Schizophrenia - a lecture

Please note that the information contains original and previously published data and as such is not attributed. Writer takes no responsibility for originality of the content, it is purely for the purpose of education of healthcare individuals. If you have any questions about the content or would like the information presented by a qualified psychiatric nurse practitioner and naturopathic practitioner please contact me at naturalpsych@hotmail.com

Respectfully,
Dr. Eric Malz


Definition
Schizophrenia is a brain disorder that affects a person's ability to perceive the world and to process information. The word "schizophrenia" derives from the Greek, "schizo" meaning "split" and "phrenia" meaning mind. Thus, those diagnosed with schizophrenia often display flat or inappropriate affect, reflecting a splitting apart of normal emotions from responses, and a separation of thought and perceptual experiences from rational processes. This derivation misleads many into thinking schizophrenia is related to "multiple personality" like in the movies "The Three Faces of Eve" and "Sibyl". Multiple Personality Disorder, now known as Dissociative Identity Disorder, is one of the dissociative disorders and has nothing to do with schizophrenia.
Symptoms
The symptoms of schizophrenia tend to fall into four categories:
· People with schizophrenia may experience hallucinations. That is, they may hear or see things that are not there. Just as in a dream, where fantastic events can not be distinguished from real events, hallucinations can not be distinguished from real events. Thus, the hallucination of a voice talking is perceived in the brain just like a real person talking.
· Another symptom of schizophrenia is delusions, or false beliefs. These false beliefs may be very difficult for family or friends to understand, since they do not make sense. Again, a delusion seems as real to the person as a belief grounded in reality. This experience is also much like a dream experience. Just as in a dream, the reality of the dream situation, (for instance, that someone is plotting against one), seems very real. However, for the normal person, upon waking, it is clear that the plot was "just a dream". For the person with schizophrenia, the plot, or other delusion, continues to seem real.
· Other symptoms of schizophrenia may affect a person's ability to feel emotions--the abililty to be angry or happy may be dulled, or even gone. When this happens a person understandably will have decreased expression of emotions. In addition, a person with schizophrenia may have decreased motivation and become socially isolated, again understandable if nothing seems rewarding or very much fun.
· Finally, a person with schizophrenia may have disorganized speech or behavior; so that what they do or say does not make much sense.
Different people with schizophrenia may have any of these symptoms to varying degrees. What is Wrong With The Brain in Persons With Schizophrenia?
In the last twenty years, there has been an explosion of knowledge about how the brain works. It is clear the brain functions in a highly integrated manner, and that there are neural circuits essential to normal brain function. These circuits are not unlike a very complicated road system, where information may travel down a main road, but may also get to the appropriate destination by alternative routes. Like the "alternative routes" that one may use in a traffic jam, the "alternative routes" may not be as efficient as the main route. Throughout life, but especially during childhood and adolescence, major pruning of redundant "routes" occurs. This neural pruning prepares the individual for the tasks of adulthood, but in the course of the changes, an "alternative route" may be cut off in a person with schizophrenia unmasking the problematic "main route", and thus the symptoms of schizophrenia.
Information is transmitted through these neural circuits, or "routes", via a relay of chemicals called neurotransmitters. There are probably hundreds of neurotransmitters in the brain. Substantial research is directed at better understanding how neurotransmitter systems work in healthy brains and in brains with schizophrenia, but little is known for sure. One hypothesis that is the focus of a great deal of research is that the dopamine neurotransmitter system in a part of the brain involved in emotion and information processing, the mesolimbic system, is involved in hallucinations and delusions. A related hypothesis is that the dopamine system in another brain area--the prefrontal cortex--is involved in the decrease in experience of emotions and other negative symptoms of schizophrenia. However, there are hypotheses that many neurotransmitter systems may be involved in schizophrenia, including norepinephrine, acetylcholine, and serotonin, to name just a few
addition, the symptoms can be very mild, or very severe. Possible Causes of Schizophrenia
Like pneumonia, which can be caused by various bacteria, viruses, or chemicals, schizophrenia probably has multiple causes, all of which affect the brain in related ways. Research suggests that both genes and environmental factors are involved in developing schizophrenia. While 1 out of every 100 persons has schizophrenia, having a biological relative with schizophrenia increases a person's risk of developing this disorder. A person who has a genetically identical twin with schizophrenia has a 50% chance of having schizophrenia and a 50% chance of not having schizophrenia. A person with a sibling or a parent with schizophrenia has a 10% of having schizophrenia and 90% chance of not having schizophrenia. Thus, research is aimed at finding both the genetic factor that may put a person at increased risk for schizophrenia, and the environmental factors that may be involved. There is active and exciting research to find the genes that increase risk for schizophrenia. Three areas on various chromosomes have been linked to schizophrenia in more than one study; however, the actual gene that increases risk for schizophrenia has not yet been found.
The search for possible environmental factors is in very early stages. One prominent theory is that schizophrenia results from altered brain development during fetal life, occuring from in utero environmental stressors. For example, several, but not all, studies have shown that individuals who were fetuses during influenza epidemics are at increased risk of schizophrenia. A few studies have shown that indiivuduals that were fetuses and their mothers endured severe starvation during that preganancy are at increased risk for schizophrenia. Another study has shown that Rh incompatibility between mother and fetus increases risk for schizophrenia. During fetal life the brain is actively developing. The theory is that these stressors somehow interfere with brain development during a critical stage. In post-mortem studies the brains of individuals with schizophrenia have been examined. Here, several researchers have found that the organization of brain cells was more random than in the brains from mentally healthy individuals. In addition, they have found "nests" of brain cells in patients with schizophrenia in the mesolimbic areas of the brain, suggesting that these cells were somehow stopped in their programmed migration to their final resting place. These and other studies hold promise for our eventual understanding of how genes and environment may interact to cause schizophrenia. Regardless, evidence is overwhelming that schizophrenia is a biologically based illness and that the previous view that parents or families cause schizophrenia is totally without merit.
Treatment of Schizophrenia
Antipsychotic medications are the cornerstone of treatment of schizophrenia. It is clear that antipsychotic medications eliminate or lessen the symptoms of schizophrenia in most patients. Without medications, symptoms will almost always occur. With each reoccurance of symptoms, the symptoms usually take longer to get better, and may not respond as well. When individuals with schizophrenia have repeated exacerbations of symptoms , or "relapses", they may often develop chronic symptoms that do not respond well to medication. The goal of medication treatment is to take medications when symptoms first occur, and to stay on medications even if symptoms go away entirely, to help prevent future relapses. Research now suggests that ongoing hallucinations and delusions are symptoms of a toxic brain process, that may be further damaging the brain. Control of the symptoms may also mean that this brain damaging process is also halted. Regardless, several studies have shown that the earlier a person with schizophrenia gets treatment, the more mild the illness.
Antipsychotic medications may have troublesome side effects. This is especially true for the older medications (chlorpromazine, thioridazine, mesoridazine, fluphenazine, trifluoperazine, perphenazine, thiothixene, molindone, loxapine, haloperidol), where side effects such as a "zombie" feeling, muscle stiffness, sedation, dry mouth, constipation, blurred vision, and many other side effects are very common. Newer medications (risperidone, olanzapine) offer the hope of being an effective treatment of hallucinations and delusions, with many fewer side effects. We are finding that patients are more willing to take the newer medications since the side effects are few, and most patients report no side effects at all on these newer medications. However, the newer medications do not work for everybody and still cause side effects in some people. Like the treatment of diabetes with insulin, the antipsychotic medications control the symptoms but do not cure the disease. Thus, there continues to be active research to find newer and better medication treatments.

Comparing Western and Eastern Medical and Psychiatric Treatment - A lecture

Please note that the information contains original and previously published data and as such is not attributed. Writer takes no responsibility for originality of the content, it is purely for the purpose of education of healthcare individuals. If you have any questions about the content or would like the information presented by a qualified psychiatric nurse practitioner and naturopathic practitioner please contact me at naturalpsych@hotmail.com

Respectfully,
Dr. Eric Malz


Lecture Outline


1. Ancient cultural beliefs
B. Current Issues
1. The changing complexion of health care
2. Barriers to acceptance of alternative therapies
C. Application of selected alternative therapies: An overview
1. Mind-Body Intervention
D. Alternative systems of medical practice
E. Pharmacologic and biologic Treatments
F. Diet and nutrition

I am also wondering if you could include about 15 minutes about:
self help groups, group therapy and family therapy. We offer them a
definition of each but you would probably be able to make it more
real for them.


INTRODUCTION:
First I want you to write down your mood – one is for being down after failing a test and 10 being in a great mood because you knew the answers to the test and didn’t get caught.


· I have my bachelors from FDU, Masters from Yale and Columbia and
· PhD and ND from Clayton College and have been A NATUROPATH.
· a trained drug and alcohol counselor
· I’ve been a hospital administrator but really wanted to be a nurse so I changed my career to match my goals – to be in a better position to help people.
· I found natural health as a perfect supplement to my education

NP WORKING WITH SUBSTANCE ABUSE:
· Being a psychiatric nurse practitioner,
· I WORK AT GOUVERNEUR HOSPITAL, par of the City’s Health and Hospital’s Corp, and
· IN NEW JERSEY I WORK AT A VOCATIONAL/REHABILITATION FACITLITY.

I WORK IN psychiatry, substance abuse treatment AND
· HELP PEOPLE COPE WITH MENTAL ILLNESS,
· I TRY TO NORMALIZE MY CLIENTS.
· HELP THEM TO FEEL THAT THEY CAN GO ON WITH THEIR LIVES,
· REDUCE THE STIGMA. I FIND THAT
· ADDING A NATURAL HEALTH COMPONENT HELPS DO THAT, IT
· GIVES MY CLIENTS SOME CONTROL OVER THEIR LIVES.
· MY patients have the desire for natural healing (very strong in Asian community).
· I have developed a means of combining all my strengths to help my patients do well.

(tell a joke - then ask)

How is your mood now!!! Has there been a change!!!!!!!!!!!!!!!!!!!!!!

The purpose of this exercise is to illustrate how moods can be changed in a variety of ways - by medication - by therapy - by just hearing a joke - there are many methods and I will discuss how in my practice I using several techniques as a doctor of naturopathy and a psychiatric nurse practitioner to creatively help clients:





Complementary and Alternative Therapies
I. Alternative Therapy Fields
Introduction:
· This lecture will describe a variety of healthcare delivery systems.
· I will discuss eastern,
· western,
· holistic and a
· variety of natural medicine techniques.



· Alternative Medicine vs Complementary Medicine:

Alternative medicine practices are used instead of standard medical treatments. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a physician.

· Alternative medicine is distinct from complementary medicine which is meant to accompany, not to replace, standard medical practices. Alternative medical practices are generally not recognized by the medical community as standard or conventional medical approaches.

