been a mind blower. Nevertheless, since I failed to make the five-storied multi-axis diagnoses at the end of psychiatric evaluations, I was faulted. Her notes read, "This psychiatrist appears to be capable of making the five-storied multi-axial diagnoses when he chooses as he does when filling forms for disability or sending reports to courts, but he does not do so for his clinical work and this is a serious lapse."

Now is it? Really?

The five-tiered diagnostic system that the American Psychiatric Association has thrown at the psychiatric profession like the ten plagues of Egypt is the biggest heap of bull ever crapped upon a profession and on patients who must adhere to that discipline for their treatment.

Yes, yes, it does make the psychiatrist feel he has done a wonderful job of evaluating his patient and he can feel so without having a whit of understanding what is really wrong with that patient.
It gives the psychiatrist a sense of having done something very complete, something very profound, something very complex, something that looks so long and mighty in comparison to a one or two word diagnoses of other medical specialties; and he can get that "feel good all over" feeling without having done anything really meaningful.

Diagnostic labels have no real meaning in psychiatry, no matter which DSM diagnostic category they belong to. Every symptom, complaint and problem has to be deciphered on its own right, regardless of what diagnostic rubric it is subsumed under.

For example, if one is diagnosed as having depression, it is no big feat. Anyone with even the most elementary clinical sense and a modicum of intelligence can make that out if a person is listened to for even a few minutes. As far as psychopharmacology is concerned we treat all forms of depression with the same broad brush; the same psychopharmacological agents. When one goes to other diagnoses, like obsessions or disturbances of the periodicities of mood (various forms of manic-depressive illnesses), the story is exactly the same. Making the diagnosis is child's play.

The difficulty is getting behind the diagnosis to figure out why the patient became depressed and what difficulties the patient is trying to master with the periodic mood shifts. What is the meaning of his obsessions and what contradictory impulses is the patient trying to express through his obsessive thinking and compulsive actions? These tasks, unfortunately, are not made easy, but become even more difficult when one must think through the foggy glasses of the multi-axial system.

In fact, once one makes a complete diagnosis with its impressive five or more lines, there is no motivation left to do anything more with patient's complaints. Now, even if one grants that the Axis I and the primary psychiatric diagnoses have some value, at least for the purpose of coding and billing, and as scaffolding for broadly conceptualizing patients' problems at gross level, the other Axes are totally useless if not outright harmful.


Axis II, the personality disorders, have no specific psychopharmacological agents that alter them. As far as psychotherapy is concerned it is outright nonsense to say that the therapists use one form of psychotherapy for one personality disorder and something else for another.

Axis III is a joke among therapists. Only medical doctors are truly capable of filling that section correctly. No psychiatrist performs thorough physical examinations. When it comes to writing that section of the multi-axial system the only thing the psychiatrist does is throw in a couple of patient's medical problems as an afterthought. The medical problem to mention is the same as picking a rabbit out of a hat. No attention is ever given to it again.

Axis IV is even more ridiculous. Naming a couple of psychosocial stressors and guessing their severity doesn't have any meaning in actually comprehending the patient's real life situation. These factors cannot be captured in one or two lines. By declaring that the stressor is legal versus marital versus school based, has no relevance to how one approaches patients. Does saying it is a very severe stressor versus a moderately severe stressor change one's approach to handling the patient? Does any psychiatrist ever declare a patient has less than moderately severe stressors.

Axis V is a worthless apex other than knowing some broad markers like Medicare will object to paying for inpatient care unless the GAF score is less than 40. In fact, it is now a clinician's game to start with a ridiculously low initial GAF score and gradually peg it upwards on paper to show progress.

The multi-axial diagnostic system in psychiatry is the biggest hoax and monstrosity perpetrated upon mental patients by the American Psychiatric Association. It was done at the behest of the pharmaceutical industry and it has primarily benefited them. With the advent of the multi-axial system psychiatrists slowly but surely abandoned listening to patients beyond getting enough information to pigeon-hole them into the DSM multi-axial system and then start medicating him as if there is no tomorrow.




Wednesday, August 18, 2010

Successful analysis of a dream leading to relief from symptoms

This dream is of a 17 year old teenager; a talented musician who was plagued with crippling anxiety. Around the age of 10 or so he had crippling obsessions. He had the following dream, the successful analysis of which resulted in significant improvement:

I am in my house, in my room, where I feel the safest. I hear commotion on the ground floor, as if somebody is throwing pots and pans and causing other disturbance. I come down and see my parents sitting on the dinner table. My sister is sitting on the bar stool. She is flipping a religious book. It is more like illustrated book of religious symbols, something like a comic book, for children. It is open at a page where there is cross. It is violet in color. And there is writing next to it that declares that I will be crucified for my sins. I view it sarcastically. I see two severed heads in the oven. It is grotesque but there is no blood to it. There is a sticky pad note on the oven that I will meet the same fate. Then we all sit down to dinner. Everybody knows that I will be killed, but my family is indifferent to it. Somebody comes and grabs me from behind and is about to strangle me when I wake up with fright in cold sweat. It took me long time to realize that the dream is not true.

The boy came to treatment because of harrowing anxiety, constant irritability towards parents including feelings that they should die, feelings of unreality, severe fears of others, feeling that his friends and others kids don't like him, feeling like he is a fake and not a real person, fear that others can sense his thoughts and know that he is evil, guilt about having sex with his girlfriend, and thoughts of ending it all with suicide.
The only relief from the turmoil in his mind and difficulty in interacting with people was in giving himself to writing music and playing it with his band.

Fragments of some of his dreams had been analyzed before, and the therapy had proceeded far enough for him to have the insight that his obsessions were displaced expression of his repressed hostility. It was this awareness, along with the fact that he did not fear censure expressing such thoughts in therapy, that allowed his mind to dream the above frightening dream.

I am in my house, in my room, where I feel the safest.


This was the actual state of affair in his life as well. He was running away from the world out of fear of the consequences of his hostile impulses. The house and his room symbolized withdrawal into the womb - primal womb fantasy - where the dangers of the external world could not follow him.

I hear commotion on the ground floor, as if somebody is throwing pots and pans and causing other disturbance.


This was the stirrings of his hostile impulses in the dream. In the dream he had taken refuge in the sanctuary of your room, but his destructive impulses were following to and he had to pay attention to them as they emerged in form of pots and pans being thrown around in the kitchen. And they were emerging in regression. When he was much younger, he was given to throwing things in the kitchen when things did not go his way.

I come down and see my parents sitting on the dinner table. My sister is sitting on the bar stool


Now these three are the primary objects of his hostility. This had been established in earlier sessions through analysis of some of his obsessions. One such obsession was the compulsion to do everything four times. For example he had to open and close the refrigerator four times to make sure that the food inside had not gone bad [which would result in food poisoning of his sister, parents and himself; he had suffered from a few episodes of food poisoning himself]. There were four members in the family and opening and closing four times was "undoing the death wish" four times. If his attention was not fully upon this undoing process then he would have to repeat the ritual in multiple of four. He would have to do opening and closing of the fridge 16 or 64 times.
His parents were on the table and the sister on the bar stool symbolized the different level of respect he accorded to his parents versus his sister. He had much greater hostility to his sister and less guilt over its emergence. That he had less probelm over visualizing his sister's death had been confirmed through analyzing a tormenting obsession of his from the past. The obsession involved checking and rechecking the toilet to make sure the cat [sister] had not drowned and died in it.

She is flipping a religious book. It is more like illustrated book of religious symbols, something like a comic book, for children. It is open at a page where there is cross.

Here the dream work had changed the logical sequence of the thoughts behind the facade of the dream. The punishment for the transgressions was being shown before the actual crime. The cross was showing that he will be nailed to the cross as a punishment for his death wishes.
The fear that he will be nailed to the cross or subjected to other severe punishments was reinforced by his attending the Bible classes and listening to the sermons in the church when he was 10 to 11 years old. At that age his obsessions were at their zenith; sometimes he would lay awake all night dreading his impending death.
Now at age 10, he believed in what was being taught to him in the church, about sin and punishment. But at 17, and under the influence of therapy, he was having doubts that if it was really possible for him to be nailed to the cross for having thoughts of his parents death. So the whole religious an-eye-for-an-eye doctrine was being mocked by declaring that it is as good as a comic book.

It is violet in color.
And there is writing next to it that declares that I will be crucified for my sins. I view it sarcastically.

The association to the violet color was weakness and sissy stuff. This was once again making a mockery that one cannot take seriously what is taught in church about sin and punishment.

I see two severed heads in the oven.