A: Medicine Prior to 1800
· Prior to 1800 it was not possible to refine therapeutic agents from a plant. One had to chew its leaves, flowers or roots or drink a tea made from its components. One example is

· the White willow bark tea: has therapeutic properties. It would relieve headache, pains and fever, it was refined as salicylic acid – aspirin.

· The Chinese epedra, a bush, when ground and used in a tea would relieve asthma and respiratory symptoms.

B: Age of Heroic Medicine
About 1780 a new, more modern treatment came into vogue. In fact you can still see remnants of the treatment in barber poles, because


· Age of Heroic Medicine (1780-1850), educated professional physicians aggressively practiced "heroic medicine,"

· (GETTING RID OF BAD BLOOD) The treatments included bloodletting (venesection), intestinal purging (calomel) , vomiting (tartar emetic), profuse sweating (diaphoretics) and blistering. Physicians originally treated diseases like syphilis with salves made from mercury. These medical treatments were well-intentioned, and often well-accepted by the medical community, but were actually harmful to the patient.

· The death of George Washington, on December 14, 1799, may have partially resulted from shock from blood-letting. In fact, the place where these doctors practiced was in offices with a pole that advertised their practice. It is sill evident in most cities. The pole revolves and demonstrates blood trickling from a blood letting site. A BARBER Shop POLE.

· barber poles advertised their art, the art of blood letting this was the


II. Ancient Cultural Beliefs
A: Homeopathy : Samuel Hahnemann -
A german physician Samuel Hahnemann became frustrated after obtaining his medical training and subsequently set out to change medical care. He developed a theory that a substance that causes a symptom in a healthy person, could cure a sick person with the same malady. He called it the

· law of Similars. Since this was the only successful treatment for Choloera epidemics of the 1840’s and developed a following.

The question about homopathy, a process where a substance that causes a malady (belladona) to become worse is then diluted to the point where there is not a molecule ( the point where there is less than one molecule of the original substance present, but the belief is that by diluting it by Succussing it, the remedy becomes stronger. What western medical training suggests is that people given such treatments might heal though two effects, one the placebo effect and secondly by good nursing care. The first is the stong belief that the cure will work, which is where the mind body connection comes in. the second is with good care, cleaning the wound, proper nutrition, good sleep and care, many maladies will clear just though the body’s own defense mechanisms.


· Why isn’t Homeopathy practiced more widely today?
But due to a groundswelling by Allopathic doctors – who belived in the conventional methods, the use of homeopaths was outlawed by legitlation by the end of the 1840’s. In 1846 the American Medical Association began as a means of keeping all inappropriately trained practioners from practicing medicine. Of course there is Hahnemann Medical College in Pennsylvania.

The difference according to Andrew Weil is that western medicine relies on the properties of the medication administered and homeopathic medicine relies on the spirit of the medicine, the therapeutic power of how the medicine changed the water or alcohol it was diluted in and this causes its power.

At this time, there are Homeopathic practitioners, but most are not physicians. People are considering a return to the ideas of non conventional medicine because the invasive procedures, the increase in perception of medical illness and its expense has people re-thinking as to what is the best way to treat disease. So the re-emergence of alternative health methods.

B. Ancient Cultural Belifs

· What is health. It can be stated as the freedom from disease – and that is the western medical term for it. But the
· Anglo Saxon root for health is wholeness. So the treatment for disease is to return the body to wholeness

· Many cultures look at health and well being as that power is in circles. Everything tries to be round. Ancient Indians believed life is a circle.

· Planets and stars are circular. A plant grows from a seed, it flourishes and then dies and the residual products from his flowers and leaves come back to earth to provide nourishment for the next plant. Birds make their nests in circles.

· The seasons are circular. The Black Elk Indians are quoted in Dr. Weil’s book, HEALTH AND HEALING. When they were banished to the reservation. Lamenting the US built houses on reservations. The shaman stated that the US houses have no power, they are square. The lack of circularity introduces spiritual sickness and imperfection and a loss of wholeness.

· The circle of YIN yang of Chinese traditional medicine discusses the complimentary systems of life.

Types of Ancient Cultural Beliefs

· Acupuncture (using needles to release pain and balance the body), acupressure (the use of pressure to cause a similar effect as acupuncture).
· Give examples of using Auricular acupuncture for detox (distribute picture of Auricular acupuncture)

· I used acupuncture as part of my work as a nurse/counselor at Gracie Square Hospital – I saw the ability for using five of the over two hundred acupuncture points that are in the ear to help reduce stress.

· Ayurveda (Indian based system to use the mind and body to help one heal) belief system that your systemic type, your appearance, your habits, methods of perceiving the world and how the world perceives them results in health or lack of it. Dr. Chopra uses an example of a woman with cancer. She started seeing the doctor and ate specific foods, said specific prayers, did specific exercises, said certain phrases, basically stating that she did not have cancer and it would not control her. It was successful for a time, but she stopped believing and the cancer returned.
· herbalism (using herbs to help one heal from maladies), using fox glove - digitalis -as a treatment for heart disease. ,
· Naturopathy is a system of therapy and treatment which relies exclusively on natural remedies, such as sunlight, air, water, supplemented with diet and therapies such as massage ) I am a trained naturopath. I will discuss how I use this later. THE NATUROPATH IS THE GENERAL PRACTITIONER

· Qi Gong Qi gong: ("chee-GUNG") A component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi (an ancient term given to what is believed to be vital energy) in the body, improve blood circulation, and enhance immune function,

· Reflexology – using the foot as a guide. Stimulation of certain areas helps promote healing,

· Spiritual healing – Use of a belief system to improve well being – placebo effect

· Tai Chi, Traditional Chinese Medicine, yoga,

· Reiki – the belief that a healer can stimulate healing and improve balance by using the energy fields in the body,
· spiritual healing, Shamanism

· traditional Chinese Medicine (TCM),

· yoga.

· Spirituality (religion is medicine for the soul) – will discuss how religion is a very important part of treatment – a very important part of your practice as a nurse will be to help people use their resources. One way of coping with stress is religion, it gives comfort – it definitely has healing properties

III. Biomedical model Concepts

· There are many ancient techniques and some modern techniques that have been brought into modern day medicine, because for one reason or another, the therapy was not found to be a threat to the practice of medicine.

· Chiropractic: chiropractic medicine – using stimulation of the spine to heal stressors and relieve pain, osteopathic manipulative therapy (OMT), the difference is the osteopath has a medical license. Was permitted as a reimbursable treatment in the 1960’s, before then this was considered heretical medicine.

· massage therapy – therapeutic techniques designed to de stress the body and work through problems by relaxation,

· diet therapy – use of nutrition to heal – if one is obese you have much higher risk for heart disease, stroke and diabetes, diet therapy is very important especially since many medications cause increase in weight

· hypnosis – using subconscious suggestions to help people heal.

· massage therapy – using massage to ease stress,

· nutritional therapy - There are certain foods that are helpful. For example for menstruation pain, raspberry tea is very soothing ,

· osteopathic manipulative therapy (OMT) – belief in manipulations of the spine to cure illness,

· Aromatherapy (using smells to elicit specific healing responses (when you want to sell your house – a good real estate agent will tell you to bake a pie with cinnamon in it, why because it brings feelings of warmth and comfort. Herbs can be used to be calming and soothing

· Biofeedback - Not really. Biofeedback began to be used therapeutically after WWII to help returning veterans who needed physical therapy, and who were pleased to discover that being able to “see” their muscle activity at work helped them to establish greater control over it. Other forms of biofeedback, such as work with skin temperature, electrodermal activity, and neurofeedback, were also being studied, and neurofeedback, in particular, captured the public attention in the 60’s and early 70’s, when work with alpha brain waves, as Dr. John Basmajian puts it, “emerged prematurely from the laboratory”, and enjoyed a brief popularity before returning to the research arena for further much-needed study. Since that time, much research has been done with establishing voluntary control over the autonomic nervous system through the use of biofeedback, and it has been found to be a very effective therapeutic tool for the treatment of many stress-related disorders.,

· ECT: This method of providing electro shock to the brain helps people who have untreatable depression.

· One client of mine was in therapy, she had been an executive secretary, had a college degree. Her life had deteriorated to living in a supportive housing faciltiy. She would say that she had no energy during the day, but, for years she would do the minimum to get by. She received antidepressants and mood stabilizers. Then one day, her neighbors went to her room, because they hadn’t seen her for a few days. All she would do is look out the window, she wasn’t washing, she had no appetite, she basically was exhibiting failure to thrive. So she was hospitalized and given ECT. She was a different woman after that. She has reconnected with her sister and sees her every day – hadn’t talked with her for years. Now she is doing much better. Is electroshock therapy for every one, no but it certainly is better than the existance this woman had.

· BEHAVIORAL HEALTH IS THE ONE DISCIPLINE THAT INCORPORATES COMPLIMENTARY HEALTH

· Barriers to alternative health
Healthcare that is no paid for by insurance companies. The greatest boon to chiropractors came in the 1960’s when chiropractors became a reimbursable treatment.
Currently, accupuncturists are state licenses, but reimbursement is difficult – therefore – a tough decision to work as a accupuncturist – unless you are also a medical doctor. My patients are constantly telling me that they found this remedy and that at the health food store. I am skeptical because these “treatments” are labeled as food and so there is no control as to their therapeutic properties. If you’re on medicaid or a fixed income – this is a terrific strain. So I use the qualities of naturalism and main stream psychiatry and encourage my patients to try these methods to imrove their moods.

PART 2 Western/Modern Medicine
· The next part of this lecture will be to discuss Western, modern medicine and how I have incorporated Naturopathy into my psychiatric nurse practitioner practice.

· Just to loop back on those medications that were synthesized products from plants, some don’t always work like they were supposed to.

· Invention of syringe:

· As I mentioned, before 1800, there were no synthesized compounds. One of the first was morphine, which was compounded from the Coca plant. Alexander Wood in 1853 invented the syringe and his wife became the first morphine addict. There are many safe uses for other products made from the Coca plant, Novocain, for instance, but the problem is, when you synthesize a medication from a plant, it becomes much more potent, south American natives chew coca leaves and obtain many therapeutic effects but the morphine had only certain properties narcotic

E. Pharmacologic and biologic Treatments

Mind Body Medicine – Psychiatry is a treatment modality that is based on Mind/Body medicine:

· An example of mind/body medicine:

· Example of Equlibrium and Health:
· Health as wholeness – holeness as balance. Our bodies prefer to be in a state of balance, however it is a dynamic balance.
· NO one is perfectly healthy. I see this everyday in my practice.


· Stress has direct relationship with somatic illness – people complain of acid indigestion and headaches and the origins can be directly related to stress, it is also a precurser of depression.

· Typically my patient will come in and say,
· “Hey doc, I feel terrible, I don’t have any energy”.

· So being a psychiatric nurse practitioner, one would start thinking, well sadness, well depression, well maybe suicidality”.

· But because I understand that life has to be in balance, I start to ask questions. When did you get to sleep last night – Oh, I only slept 2 hours.
· OK, how what did you have for breakfast, “Well I had a cup of coffee”.
· So what have we learned from two questions.
· We always have to look at people as a whole.(that’s what nurses do look at things holistically)


· You know, I didn’t sleep well either, you’re not that special”

· Maybe it’s nutritional. Maybe you need to see a nutritionist to look at what you’re eating – are you a McDonald;s junkie. Are you getting enough exercise. The wonderful thing about exercise are those endorphines. When you get the runners high, you really do feel better.


Types of therapy

There’s individual , group, milieu

Individual: Make them cry –the answer isn’t immediate
· Working as a visiting nurse, my patients would tell me, “Oy my back hurts, and I have such pain when I walk and my eyes aren’t so good” They’re 80 years old, I ask them, if they were 50 and it was a work day what would you do. “of course, I would get up and go to work” I am constantly telling people to dirvert their attention from their problems.

Family Therapy- the identified patient
Suppports, triggers,

Group: Group sessions help each other
· Assistant group leader; patient in my group believed he was my co leader in my group. He said he was recovering from heroin addiction and his mother went off, left him, to go off with a young stud in Mexico. Subsequently was seen in my detox months later. He picked up heroin but was smiling. He had bladder cancer. Why was that good news, he’s back on heroin and now he has cancer. Well his mom returned to take care of him. What came first the need for his mom’s nurturing or the cancer. I cannot say.;-

· Group – lady angry – in opd detox group. stating she had met a woman who remembered that she heard the young girl scream from the closet each day. Patient states she took out her anger by breaking glass on the floor. Its ok he has shooes.

Melieu: using the setting; give example

· Delusions:
I was doing a C and L for a Spanish speaking male. I had the head nurse interpreting for me. This fellow used to work in a cemetery, now he’s in a nursing home and I’m evaluating him for depression. He says, “Hey, don’t I know you”. I said I didn’t think so. He continued, “Didn’t I raise you from the dead”.

· Hallucinations:
There is a 85 year old Spanish speaking woman in the nursing home. I am seeing her because she is agitated. When I meet her, I ask her what is wrong. First I have to tell you that this nursing facility is well run with no health violations. Well, the lady says, I am tired of the rats biting me at night – I wouldn’t give this a second thought since she has a prior diagnosis of schizophrenia but she is pointing to areas on both wrists with marks on her – self inflicted – but it got me going.


· So lets get to how I use natural health methods: As a psychiatric nurse practitioner with a doctorate in Naturopathy, I tell my clients that there is nothing more natural or holistic than using words to change mood.

· (we started out this lecture by changing your mood with a joke)

· There is evidence that stress directly leads to heard disease. So if we can reduce stress by therapy, by the use of adjunctive medication, then we can reduce morbidity.


· Dwelling on your negativity only causes the stresses to increase

· I work in day treatment program for mr/mental patients. The ability to go to program on a daily basis and accomplish something is very powerful.

· Drug addiction: One aspect of psychaitry is dealing with drug addiction. Why, people self medicate.

· If you have a headache you have choices, aspirin, motrin, naproxyn, tylenol.

· You don’t call a doctor and ask for advice. Well this is a method some people use for mood regulation.

· You’ve all heard of the person going to the party, “oh have a drink and loosen up”

· This is using alcohol’s disinhibiting property.

· People use cocaine to elevate mood,

· they use heroin to aleviate psychotic symptoms.

· People use marijuana to escape. That’s the key word.


· Using all these and other substances results in an escape from reality. You don’t worry, you’ve escaped your stresses.

· The problem with this is – in order to have the same relief, the same escape it takes more and more and if you don’t take the substance you feel much worse – withdrawl.

· Detoxes were set up because stopping drinking.

· Using drugs like cocaine increases dopamine – the bodys reward system – excited euphoria. Dopamine has many other functions as well.

· Estasty on the other hand, reduces the dopaimen. Parkinsonism is the lack of dopamine. Endorphins is the opiod effect. It occurs naturally in the body, can be induced by the mind or runner’s high. Opiates induce this same effect artificially.

· I once gave a lecture about drug addiction to a group of nurses, trying to give them a clue as to why their patient’s were using drugs. We talked about the self medication theory. We can actually discuss this a bit now. When I got to the part where I talked about cocaine use – they tell me – is like having a climax during sex- several hands raised and the staffmember wanted to know where they could get some. It would be ok except for the fact that it’s illegal, unhealthy, and potentially dangerous.

· Why people want to stop using?:

· expense, losses, controls their lives.

· Methodone is a substitute but patient’s need daily fix.

Some definitions – types of clients that I see; LET ME SAY FIRST, THAT MOST OF MY CLIENTS REALLY WANT HELP AND DO VERY WELL ON MEDICATIIONS – THESE ARE THE EXCEPTIONS


· MANIPULATION:
o Person who wanted detox and to call his wife –
manipulation.Dual Diagnosis Substance abuse and psychiatric illness treatment neede:

· I had a guy come in for an intake for psychiatric serverices: Stated he had just gotten out of NYU medical center due to taking an OD, taking a bottle of lamictal with vodka. He said he was missing the lamictal but continued his lexapro which he still had. He has been coping by buying a small amount of vodka to keep him steady. Turns out he was drinking a half pint a day, but he said he had not relapsed because he has his AA book and reads it every day. De nial is not a river in egypt –its what this guy had.

· Grandiose and in denial:
I was working as a nurse in a detox doing intakes. Patient asked to use the phone. “Hi honey, yeah I’m in the detox, I’ll be here five days, time to get cleaned out, clean up my act. Give my love to the kids. OK now can I call my wife”

· Impaired coping mechanisms:
This is a young Asian, single male who was smuggled over from China. He is constantly having problems, but appears to be a good problem solver! He earns money by going back and forth to the NJ Casinos via bus. The company provides $7 as an incentive for clients to go gambling in Atlantic City, but our entrepreneur decided this is a good job, “money for nothing!” But our valiant fellow is generous as well. He always gives the driver $1 tip as an incentive for doing a good job.

· Also impaired coping mechanisms:
This is a young Asian, single male who has been in the hospital many times since being smuggled from China. He comes to see me and my associate for symptoms that include a belief that he is a space alien and he believes his fellow aliens have given him a space ship to rent out. That’s how he makes a living. This fellows main problem, at this time is, he isn’t quite sure how to run the space ship. He says, “The instructions aren’t in Chinese” My associate and I decided that there must be another way because in Star Trek the characters can go into any random space ship and fly off. Our answer is, “The Universal Translator”





· The importance of medication education:
This person comes to a day program, probably mentally diminished. She qualifies for the following reason:
She came over to a counselor friend of mine. She said, “I’m confused. I looked at the package insert for the psychiatric medication I’m taking and it says, “THIS MEDICINE REDUCES SEX DRIVE”. I was wondering, how does this effect me, I don’t drive???

PART 3 SELF HELP, FAMILY AND GROUP THERAPY




· Self help groups:
There are many examples. Weight watchers, AA, NA, CA, MA. The theory is the same. If you’re trying to quit anything, having a group is important to support you on your attempt. AA is the original self help group. Before AA, alcholism was considered a lack of will power and moral weakness, through AA people who were alcoholics went to sanitoriums or the salvation army. Bill Wilson and Dr. Bob.came up with a way that people could teach each other the methods to stop drinking and support each other during the process.


· Family therapy – many times I will see someone and they are in doing well, but their family members don’t change their perception of the person and keep pushing the same buttons. I have treated drug abusers that leave rehab after learning how to be clean and sober and they return months later. The reason is, the family members don’t know how to react to their ‘changed’ relative or friend. It’s uncomfortable when your husband is usually drunk and you make the family decisions. All of a sudden, the rules have changed, now he’s asserting himself, you’ve got to change and change is uncomfortable so unconsciously the patient is encouraged to return to the old habits so the equilibrium of the family doesn’t change. Therapy is very important because one person is in therapy and changes – you need the support of his primary group to reinforce these changes.


· Group therapy- I do a medication management group. The best part of a group is that patients can talk about how they feel and it’s the group leader’s job to get the reaction of peers. If I lecture about a topic it’s not group. If a topic is brought up and a peer reacts to it – there’s more power. Patient’s typically say that they are thinking of something and a peer talked about it. Medication group. Talking about how a peer lost her mother. The patient had attempted suicide a couple of days later. One patient stated, we shouldn’ t let people come to the program when that happens because it made me feel bad. Well it brought back her issues of loss with her parents and depression. Other paients made statements about their loss. The result was I was able to process their feelings and offered that the purpose of the program is to offer client’s support with their own issues and offer a safe place to come when they’re feeling hopeless.




Hypnosis explanation: Psychiatrists theorize that the deep relaxation and focusing exercises of hypnotism work to calm and subdue the conscious mind so that it takes a less active role in your thinking process. In this state, you're still aware of what's going on, but your conscious mind takes a backseat to your subconscious mind. Effectively, this allows you and the hypnotist to work directly with the subconscious. It's as if the hypnotism process pops open a control panel inside your brain.
It provides an especially convincing explanation for the playfulness and uninhibitedness of hypnotic subjects. The conscious mind is the main inhibitive component in your makeup -- it's in charge of putting on the brakes -- while the subconscious mind is the seat of imagination and impulse. When your subconscious mind is in control, you feel much freer and may be more creative. Your conscious mind doesn't have to filter through everything.
Hypnotized people do such bizarre things so willingly, this theory holds, because the conscious mind is not filtering and relaying the information they take in. It seems like the hypnotist's suggestions are coming directly from the subconscious, rather than from another person. You react automatically to these impulses and suggestions, just as you would to your own thoughts. Of course, your subconscious mind does have a conscience, a survival instinct and its own ideas, so there are a lot of things it won't agree to.
The subconscious regulates your bodily sensations, such as taste, touch and sight, as well as your emotional feelings. When the access door is open, and the hypnotist can speak to your subconscious directly, he or she can trigger all these feelings, so you experience the taste of a chocolate milkshake, the satisfaction of contentment and any number of other feelings.
Additionally, the subconscious is the storehouse for all your memories. While under hypnosis, subjects may be able to access past events that they have completely forgotten. Psychiatrists may use hypnotism to bring up these memories so that a related personal problem can finally be resolved. Since the subject's mind is in such a suggestible state, it is also possible to create false memories. For this reason, psychiatrists must be extremely careful when exploring a hypnotic subject's past.