The patient did not agree with my construction that they were the heads of his parents. Instead he said they were the heads of his grandfather and his girlfriend.
Why them?
Because his grandfather was given to licentiousness and in his mind she was no different.
The interpretation was easy. It was she who had tempted him into sex, and it is she who is now causing this castration anxiety, and it is she who should be punished by beheading (a regular substitutive symbol for castration) not me.

It is grotesque but there is no blood to it.


It is lessening of the dread of castration to let him sleep. The essential nature of dream is to protect the person from waking.

There is a sticky pad note on the oven that I will meet the same fate.


His parents were in the habit of leaving sticky notes as a way of communicating in the family and generally for ordering the children to do things. This lack of direct communication, by the way, also contributed for the child to develop obsessions.
So the fear of castration had its origin in fear of parents (father).

Then we all sit down to dinner. Everybody knows that I will be killed, but my family is indifferent to it.

It is unclear why they are having dinner. This part escaped analysis or rather I failed to inquire in to it. Perhaps it has to do with oral aggression and impulse to poison their food. Recall here his dread that he will poison them with rotten food of the refrigerator. Also at this point he also recalled a dream in which he was contaminated and had to go through a door to a chamber where he was decontaminated. This contamination dream alluding to his wish to contaminate the food of his family.

The indifference of the family was alluding to the punishment being well deserved. Since he was wishing them dead, they were indifferent to his death.

Somebody comes and grabs me from behind and is about to strangle me when I wake up with fright in cold sweat.


This was his own violent impulses that were being redirected from others on to himself. The dreams showed it as causing the beheading of his girlfriend and grandfather and poisoning of his family but the facade could not be maintained too long and the aggression found its final outlet against his own self. Here too the dream kept on its purpose of maintaining the sleep by projecting out the violent impulse as coming from a stranger with which he can fight, but then the fear led to his not breathing [sleep apnea] and he woke up in cold sweat.

It took me long time to realize that the dream is not true.


This signified the intensity/strength of his desire to do harm and gave the vividness and sense of reality to the dream

Monday, August 16, 2010

Excessive and instant gratification and the rise of ADHD

The last fifty years have been decades of unprecedented prosperity. This has had a profound effect upon the way we are bringing up children. Our children are growing up in homes where they are constantly placated and amused by having access to endless numbers of toys. Whenever they are bored they can immediately go to their video games, computer, television, phone a friend or text on their cell phones. Their every need is instantly acknowledged and fulfilled.

This state of affairs is perhaps at least partially responsible for the explosive rise in the incidence of ADHD. I see an intimate connection between instant gratification which has become the norm in bringing up children in today's culture and the proliferation of the disorder of Attention.

Such a constant state of satisfaction leads children to develop a very high rate of dopamine secretion and a mental makeup which seeks pleasure continually and instantly. When such children attend classrooms and have to learn tasks that are not always a matter of instant gratification they quickly lose interest and attention.

A child who grows up in a culture of instant gratification is used to getting immediate success. If one toy ceases to give pleasure his modus operandi has been to move on to the next one. If one show on television does not keep him amused he changes the channel. His video games have allowed endless shooting of the bad guys and therefore quick successions of dopamine secretion.

Tasks required at school are neither highly rewarding, at least not immediately, nor do the reward occurs frequently. One must go through a number of stages of hard work before reaching one's goal/success. Consequently, the secretion of dopamine, the reward neurotransmitter, does not happen that readily. The task has to be painfully mastered before pleasure is allowed. The
child who has grown up in a culture of instant gratification loses interest quickly at hard tasks that school demands and starts daydreaming of scenarios which promise instant pleasure because his brain is conditioned to have very high levels of dopamine secretion. He is also fidgety because in his unconscious he is conjuring up scenes where he would rather be instead of where he is at the moment. His body, without his conscious knowledge, squirms and moves to get out of his seat. This is the "hyper" part of the ADHD.

If a child comes from a background where taking on the challenge of hard tasks is considered worthwhile because there is a big reward at the end, in other words where there is great desire in the child, constitutionally or because of upbringing, to please parents and teachers, he may overcome this need for instant gratification. Otherwise, he starts developing defiant attitude towards authority if they keep on pressuring him to pay attention to the task at hand rather than daydream. This is the oppositional defiant aspect of ADHD.