American Holistic Nurses Association (AHNA)
The American Holistic Nurses Association (AHNA) embraces nursing as a lifestyle and a profession and provides a means to create bonds within the nursing community. Because true healing comes from within, the AHNA recognizes that nurses must first heal themselves before they can facilitate the healing of others. There are many roads to healing, and individuals must seek their own paths. The AHNA serves as a bridge between the traditional medical paradigm and universal complementary and alternative healing practices.
The AHNA was founded in 1981 as a 501(c)(3) non-profit educational organization. Its membership is open to nurses and other individuals interested in holistically-oriented health care practices throughout the United States and the world. AHNA supports the education of nurses, allied health practitioners, and the general public on health-related issues.
AHNA supports the concepts of holism: a state of harmony among body, mind, emotions and spirit within an ever-changing environment. The vision of the American Holistic Nurses Association is to be the definitive voice for holistic nursing. It is the mission of the American Holistic Nurses Association to unite nurses in healing.
The AHNA philosophy embraces the beliefs that:
1. Nursing is both an art and a science with the primary purpose to nurture others towards the wholeness inherent within them.
2. Nurses have a unique opportunity to provide services that facilitate wholeness.
3. Holistic Nurses demonstrate expertise in a variety of roles and activities.
4. Holistic nursing assists people to assume personal responsibility for self-care.
5. Clients, families, and communities have the right to health care that honors the body, mind, and spirit.
6. Disease and distress are viewed as an opportunity for increased awareness of the interconnectedness of body, mind, and spirit.
7. Holistic modalities and therapies provide support and options in healing.
8. The American Holistic Nurses' Association serves as a foundation and dynamic force for nursing practice. We are committed to unity and healing self, the nursing profession, and the planet.

Benzodiazepine Abuse - lecture - not original material

Benzodiazepine Abuse:
Please note that the information contains original and previously published data and as such is not attributed. Writer takes no responsibility for originality of the content, it is purely for the purpose of education of healthcare individuals. If you have any questions about the content or would like the information presented by a qualified psychiatric nurse practitioner and naturopathic practitioner please contact me at naturalpsych@hotmail.com


Respectfully,
Dr. Eric Malz

The way in which GABA sends its inhibitory message is by a clever electronic device. Its reaction with special sites (GABA-receptors) on the outside of the receiving neuron opens a channel, allowing negatively charged particles (chloride ions) to pass to the inside of the neuron. These negative ions "supercharge" the neuron making it less responsive to other neurotransmitters which would normally excite it. Benzodiazepines also react at their own special sites (benzodiazepine receptors), situated actually on the GABA-receptor. Combination of a benzodiazepine at this site acts as a booster to the actions of GABA, allowing more chloride ions to enter the neuron, making it even more resistant to excitation. Various subtypes of benzodiazepine receptors have slightly different actions. One subtype (alpha 1) is responsible for sedative effects, another (alpha 2) for anti-anxiety effects, and both alpha 1 and alpha 2, as well as alpha 5, for anticonvulsant effects. All benzodiazepines combine, to a greater or lesser extent, with all these subtypes and all enhance GABA activity in the brain.
As a consequence of the enhancement of GABA's inhibitory activity caused by benzodiazepines, the brain's output of excitatory neurotransmitters, including norepinephrine (noradrenaline), serotonin, acetyl choline and dopamine, is reduced. Such excitatory neurotransmitters are necessary for normal alertness, memory, muscle tone and co-ordination, emotional responses, endocrine gland secretions, heart rate and blood pressure control and a host of other functions, all of which may be impaired by benzodiazepines. Other benzodiazepine receptors, not linked to GABA, are present in the kidney, colon, blood cells and adrenal cortex and these may also be affected by some benzodiazepines. These direct and indirect actions are responsible for the well-known adverse effects of dosage with benzodiazepines.
ADVERSE EFFECTS OF BENZODIAZEPINES
Oversedation. Oversedation is a dose-related extension of the sedative/hypnotic effects of benzodiazepines. Symptoms include drowsiness, poor concentration, incoordination, muscle weakness, dizziness and mental confusion. When benzodiazepines are taken at night as sleeping pills, sedation may persist the next day as "hangover" effects, particularly with slowly eliminated preparations (Table 1). However, tolerance to the sedative effects usually develops over a week or two and anxious patients taking benzodiazepines during the day rarely complain of sleepiness although fine judgement and some memory functions may still be impaired.
Oversedation persists longer and is more marked in the elderly and may contribute to falls and fractures. Acute confusional states have occurred in the elderly even after small doses of benzodiazepines. Oversedation from benzodiazepines contributes to accidents at home and at work and studies from many countries have shown a significant association between the use of benzodiazepines and the risk of serious traffic accidents. People taking benzodiazepines should be warned of the risks of driving and of operating machinery.
Drug interactions. Benzodiazepines have additive effects with other drugs with sedative actions including other hypnotics, some antidepressants (e.g. amitriptyline [Elavil], doxepin [Adapin, Sinequan]), major tranquillisers or neuroleptics (e.g. prochlorperazine [Compazine], trifluoperazine [Stelazine]), anticonvulsants (e.g. phenobarbital, phenytoin [Dilantin], carbamazepine [Atretol, Tegretol]), sedative antihistamines (e.g. diphenhydramine [Benadryl], promethazine [Phenergan]), opiates (heroin, morphine, meperidine), and, importantly, alcohol. Patients taking benzodiazepines should be warned of these interactions. If sedative drugs are taken in overdose, benzodiazepines may add to the risk of fatality.
Memory impairment. Benzodiazepines have long been known to cause amnesia, an effect which is utilised when the drugs are used as premedication before major surgery or for minor surgical procedures. Loss of memory for unpleasant events is a welcome effect in these circumstances. For this purpose, fairly large single doses are employed and a short-acting benzodiazepine (e.g. midazolam) may be given intravenously.
Oral doses of benzodiazepines in the dosage range used for insomnia or anxiety can also cause memory impairment. Acquisition of new information is deficient, partly because of lack of concentration and attention. In addition, the drugs cause a specific deficit in "episodic" memory, the remembering of recent events, the circumstances in which they occurred, and their sequence in time. By contrast, other memory functions (memory for words, ability to remember a telephone number for a few seconds, and recall of long-term memories) are not impaired. Impairment of episodic memory may occasionally lead to memory lapses or "blackouts". It is claimed that in some instances such memory lapses may be responsible for uncharacteristic behaviours such as shop-lifting.
Benzodiazepines are often prescribed for acute stress-related reactions. At the time they may afford relief from the distress of catastrophic disasters, but if used for more than a few days they may prevent the normal psychological adjustment to such trauma. In the case of loss or bereavement they may inhibit the grieving process which may remain unresolved for many years. In other anxiety states, including panic disorder and agoraphobia, benzodiazepines may inhibit the learning of alternative stress-coping strategies, including cognitive behavioural treatment.
Paradoxical stimulant effects. Benzodiazepines occasionally cause paradoxical excitement with increased anxiety, insomnia, nightmares, hallucinations at the onset of sleep, irritability, hyperactive or aggressive behaviour, and exacerbation of seizures in epileptics. Attacks of rage and violent behaviour, including assault (and even homicide), have been reported, particularly after intravenous administration but also after oral administration. Less dramatic increases in irritability and argumentativeness are much more common and are frequently remarked upon by patients or by their families. Such reactions are similar to those sometimes provoked by alcohol. They are most frequent in anxious and aggressive individuals, children, and the elderly. They may be due to release or inhibition of behavioural tendencies normally suppressed by social restraints. Cases of "baby-battering", wife-beating and "grandma-bashing" have been attributed to benzodiazepines.
Depression, emotional blunting. Long-term benzodiazepine users, like alcoholics and barbiturate-dependent patients, are often depressed, and the depression may first appear during prolonged benzodiazepine use. Benzodiazepines may both cause and aggravate depression, possibly by reducing the brain's output of neurotransmitters such as serotonin and norepinephrine (noradrenaline). However, anxiety and depression often co-exist and benzodiazepines are frequently prescribed for mixed anxiety and depression. Sometimes the drugs seem to precipitate suicidal tendencies in such patients. Of the first 50 of the patients attending my withdrawal clinic (reported in 1987), ten had taken drug overdoses requiring hospital admission while on chronic benzodiazepine medication; only two of these had a history of depressive illness before they were prescribed benzodiazepines. The depression lifted in these patients after benzodiazepine withdrawal and none took further overdoses during the 10 months to 3.5 years follow-up period after withdrawal. In 1988 the Committee on Safety of Medicines in the UK recommended that "benzodiazepines should not be used alone to treat depression or anxiety associated with depression. Suicide may be precipitated in such patients".
"Emotional anaesthesia", the inability to feel pleasure or pain, is a common complaint of long-term benzodiazepine users. Such emotional blunting is probably related to the inhibitory effect of benzodiazepines on activity in emotional centres in the brain. Former long-term benzodiazepine users often bitterly regret their lack of emotional responses to family members - children and spouses or partners - during the period when they were taking the drugs. Chronic benzodiazepine use can be a cause of domestic disharmony and even marriage break-up.
Adverse effects in the elderly. Older people are more sensitive than younger people to the central nervous system depressant effects of benzodiazepines. Benzodiazepines can cause confusion, night wandering, amnesia, ataxia (loss of balance), hangover effects and "pseudodementia" (sometimes wrongly attributed to Alzheimer’s disease) in the elderly and should be avoided wherever possible. Increased sensitivity to benzodiazepines in older people is partly because they metabolise drugs less efficiently than younger people, so that drug effects last longer and drug accumulation readily occurs with regular use. However, even at the same blood concentration, the depressant effects of benzodiazepines are greater in the elderly, possibly because they have fewer brain cells and less reserve brain capacity than younger people.
For these reasons, it is generally advised that, if benzodiazepines are used in the elderly, dosage should be half that recommended for adults, and use (as for adults) should be short-term (2 weeks) only. In addition, benzodiazepines without active metabolites (e.g. oxazepam [Serax], temazepam [Restoril]) are tolerated better than those with slowly eliminated metabolites (e.g. chlordiazepoxide [Librium], nitrazepam [Mogadon]). Equivalent potencies of different benzodiazepines are approximately the same in older as in younger people (Table 1).
Adverse effects in pregnancy. Benzodiazepines cross the placenta, and if taken regularly by the mother in late pregnancy, even in therapeutic doses, can cause neonatal complications. The foetus and neonate metabolise benzodiazepines very slowly, and appreciable concentrations may persist in the infant up to two weeks after birth, resulting in the "floppy infant syndrome" of lax muscles, oversedation, and failure to suckle. Withdrawal symptoms may develop after about two weeks with hyperexcitability, high-pitched crying and feeding difficulties.
Benzodiazepines in therapeutic doses appear to carry little risk of causing major congenital malformations. However, chronic maternal use may impair foetal intrauterine growth and retard brain development. There is increasing concern that such children in later life may be prone to attention deficit disorder, hyperactivity, learning difficulties, and a spectrum of autistic disorders.
Tolerance. Tolerance to many of the effects of benzodiazepines develops with regular use: the original dose of the drug has progressively less effect and a higher dose is required to obtain the original effect. This has often led doctors to increase the dosage in their prescriptions or to add another benzodiazepine so that some patients have ended up taking two benzodiazepines at once.
However, tolerance to the various actions of benzodiazepines develops at variable rates and to different degrees. Tolerance to the hypnotic effects develops rapidly and sleep recordings have shown that sleep patterns, including deep sleep (slow wave sleep) and dreaming (which are initially suppressed by benzodiazepines), return to pre-treatment levels after a few weeks of regular benzodiazepine use. Similarly, daytime users of the drugs for anxiety no longer feel sleepy after a few days.
Tolerance to the anxiolytic effects develops more slowly but there is little evidence that benzodiazepines retain their effectiveness after a few months. In fact long-term benzodiazepine use may even aggravate anxiety disorders. Many patients find that anxiety symptoms gradually increase over the years despite continuous benzodiazepine use, and panic attacks and agoraphobia may appear for the first time after years of chronic use. Such worsening of symptoms during long-term benzodiazepine use is probably due to the development of tolerance to the anxiolytic effects, so that "withdrawal" symptoms emerge even in the continued presence of the drugs. However, tolerance may not be complete and chronic users sometimes report continued efficacy, which may be partly due to suppression of withdrawal effects. Nevertheless, in most cases such symptoms gradually disappear after successful tapering and withdrawal of benzodiazepines. Among the first 50 patients attending my clinic, 10 patients became agoraphobic for the first time while taking benzodiazepines. Agoraphobic symptoms abated dramatically within a year of withdrawal, even in patients who had been housebound, and none were incapacitated by agoraphobia at the time of follow-up (10 months to 3.5 years after withdrawal).
Tolerance to the anticonvulsant effects of benzodiazepines makes them generally unsuitable for long-term control of epilepsy. Tolerance to the motor effects of benzodiazepines can develop to a remarkable degree so that people on very large doses may be able to ride a bicycle and play ball games. However, complete tolerance to the effects on memory and cognition does not seem to occur. Many studies show that these functions remain impaired in chronic users, recovering slowly, though sometimes incompletely, after withdrawal.
Tolerance is a phenomenon that develops with many chronically used drugs (including alcohol, heroin and morphine and cannabis). The body responds to the continued presence of the drug with a series of adjustments that tend to overcome the drug effects. In the case of benzodiazepines, compensatory changes occur in the GABA and benzodiazepine receptors which become less responsive, so that the inhibitory actions of GABA and benzodiazepines are decreased. At the same time there are changes in the secondary systems controlled by GABA so that the activity of excitatory neurotransmitters tends to be restored. Tolerance to different effects of benzodiazepines may vary between individuals - probably as a result of differences in intrinsic neurological and chemical make-up which are reflected in personality characteristics and susceptibility to stress. The development of tolerance is one of the reasons people become dependent on benzodiazepines, and also sets the scene for the withdrawal syndrome, described in the next chapter.
Dependence. Benzodiazepines are potentially addictive drugs: psychological and physical dependence can develop within a few weeks or months of regular or repeated use. There are several overlapping types of benzodiazepine dependence.
Therapeutic dose dependence. People who have become dependent on therapeutic doses of benzodiazepines usually have several of the following characteristics.
1. They have taken benzodiazepines in prescribed "therapeutic" (usually low) doses for months or years.
2. They have gradually become to "need" benzodiazepines to carry out normal, day-to-day activities.
3. They have continued to take benzodiazepines although the original indication for prescription has disappeared.
4. They have difficulty in stopping the drug, or reducing dosage, because of withdrawal symptoms.
5. If on short-acting benzodiazepines (Table 1) they develop anxiety symptoms between doses, or get craving for the next dose.
6. They contact their doctor regularly to obtain repeat prescriptions.
7. They become anxious if the next prescription is not readily available; they may carry their tablets around with them and may take an extra dose before an anticipated stressful event or a night in a strange bed.
8. They may have increased the dosage since the original prescription.
9. They may have anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical symptoms despite continuing to take benzodiazepines.
The number of people world-wide who are taking prescribed benzodiazepines is enormous. For example, in the US nearly 11 per cent of a large population surveyed in 1990 reported some benzodiazepine use the previous year. About 2 per cent of the adult population of the US (around 4 million people) appear to have used prescribed benzodiazepine hypnotics or tranquillisers regularly for 5 to 10 years or more. Similar figures apply in the UK, over most of Europe and in some Asian countries. A high proportion of these long-term users must be, at least to some degree, dependent. Exactly how many are dependent is not clear; it depends to some extent on how dependence is defined. However, many studies have shown that 50-100 per cent of long-term users have difficulty in stopping benzodiazepines because of withdrawal symptoms, which are described in Chapter III.
Prescribed high dose dependence. A minority of patients who start on prescribed benzodiazepines begin to "require" larger and larger doses. At first they may persuade their doctors to escalate the size of prescriptions, but on reaching the prescriber's limits, may contact several doctors or hospital departments to obtain further supplies which they self-prescribe. Sometimes this group combines benzodiazepine misuse with excessive alcohol consumption. Patients in this group tend to be highly anxious, depressed and may have personality difficulties. They may have a history of other sedative or alcohol misuse. They do not typically use illicit drugs but may obtain "street" benzodiazepines if other sources fail.
Recreational benzodiazepine abuse. Recreational use of benzodiazepines is a growing problem. A large proportion (30-90 per cent) of polydrug abusers world-wide also use benzodiazepines. Benzodiazepines are used in this context to increase the "kick" obtained from illicit drugs, particularly opiates, and to alleviate the withdrawal symptoms of other drugs of abuse (opiates, barbiturates, cocaine, amphetamines and alcohol). People who have been given benzodiazepines during alcohol detoxification sometimes become dependent on benzodiazepines and may abuse illicitly obtained benzodiazepines as well as relapsing into alcohol use. Occasionally high doses of benzodiazepines are used alone to obtain a "high".
Recreational use of diazepam, alprazolam, lorazepam, temazepam, triazolam, flunitrazepam and others has been reported in various countries. Usually the drugs are taken orally, often in doses much greater than those used therapeutically (e.g.100mg diazepam or equivalent daily) but some users inject benzodiazepines intravenously. These high dose users develop a high degree of tolerance to benzodiazepines and, although they may use the drugs intermittently, some become dependent. Detoxification of these patients may present difficulties since withdrawal reactions can be severe and include convulsions.
The present population of recreational users may be relatively small, perhaps one tenth of that of long-term prescribed therapeutic dose users, but probably amounts to some hundreds of thousands in the US and Western Europe, and appears to be increasing. It is a chastening thought that medical overprescription of benzodiazepines, resulting in their presence in many households, made them easily available and undoubtedly aided their entry into the illicit drug scene. Present sources for illicit users are forged prescriptions, theft from drug stores, or illegal imports.
Socioeconomic costs of long-term benzodiazepine use. The socio-economic costs of the present high level of long-term benzodiazepine use are considerable, although difficult to quantify. Most of these have been mentioned above and are summarised in Table 3. These consequences could be minimised if prescriptions for long-term benzodiazepines were decreased. Yet many doctors continue to prescribe benzodiazepines and patients wishing to withdraw receive little advice or support on how to go about it. The following chapter gives practical information on withdrawal which, it is hoped, will be of use both to long-term benzodiazepine users and to their physicians.
TABLE 3. SOME SOCIOECONOMIC COSTS OF LONG-TERM BENZODIAZEPINE USE
1. Increased risk of accidents - traffic, home, work.
2. Increased risk of fatality from overdose if combined with other drugs.
3. Increased risk of attempted suicide, especially in depression.
4. Increased risk of aggressive behaviour and assault.
5. Increased risk of shoplifting and other antisocial acts.
6. Contributions to marital/domestic disharmony and breakdown due to emotional and cognitive impairment.
7. Contributions to job loss, unemployment, loss of work through illness.
8. Cost of hospital investigations/consultations/admissions.
9. Adverse effects in pregnancy and in the new-born.
10. Dependence and abuse potential (therapeutic and recreational).
11. Costs of drug prescriptions.
12. Costs of litigation.

Bipolar Disorder Lecture - not original material

Benzodiazepine Abuse:
Please note that the information contains original and previously published data and as such is not attributed. Writer takes no responsibility for originality of the content, it is purely for the purpose of education of healthcare individuals. If you have any questions about the content or would like the information presented by a qualified psychiatric nurse practitioner and naturopathic practitioner please contact me at naturalpsych@hotmail.com


Respectfully,
Dr. Eric Malz



Bipolar Disorder:
What Is Bipolar Disorder?
Bipolar disorder used to be known as manic depression. It's a serious illness, one that can lead to risky behavior, damaged relationships and careers, even suicidal tendencies -- if it's not treated.
Bipolar disorder is characterized by extreme changes in mood (poles) -- from mania to depression. Between these mood swings, a person with Bipolar disorder may experience normal moods.
"Manic" describes an increasingly restless, energetic, talkative, reckless, powerful, euphoric period. Lavish spending sprees or impulsive risky sex can be irresistible. Then, at some point, this high-flying mood can spiral into something darker -- irritation, confusion, anger, feeling trapped.
"Depression" describes the opposite mood -- sadness, crying, sense of worthlessness, loss of energy, loss of pleasure, sleep problems.
But because the pattern of highs and lows varies for each person, bipolar disorder is a complex disease to diagnose. For some people, mania or depression can last for weeks or months, even for years. For other people, bipolar disorder takes the form of frequent and dramatic mood shifts.
"There's a whole spectrum of symptoms and mood changes that have been found in bipolar disorder," says Michael Aronson, MD, a clinical psychiatrist and consultant for WebMD. "It's not always dramatic mood swings. In fact, some people seem to get along just fine. The manic periods can be very, very productive. They think things are going great."
The danger comes, he says, when the mania grows much worse. "The change can be very dramatic, with catastrophic results. People can get involved in reckless behavior, spend a lot of money, there may be sexual promiscuity, sexual risks."
The depressed phases can be equally dangerous: A person may have frequent thoughts of suicide.
If you or someone you know has thoughts of death or suicide, contact a health-care professional, loved one, friend, or call 911 immediately.
Bipolar disorder is equally difficult for families of those affected. The condition is the most difficult mental illness for families to accept, Aronson tells WebMD. "Families can more easily accept schizophrenia, to understand that it is an illness. But when a person is sometimes very productive, then becomes unreasonable or irrational, it wreaks more havoc on the family. It seems more like bad behavior, like they won't straighten up."
If this rings true -- either for you or a loved one -- the first step in tackling the problem is to see a psychiatrist. Whether it's bipolar disorder or another mood-related problem, effective treatments are available. What's most important is that you recognize the problem, and start looking for help.