Of course, there is also another very important factor to the cause of oppositional defiance of ADHD children. When a child goes to school and finds that other children perform better because they can pay attention to what is taught while he cannot, the same humiliating situation is most likely also occurring at home where his siblings who do not suffer from attention problems are doing better than him. In these cases, murderous (obsessional) rage is generated. This rage finds expression in defiance, failure to perform tasks, stubbornness, arguing, and doing just the opposite of what is demanded. Later, obsessional defenses will emerge to control this rage.

Dopaminergic drugs work by keeping a constantly high level of dopaminergic activity. This removes from the child the motivation to be some other place doing tasks that will boost up his dopamine secretion. Since it is already artificially high from the dopamine pills the child does not have to daydream nor fidget to be "elsewhere" where there is better promise for immediate gratification. This enables him to pay attention to what is being taught.

Also, the function of dopamine is not so much to give pleasure as to enable one to focus/pay attention. What gives us pleasure is what we focus upon. Dopamine narrows the range of our perceptual and motor world allowing focus which in turns allows pleasure. The high rate of dopamine activity brought on by the dopaminergic neurotransmission enhancing drug gives the illusion to the ADHD afflicted child that what is being taught is what is giving pleasure/satisfaction, so he focuses upon whatever is happening right then and there.

Friday, August 6, 2010

The myth of therapeutic ranges for Lithium and Depakote in psychiatric disorders

In medicine we often operate on assumptions that have all the trappings of science, but are in actuality untested conventions. Sometimes these conventions get so much legitimacy that we believe we are practicing top notch evidence-based science while in reality we are harming our patients.

One such convention is the belief that lithium's therapeutic range is between 0.5 to 1.5. This convention receives so much currency that clinical labs across the world give it as the standard normal range. In reality many patients, especially aggressive developmentally disabled ones, show good response to lithium levels well below the recommended 0.5; ironically, when their levels are pushed higher into the so designated 'therapeutic range', they show subtle cognitive and neuromuscular problems.

It is not uncommon for me to receive a request from a patient's Primary Care Physicians (PCP) to increase his lithium dose because the blood level is below the therapeutic range. Requests are received only if the smarty-pants doctor has not already gone ahead and raised it, convinced he knows more than a psychiatrist on how to medicate mental patients. This high-handedness often happens in the ERs as well, where the ER doctors, unilaterally change the dose of psychiatric medications, going just by what they know about therapeutic ranges as given in their lab reports.

Bipolar patients appear to be special target for overmedication. The drug most often used with them, Depakote, it's therapeutic range is believed to be between 50 to 150. I have always wondered why the range spreads so neatly between 50 and 150, with 100 as the dead center. With 50, 100, and 150 being such perfect numbers, God was really acting the mathematician when forging the treatment of Bipolar Disorder. Could that perfect spread be an unconscious plagiarism of the lithium therapeutic range having been declared as 0.5 to 1.5, if one ignores the decimal points?

Once, world-famous Dr. Charles Nemeroff came to Detroit to a Marriott Hotel at the behest of Depakote company. We were each paid $500.00 (in addition to an eye-popping spread of breakfast, lunch, and a range of exquisite wines) to listen to him and his buddy, Dr. Henry Nasrallah. Drs. Nemeroff and Nasrallah rebuked the gathering for not diagnosing enough people as Bipolar. In addition, they further rebuked, that those who do get diagnosed as Bipolar even they do not receive enough Depakote to keep their levels north of 100. When I expressed concern that everybody and his mother is getting diagnosed as Bipolar, and the ideal therapeutic point of 100 sounds outright fishy, and was probably arbitrarily chosen because 100 is a sexy number, I received the dirtiest possible look that could be given by a platform performer.

Like with lithium, Depakote seems to work quite well for many patients at dosages well below what it touted as its therapeutic range. While unnecessarily high dosages of Depakote does not do too much harm beyond making profits for drug companies and their hired-hand doctors, and occasional liver failure, high lithium levels for prolonged periods do serious damage to kidneys.

Over the years I have seen many patients developing renal failures because their doctors kept their lithium levels around 1, or higher, without ever testing whether they could be managed at lower levels.

Of course, some patient do require therapeutic levels of 1 or even slightly higher, and I'm not recommending that such patients have their lithium levels lowered and be subjected to possible relapse. But, in my clinical experience rarely does a patient require lithium levels above 1.1 and many patients do well on levels below 0.5. Even those who require lithium levels above 1.0 during acute mania, the psychiatrist should be ever alert to lower it once his mood stabilizes.