Bipolar Disorder:
What Causes Bipolar Disorder?
Doctors don't completely understand the causes of bipolar disorder. But they've gained greater understanding in the past 10 years.
Bipolar disorder often runs in families, and researchers believe there is a genetic component. There is also growing evidence that environment and lifestyle have an affect on the disorder's severity. Stressful life events -- or alcohol or drug abuse -- can make bipolar disorder more difficult to treat.
Experts believe bipolar disorder is caused by an underlying problem with the balance of brain chemicals. When the levels are too high, mania occurs; when the levels are low, there is depression.
Bipolar Disorder:
Hypomania and Mania Symptoms
The dramatic mood swings of bipolar disorder do not follow a set pattern. Depression does not always follow mania. A person may experience the same mood state several times -- for weeks, months, even years at a time -- before suddenly having the opposite mood. Also, the severity of mood phases can differ from person to person.
Hypomania is a less severe form of mania. Hypomania is a mood that many don't perceive as a problem. It actually may feel pretty good. You have a greater sense of well-being and productivity. However, for someone with bipolar disorder, hypomania can evolve into mania -- or can switch into serious depression.
The experience of these manic stages has been described this way:
Hypomania: At first when I'm high, it's tremendous ... ideas are fast ... like shooting stars you follow until brighter ones appear... . All shyness disappears, the right words and gestures are suddenly there ... uninteresting people, things become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria ... you can do anything ... but somewhere this changes.
Mania: The fast ideas start coming too fast and there are far too many ... overwhelming confusion replaces clarity ... you stop keeping up with it … memory goes. Infectious humor ceases to amuse. Your friends become frightened ... everything is now against the grain ... you are irritable, angry, frightened, uncontrollable, and trapped.
If you have three or more of the mania symptoms below most of the day -- nearly every day -- for one week or longer, you may be having a manic episode:
· Excessive happiness, hopefulness, and excitement
· Sudden changes from being joyful to being irritable, angry, and hostile
· Restlessness, increased energy and less need for sleep
· Rapid talk, talkativeness
· Distractibility
· Racing thoughts
· High sex drive
· Tendency to make grand and unattainable plans
· Tendency to show poor judgment, such as deciding to quit a job
· Inflated self-esteem or grandiosity -- unrealistic beliefs in one's ability, intelligence, and powers; may be delusional
· Increased reckless behaviors (such as lavish spending sprees, impulsive sexual indiscretions, abuse of alcohol or drugs or ill-advised business decisions)
Some people with bipolar disorder become psychotic, hearing things that aren't there. They may hold onto false beliefs, and cannot be swayed from them. In some instances, they see themselves as having superhuman skills and powers -- even consider themselves to be god-like.
Bipolar Disorder:
Depression Symptoms
The dramatic mood swings of bipolar disorder do not follow a set pattern. Depression does not always follow mania. A person may experience the same mood state several times -- for weeks, months, even years at a time -- before suddenly having the opposite mood. Also, the severity of mood phases can differ from person to person.
The depressive periods can be equally intense. Sadness and anxiety affect every aspect of life -- thoughts, feelings, sleeping, eating, physical health, relationships, ability to function at work. If depression is not treated, it only grows worse. There may seem to be no way out of this overwhelming mood.
These depressive feelings have been described this way:
Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless... . [I am] haunt[ed] ... with the total, the desperate hopelessness of it all. Others say, "It's only temporary, it will pass, you will get over it," but, of course, they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think, or care, then what on earth is the point?
A depressive episode involves five or more of these symptoms most of the day -- nearly every day -- for two weeks or longer:
Symptoms of depression:
· Sad, anxious, irritability
· Loss of energy
· Feelings of guilt, hopelessness, or worthlessness
· Loss of interest or enjoyment from things that were once pleasurable
· Difficulty concentrating
· Uncontrollable crying
· Difficulty making decisions
· Irritability
· Increased need for sleep
· Insomnia
· Change in appetite causing weight loss or gain
· Thoughts of death or suicide
· Attempting suicide
When a person with psychosis is in a depressive stage, there may be delusions of guilt or worthlessness -- perhaps there is an inaccurate belief of being ruined and penniless, or having committed a terrible crime.
If untreated, depressive episodes tend to come closer together and are harder to treat. They may switch into mania. But treatment can prevent this from happening. With medication and therapy, its possible to live normally -- to have a happy, productive life.
Bipolar Disorder:
What Are the Treatments for Bipolar Disorder?
The most effective treatment for bipolar disorder is a combination of medication and psychotherapy. Most people take more than one medication, like a mood-stabilizing drug and an antidepressant. However, it's important that treatment be ongoing -- even after you feel better -- to keep mood swings under control.
One note of caution: The FDA has determined that antidepressant medications can increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders. If you have questions or concerns, discuss them with your health-care provider.
After remission from an acute episode of bipolar disorder, a person is at high risk for relapse for about six months. Thus, maintenance (ongoing) therapy is often recommended.
Anyone who has experienced two to three episodes of bipolar disorder is considered a long-term -- if not lifetime -- bipolar patient. That person should have maintenance therapy. Once your doctor has helped stabilize the moods of the acute phase of the disorder (either a manic or depressive episode), drug therapy is continued indefinitely -- often at lower doses.
Remember this: Even if you have been without bipolar symptoms for several months, do not stop taking your medications. Your doctor may lower your doses, but discontinuation of medications will put you at risk for recurrence of bipolar symptoms.
Bipolar Disorder:
Diagnosis of Bipolar Disorder
Diagnosis is made only by taking careful note of symptoms, including their severity, length, and frequency. The most telling symptoms include severe mood swings (going from extreme highs to extreme lows) that don't follow a set pattern.
The psychiatrist will ask questions about personal and family history of mental illness. The doctor will also ask detailed questions about symptoms, including how long they last and how frequently they occur. Other questions will focus on reasoning, memory, ability to express oneself, and ability to maintain relationships.
Blood and urine tests -- such as a toxicology screening -- may be done to rule out other causes of symptoms. In a toxicology screening, blood, urine, or hair are examined for the presence of drugs. Blood tests also include a check of thyroid stimulating hormone (TSH) level, since depression is sometimes linked to thyroid function.
Bipolar Disorder:
Can Bipolar Disorder Be Prevented?
There is no known way to prevent bipolar disorder. Because its exact cause has not yet been determined, the best attack is to know its symptoms and get treatment early. Also, because some people with bipolar disorder become suicidal if they don't get effective treatment, it's especially essential to get treatment.
Bipolar Disorder:
Convincing Someone to See a Doctor for Bipolar Disorder
Very often, people with hypomania may not realize it's a problem. They may even enjoy it, finding it to be a productive time. Others struggle with depression, not getting the help that could relieve their suffering.
Yet for various reasons, they don't get help from a doctor. They shrug off a friend or family member's concern. Others view their illness as a distraction or a weakness, and they don't want to give in to it. Still others put their health at a very low priority compared with other things in their lives.
However, fear is often the reason for not seeing a doctor. That's especially true if there is a family history of emotional problems. People in denial are protected from their worst fears. They can stay comfortably in their everyday routines -- even though relationships and careers can be at stake.
If you're concerned about a loved one, talk to him or her about seeing a doctor. Sometimes, simply suggesting a health checkup is the best approach. With other people, it's best to be direct about your concern regarding a mood disorder. Include these points in the discussion:
· It's not your fault. You have not caused this disorder. Genetics and stressful life events put people at greater vulnerability for bipolar disorder.
· Millions of Americans have bipolar disorder. It can develop at any point in a person's life, and is responsible for enormous suffering.
· Bipolar disorder is a real disease. Just like heart disease or diabetes, it requires medical treatment.
· There's a medical explanation for bipolar disorder. Disruptions in brain chemistry are involved. The brain circuits -- those that control emotion -- are not working the way they should. Because of this, people experience certain moods more intensely, for longer periods of time, and more frequently.
· Good treatments are available. These treatments have been tested and found to be effective for many, many people with bipolar disorder. Medications can help stabilize your moods. Through therapy, you can discuss feelings, thoughts, and behaviors that cause problems in your social and work life. You can learn how to master these so you can function better and live a more satisfying life.
· By not getting treatment, you risk having worse mood swings -- even becoming suicidal. You risk damaging your relationships with friends and family. You could put your job at risk. And your long-term physical health can also be affected, since emotional disturbances affect other systems in the body. This is very serious.
Trust is crucial in shaking someone's denial, in motivating him or her to get help. Trust is also important once treatment starts. Through the eyes of a trustworthy friend or family member, a bipolar patient can know when treatment is working -- when things are getting better, and when they're not. If your interest is sincere, you can be of great help to your friend or family member.
Bipolar Disorder:
Bipolar Disorder Treatment Overview
No one knows exactly what causes bipolar disorder. While genetic vulnerability and life stress are involved in triggering it, experts believe that an underlying imbalance of brain chemicals produces the symptoms. When levels of these chemicals are too high, mania occurs. When levels are low, there is depression.
This biological understanding of the disorder has opened doors for targeted treatments.
The best treatment is a combination of medication and counseling, although electroconvulsive therapy (ECT) is often successful for people who don't respond to traditional therapy or who can't take the medications.
Doctors often treat the mania symptoms with one set of drugs, and use other drugs to treat depression. Certain drugs are also used for "maintenance" -- to maintain a steady mood over time. Antidepressants are not often used alone, because they may cause rapid cycling between depression and mania.
Most people respond well to medications for bipolar disorder. For many others, the symptoms do not completely disappear despite therapy. The moods may become less intense and more manageable, however.
Remember, getting your diagnosis should come as a relief. Now you know what the problem has been and you're on the road to getting the right treatment.
Mania
If you are suffering from mania, your doctor initially may treat you with an antipsychotic drug and/or a benzodiazepine to quickly control hyperactivity, sleeplessness, hostility, and irritability.
Your doctor will also likely prescribe a mood stabilizer. Mood stabilizers help control mood swings, prevent recurrences of mood swings, and reduce the risk of suicide. They are usually taken for a long time, sometimes years. Examples include lithium and certain anticonvulsant drugs.
Treatment of mania often requires hospitalization because there is high risk for unpredictable, reckless behavior and noncompliance with treatment. For people with extreme mania, pregnant women with mania, or those people whose mania can't be controlled with mood stabilizers, doctors sometimes also recommend electroconvulsive therapy (ECT).
If mania occurs while on maintenance therapy, your doctor may simply change your medication dose. Or you may start taking an antipsychotic drug to lessen symptoms.
Nondrug treatments, such as psychotherapy, and establishing a well-ordered routine may help patients in their maintenance phase. This is often suggested along with medication.
Depression
Treating a depressive episode in bipolar disorder is controversial and challenging. Using antidepressant medication alone is not recommended because the drugs may flip a person into a manic or hypomanic episode. Hypomania is a more subdued version of mania. Antidepressants alone also may lead to rapid cycling. In rapid cycling, a person may recover more quickly from depression -- but may experience mania and then another episode of depression.
Note: In October 2004, the FDA determined that antidepressant medications can increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders. If you have questions or concerns, discuss them with your health-care provider.
In April 2002, the American Psychiatric Association suggested using lithium or the anticonvulsant drug Lamictal as an initial treatment for people in the acute depressive phase of bipolar disorder who were not already taking a mood stabilizing medication. Sometimes Lamictal is added to lithium as well.
For more severely ill patients, some doctors may prescribe lithium and an antidepressant -- usually either Wellbutrin or Paxil, though other drugs can be used.
There are other options for treating bipolar depression.
The antipsychotic drug Zyprexa is also approved to treat bipolar depression when used with the antidepressant Zoloft. Other antipsychotic medications have also been studied and found effective in varying degrees.
If all else fails, doctors may recommend electroconvulsive therapy (ECT). It helps nearly 75% of the patients who try it.
In addition, psychotherapy may be beneficial when added to drug therapy. Once depression has resolved, mood stabilizers are the best proven treatments to prevent future depression. If psychotic symptoms occur during an acute depressive episode, the doctor may recommend antipsychotic medicine.
Nondrug treatments -- such as psychotherapy and establishing a well-ordered routine -- may help patients in their maintenance phase. They are often suggested along with medication. Psychotherapy alone is not considered sufficient to treat bipolar depression.
Bipolar Disorder:
Lithium for Bipolar Disorder
Lithium (brand names Eskalith, Lithobid, Lithonate, and Lithotabs) is the most widely used and studied medication for treating bipolar disorder. Lithium helps reduce the severity and frequency of mania. It may also help relieve bipolar depression.
Studies show that lithium can significantly reduce suicide risk. Lithium also helps prevent future manic episodes. As a result, it may be prescribed for long periods of time (even between episodes) as maintenance therapy.
Lithium acts on a person's central nervous system (brain and spinal cord). Doctors don't know exactly how lithium works to stabilize a person's mood. However, it helps people with bipolar disorder have more control over their emotions and reduce the extremes in behavior.
It usually takes one to two weeks for lithium to begin working. Your doctor will want to take regular blood tests during your treatment because lithium can affect kidney function. Lithium works best if the amount of the drug in your body is kept at a constant level. Your doctor will also probably suggest you drink eight to12 glasses of water or fluid a day during treatment and use a normal amount of salt in your food. Both salt and fluid can affect the levels of lithium in your blood, so it's important to consume a steady amount every day.
The dose of lithium varies among individuals and as phases of their illness change. Although bipolar disorder is often treated with more than one drug, some people can control their condition with lithium alone.
Lithium Side Effects
About 75% of people who take lithium have some side effects, although they may be minor. They may become less troublesome after a few weeks as your body adjusts to the drug. Sometimes side effects can be relieved by tweaking the dose of lithium. However, never change your dose or drug schedule on your own. Do not the change brand of this medication without checking with your doctor or pharmacist first. If you are having any problems, talk to your doctor about your options.
Common side effects can include:
· Hand tremor (If tremors are particularly bothersome, an additional medication can help.)
· Increased thirst
· Increased urination
· Diarrhea
· Vomiting
· Weight gain
· Impaired memory
· Poor concentration
· Drowsiness
· Muscle weakness
· Hair loss
· Acne
· Decreased thyroid function (which can be treated with thyroid hormone)
Notify your doctor if you experience persistent symptoms from lithium or if you develop diarrhea, vomiting, fever, unsteady walking, fainting, confusion, slurred speech, or rapid heart rate.
Tell your doctor about history of cancer, heart disease, kidney disease, epilepsy, and allergies. Make sure your doctor knows about all other drugs you are taking. Avoid products that contain sodium, such as certain antacids. While taking lithium, use caution when driving or using machinery and limit alcoholic beverages.
If you miss a dose, take it as soon as you remember it -- unless the next scheduled dose is within two hours (or six hours for slow-release forms). If so, skip the missed dose and resume your usual dosing schedule. Do not "double up" the dose to catch up.
There are a few serious risks to consider. Lithium may weaken bones in children. The drug has also been linked to birth defects and is not recommended for pregnant women, especially during the first three months. Breastfeeding isn't recommended if you are taking lithium. Also, in a few people, long-term lithium treatment can interfere with kidney function.
Bipolar Disorder:
Anticonvulsant Medications for Bipolar Disorder
Increasingly, anticonvulsant medications are used as mood stabilizers to treat mania. Lamictal is used to treat bipolar depression as well. Occasionally, Depakote is also used to treat bipolar depression. Doctors discovered this use for the drugs when they noted improvements in mood stability among people with epilepsy. At first, anticonvulsants were prescribed only for people who did not respond to lithium. Today, they are often prescribed alone, with lithium, or with an antipsychotic drug to control mania.
Anticonvulsants work by calming hyperactivity in the brain in various ways. For this reason, some of these drugs are used to treat epilepsy, prevent migraines, and treat other brain disorders. They are often prescribed for people who have rapid cycling -- four or more episodes of mania and depression in a year.
Anticonvulsants used to treat bipolar disorder include:
· Depakote, Depakene (divalproex sodium, valproic acid, or valproate sodium)
· Tegretol (carbamazepine)
· Lamictal (lamotrigine)
· Trileptal (oxcarbazepine)
Each anticonvulsant acts on the brain in slightly different ways, so your experience may differ depending on the drug you take. In general, however, these drugs are at maximal effectiveness after taking the drug for a couple of weeks.
Anticonvulsant Side Effects
Your doctor may want to take regular blood tests to monitor your health. Some anticonvulsants can cause liver or kidney damage or decrease the amount of platelets in your blood. Your blood needs platelets to clot.
Each anticonvulsant may have slightly different side effects. Common side effects include:
· Dizziness
· Drowsiness
· Fatigue
· Nausea
· Tremor
· Rash
· Weight gain
Most of these side effects lessen with time. Long-term effects vary from drug to drug. In general:
· Pregnant women should not take anticonvulsants because they increase the risk of birth defects.
· Anticonvulsants can cause problems with the liver over the long term, so your doctor should monitor your liver closely.
Also, anticonvulsants can interact with other drugs -- even aspirin -- to cause serious problems. Be sure to tell your doctor about any drugs, herbs, or supplements you take. Don't take any other substance during treatment without talking with your doctor.
Bipolar Disorder:
Antipsychotic Medications for Bipolar Disorder
Antipsychotic medications are used as a short-term treatment to control psychotic symptoms such as hallucinations or delusions. These symptoms may occur during acute mania or severe depression.
In people with bipolar disorder, antipsychotics are also used as sedatives, for insomnia, for anxiety, and/or for agitation. Often, they are taken with a mood-stabilizing drug and can decrease symptoms of mania until mood stabilizers take full effect. Some antipsychotic medications may also help lessen bipolar depression.
Some of the newer antipsychotics seem to help stabilize moods on their own. As a result, they may be used alone as long-term treatment for people who don't tolerate or respond to lithium and anticonvulsants.
Antipsychotic drugs help balance certain brain chemicals called neurotransmitters. It is not clear exactly how these drugs work, but they usually improve manic episodes quickly.
The newer antipsychotics usually act quickly and can help you avoid the reckless and impulsive behaviors associated with mania. More normal thinking often is restored within a week.
Antipsychotics used to treat bipolar disorder include:
· Abilify (aripiprazole)
· Clorazil (clozapine)
· Geodon (ziprasidone)
· Risperdal (risperidone)
· Seroquel (quetiapine)
· Zyprexa (olanzapine)
Antipsychotics Side Effects
Certain antipsychotics cause rapid weight gain and high cholesterol levels, and they may increase the risk of diabetes. People considering an antipsychotic for bipolar disorder should first be screened for their risk for heart disease, stroke, and diabetes, according to a study published in the February 2004 issue of Diabetes Care. The study specifically recommended that doctors screen people taking Risperdal, Seroquel, or Zyprexa for diabetes, prediabetes, and high cholesterol.
Abilify does not cause weight gain but may increase the risk of diabetes.
Common side effects of antipsychotic medications include:
· Blurred vision
· Dry mouth
· Drowsiness
· Muscle spasms or tremor
· Involuntary facial tics
· Weight gain
Note: Clorazil is not used often, despite its effectiveness, for bipolar disorder. The drug can cause a rare, potentially fatal side effect affecting the blood that requires weekly or biweekly blood test monitoring.
Older antipsychotic drugs are generally not used to treat bipolar disorder. However, they may be helpful if a person has troublesome side effects or doesn't respond to the newer drugs. Older antipsychotics include Thorazine (chlorpromazine), Haldol (haloperidol), and Trilafon (perphenazine). These drugs may cause serious long-term side effects called tardive dyskinesia, a movement disorder characterized by repetitive, involuntary movement like lip smacking, protruding the tongue, or grimacing.
Bipolar Disorder:
Calcium Channel Blockers for Bipolar Disorder
Sometimes a doctor may prescribe for mania a group of drugs traditionally used to treat high blood pressure or heart problems called calcium channel blockers. These drugs are not as effective as others and are not used often.
These drugs block calcium channels, which are the small pores in cells that allow calcium to move in and out, which widens your blood vessels. It's not clear exactly how the drugs work, but they are used to lower blood pressure, improve irregular heartbeats, and treat migraines. They may also help stabilize moods.
Calcium channel blockers used to treat mania include:
· Diltiazem
· Nifedipine
· Nimodipine
· Verapamil
Calcium Channel Blockers Side Effects
Sometimes, a headache can develop after taking certain calcium channel blockers. These headaches should gradually disappear once you have been taking the medication for a while. Talk to your doctor if headaches continue. Some people also report tenderness, swelling, or bleeding of the gums when starting to take calcium channel blockers. Regular brushing, flossing, and gum massages along with routine dental visits can help lessen this effect. As with any medication, it is important to see your doctor regularly to make sure the drug is working properly.
Calcium channel blockers tend to cause fewer serious side effects than some other drugs used to treat bipolar disorder. However, they are also less effective.
Common side effects include:
· Slowed heart rate or irregular heart rhythm
· Flushing, a pounding sensation in the head, dizziness, headache
· Leg swelling
· Decreased blood pressure
· Tingling sensations in the arms or legs
· Weakness
· Constipation
Talk to your doctor if you are pregnant or could become pregnant during treatment. It isn't known if these drugs could harm the fetus.
Bipolar Disorder:
Benzodiazepines for Bipolar Disorder
Benzodiazepines rapidly help control certain manic symptoms until mood-stabilizing drugs can take effect. They are usually taken for a brief time, up to two weeks or so, with other mood-stabilizing drugs. They may also help restore normal sleep patterns in people with bipolar disorder.
Benzodiazepines slow the activity of the brain. In doing so, they can help treat mania, anxiety, panic disorder, insomnia, and seizures.
Benzodiazepines prescribed for bipolar disorder include (among others):
· Ativan (lorzepam)
· Klonopin (clonazepam)
· Valium (diazepam)
· Xanax (alprazolam)
Benzodiazepine Side Effects
The drugs act quickly and bring on a sense of calmness. They can sometimes cause lightheadedness, slurred speech, or unsteadiness.
Possible side effects include:
· Drowsiness or dizziness
· Lightheadedness
· Fatigue
· Blurred vision
· Slurred speech
· Memory loss
· Muscle weakness
Benzodiazepines can be habit-forming and addictive.
If you have been taking the benzodiazepines for a long time, you may suffer withdrawal symptoms if you stop the drug suddenly. Talk with your doctor about whether you still need the medication and, if not, how to taper off the drug.
Bipolar Disorder:
Electroconvulsive Therapy (ECT) for Bipolar Disorder
Electroconvulsive therapy (ECT), also known as electroshock therapy, is used as an acute treatment for hospitalized patients who are suicidal, psychotic, or dangerous to others. It is effective in nearly 75% of patients who have the procedure.
In electroconvulsive therapy, an electric current is sent through the scalp to the brain. It is used to treat people who are suffering from severe depression or other mental illness. ECT is one of the fastest ways to relieve symptoms in people who suffer from mania or severe depression. ECT is generally used as a last resort when the illness does not respond to medication or psychotherapy. It is also used when patients pose a severe threat to themselves or others and it is dangerous to wait until drugs take effect.
Prior to ECT treatment, a person is given a muscle relaxant and put under general anesthesia. ECT, when done correctly, will cause the patient to have a seizure, and the muscle relaxant is given to limit the size of the episode.
Electrodes are placed on the patients scalp and a finely controlled electric current is applied that causes a brief seizure in the brain. Because the muscles are relaxed, the seizure will usually be limited to slight movement of the hands and feet. Patients are carefully monitored during the treatment. The patient awakens minutes later, does not remember the treatment or events surrounding the treatment, and is often confused.
This confusion typically lasts for only a short period of time. ECT is given up to three times a week for two to four weeks.
In extremely rare cases, ECT can cause heart attack, stroke, or death. People with certain heart problems usually are not good candidates for ECT. Short-term memory loss is the major side effect, although this usually goes away one to two weeks after treatment.
Other possible side effects include:
· Confusion
· Nausea
· Headache
· Jaw pain
These effects may last from several hours to several days.
A third of people who have ECT report some long-term memory loss, but few studies have been done on this side effect
Bipolar Disorder:
Antidepressants for Bipolar Disorder
Antidepressants can help relieve depression and boost mood. It typically takes three to four weeks for most people to respond to the treatment. Sometimes a doctor will try several different antidepressants and doses before finding one that works for a patient.
There are three different types of antidepressants used to treat depression among people with bipolar disorder:
· Selective serotonin reuptake inhibitors (SSRIs)
· Monoamine oxidase inhibitors (MAOIs)
· Tricyclic antidepressants (less commonly used).
Newer "atypical" antidepressants are also being tested for use in treating bipolar depression.
Note: In October 2004, the FDA determined that antidepressant medications can increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders. If you have questions or concerns, discuss them with your health-care provider.
Treating a depressive episode in bipolar disorder is controversial and challenging. Using antidepressant medication alone is not recommended because the drugs may flip a person into a manic or hypomanic episode. Hypomania is a more subdued version of mania. Antidepressants alone also may lead to rapid cycling. In rapid cycling, a person may recover more quickly from depression -- but may experience mania and then another episode of depression.
Bipolar Disorder:
Bipolar Disorder and Going to Work
Bipolar disorder can have a big effect on your career. In a survey of people with depression and bipolar disorder conducted by the Depression and Bipolar Support Alliance, 88% said their condition affected their ability to work.
But don't get alarmed. Being diagnosed with bipolar disorder doesn't necessarily mean that you can't keep your job. Plenty of people with bipolar disorder work and live normal lives.
Should I Tell My Boss?
You don't have to talk to your boss or coworkers about your condition. Your health is your business. But if your condition has been affecting your performance at work, being open may be a good idea. Your boss and coworkers may have noticed the changes in your behavior. If you explain what's going on, they may be more sympathetic than you expect.
Making Changes
Some people with bipolar disorder find their current job just isn't a good fit. Maybe it's too stressful or the schedule is too inflexible. Maybe it doesn't let them get enough sleep. If you think your job is hurting your health, it's time to make some changes. Here are some things to consider.
· Decide what you really need from your job. Do you need to reduce your responsibilities? Do you need extra breaks during the day to reduce stress? Would you rather work independently or in a group? Do you need to work shorter hours or take time off? Or do you need a different job altogether?
· Make decisions carefully. People with bipolar disorder are prone to acting impulsively. Think through the effects of quitting your job -- both for yourself and possibly for your family. Talk over your feelings with your family, therapist, or health-care provider.
· Look into financial assistance. If you do need to take time off, see if your employer has disability insurance, or look into Social Security Disability Insurance, which will provide some income while you recover. You can also look into the Family and Medical Leave Act. Ask your doctor or therapist for advice.
· Go slowly. Returning to work after you've taken time off can be stressful. Think about starting in a part-time position, at least until you're confident that your condition has stabilized. Some people find that volunteer work is a good way to get back into the swing of things.
Bipolar Disorder Stigma
Unfortunately, you may still run into people who treat you unfairly because of your bipolar disorder. Often, their behavior stems from ignorance. They might see you as "crazy" or think your condition is "all in your head." You might be able to head off problems by teaching people a little about bipolar disorder.
But that's not always enough, and the stigma of mental illness can hold you back. Some people with bipolar disorder feel they're treated unfairly at work; they might be passed over for promotions or raises, for instance.
If you think you're being treated unfairly, there are things you can do. The Americans with Disabilities Act can protect some people who are discriminated against because of a health condition. But don't do anything rash. Research the law, and talk your situation over with friends, family, your therapist, and your health-care provider before taking action.
Bipolar Disorder:
Talking to Your Friends and Family About Bipolar Disorder
Bipolar disorder can put an enormous strain on relationships with your family and friends. When you're depressed, you may isolate yourself from the people who care about you. When you're manic or hypomanic, you might frighten or alienate them.
But your relationships with your friends and family are crucial to staying healthy. You need to keep the lines of communication open. Here are some suggestions.
· Educate your family and peers. Your friends and family may not know much about bipolar disorder, or they may have a lot of wrong impressions. Explain what it is and how it affects you. Talk about your bipolar treatment. Unfortunately, some people may be skeptical or unsympathetic. Back yourself up with brochures or printouts that you can give them. Tell them you need their help to stay well.
· Create a support team. Obviously, you don't need to tell everyone you know about your condition. But you also shouldn't rely on only one person. It's much better to have a number of people you can turn to in a crisis. Placing all the responsibility on one person is simply too much.
· Make a plan. You need to accept that during a mood swing, your judgment might be impaired. You could really benefit from people looking out for you. But your loved ones also need to be careful not to push too hard. You don't want to feel like every move you make is being scrutinized.

So work out distinct boundaries. Decide how often your friends and family should check in and what to do if things are getting out of control. If you become manic, you might agree that your loved ones should take away your car keys or credit cards so you don't do anything reckless. If you become suicidal, they certainly need to get emergency help. Coming up with an explicit plan will make everyone feel better.
· Listen. After all that you've been through, you may not want to hear the concerns of your family and friends. But the fact is that your condition does affect the people around you. During a manic or depressive phase, you may have upset people whom you care about. So try to hear them out and see things from their point of view. If you've hurt people, apologize. Reassure them that you didn't mean to act the way you did, and emphasize that you're getting treatment.
· Talk to your children. If you have kids, you should find a way to tell them what's happening. They're likely to sense that something is wrong anyway; keeping them in the dark might just make it scarier. Explain your condition in a way that's appropriate for their age. Say that it's a disease that affects your mood, but that you're getting treatment for it.
· Reach out. Bipolar disorder can make relationships hard. When you're depressed, you may want to retreat from the world. If you've just come out of a manic phase, you may not want to face people whom you treated badly. Either way, it's easy to let some friendships slip away. Don't let it happen. Force yourself to get together with other people, even if it may be hard at first. Isolating yourself is the worst thing you can do.
Bipolar Disorder:
Convincing Someone to See a Doctor for Bipolar Disorder
Very often, people with hypomania may not realize it's a problem. They may even enjoy it, finding it to be a productive time. Others struggle with depression, not getting the help that could relieve their suffering.
Yet for various reasons, they don't get help from a doctor. They shrug off a friend or family member's concern. Others view their illness as a distraction or a weakness, and they don't want to give in to it. Still others put their health at a very low priority compared with other things in their lives.
However, fear is often the reason for not seeing a doctor. That's especially true if there is a family history of emotional problems. People in denial are protected from their worst fears. They can stay comfortably in their everyday routines -- even though relationships and careers can be at stake.
If you're concerned about a loved one, talk to him or her about seeing a doctor. Sometimes, simply suggesting a health checkup is the best approach. With other people, it's best to be direct about your concern regarding a mood disorder. Include these points in the discussion:
· It's not your fault. You have not caused this disorder. Genetics and stressful life events put people at greater vulnerability for bipolar disorder.
· Millions of Americans have bipolar disorder. It can develop at any point in a person's life, and is responsible for enormous suffering.
· Bipolar disorder is a real disease. Just like heart disease or diabetes, it requires medical treatment.
· There's a medical explanation for bipolar disorder. Disruptions in brain chemistry are involved. The brain circuits -- those that control emotion -- are not working the way they should. Because of this, people experience certain moods more intensely, for longer periods of time, and more frequently.
· Good treatments are available. These treatments have been tested and found to be effective for many, many people with bipolar disorder. Medications can help stabilize your moods. Through therapy, you can discuss feelings, thoughts, and behaviors that cause problems in your social and work life. You can learn how to master these so you can function better and live a more satisfying life.
· By not getting treatment, you risk having worse mood swings -- even becoming suicidal. You risk damaging your relationships with friends and family. You could put your job at risk. And your long-term physical health can also be affected, since emotional disturbances affect other systems in the body. This is very serious.
Trust is crucial in shaking someone's denial, in motivating him or her to get help. Trust is also important once treatment starts. Through the eyes of a trustworthy friend or family member, a bipolar patient can know when treatment is working -- when things are getting better, and when they're not. If your interest is sincere, you can be of great help to your friend or family member.