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psychiatric conditions

Intermittent Explosive Disorder

Intermittent Explosive Disorder – More Than Just Anger

Intermittent Explosive Disorder (also called IED, that is appropriate as it can go off unexpectedly and cause significant damage)

Intermittent Hulk Explosive DisorderProbably everyone knows that teenage boy (or girl) who punched a hole through the wall.  Perhaps for some, this became a regular pattern of behavior during adolescence but most of those teenagers outgrew it.  In fact, at least one-quarter of teenage boys has done something dumb like punching a wall.

One boy I knew in high school even broke his hand by punching the roof of his car, and some boys were routinely doing stupid stuff.  Despite that, all of it was teenage angst and changes that can be attributed to the massive amounts of testosterone flowing through the male adolescent body – none of them had intermittent explosive disorder.

Intermittent Explosive Disorder is worse than punching a hole through a wall.

It typically is first identified in the early teens – but can be seen much earlier in some cases.    In order to be actually characterized as intermittent explosive disorder, an individual must have had three episodes of explosive behavior that is severely out of proportion to the stressor.

Intermittent Explosive Disorder HulkinsectThey must have broken or smashed something that is monetarily valuable (more than a few dollars), physically attacked or made explicit threats to attack someone with the intent of causing harm.  If these three episodes occur within the space of 12 months, the disorder is considered to be more severe.

Here is the catch.

How do you distinguish between IED, average – though extreme teenage behavior and other psychiatric conditions?  It turns out that IED is probably a diagnosis of “if nothing else fits” as other psychiatric disorders certainly overlap with similar symptoms – and you have to rule out the adolescent hormone issue.

Bipolar disorder may cause outbursts of extreme anger and agitation, Borderline personality disorder may cause outbreaks, ADHD patients can exhibit a severe lack of self-control, and drug abuse is always a potential cause.  Even though those diseases may cause IED-like events, a sustained behavior pattern is something to address.

Intermittent Explosive Disorder WarningA recent study reported by the National Institutes of Health shows that IED can actually affect up to 4 percent of adults and lead to an estimated 43 attacks over a lifespan.  The disorder may also increase that chance of depression, anxiety and substance abuse disorders.  People with IED have an obvious increased risk of legal trouble, financial difficulties, and divorce – that’s a no-brainer.

So the biggest problem for mental health professionals, like many other disorders, is to untangle all of the information leading in and out with a mix of behaviors and a mix of causes.  What came first – the chicken or the egg?  What came first – the drug abuse or the anger?  Which illness is more important – bipolar disorder or the IED?

One of the biggest clues may be in examining (or better, paying attention to) behavior that occurs before puberty.  In other words: What came first – the behavior or puberty?  Clearly if the behavior started before puberty, there was and is an issue.  If the behavior begins during adolescence – you have to wait (and hope) to see if the behavior goes away once the hormones are settled.

IED is not a simple diagnosis.

It requires a careful examination of an entire psychiatric and behavioral history – and the “ruling out” of a lot of other disorders that may be to blame.  Unfortunately, in the end – unless an underlying cause can be found, there is no medicationAnger management and cognitive behavioral therapy are likely the only answer – minimization of harm, not very satisfactory if it was your car window that got smashed in a fit of rage.

Melissa Lind

Diagnosis and Symptoms of Bipolar Disorder

Bipolar disorder is difficult to diagnose.

The average bipolar patient will see three mental health professionals before getting the right diagnosis. In fact, one-third of bipolar patients will not be diagnosed with the disorder until more than 10 years after they first seek treatment.

There is a lot of similarity between the symptoms of bipolar disorder and other psychiatric conditions, but that isn’t the only reason why it is so difficult to diagnose. Here are some of the complicating factors:

Bipolar Disorder PatientThe patient only talks about depression – as bipolar disorder is a condition that has periods of depression alternating with manic episodes, many patients present when they are depressed. This is particularly true when a patient seeks treatment for themselves. Manic patients feel good or at least energized and are unlikely to believe that anything is wrong. Either they feel terrific, or they are in a heightened “bad” mood – and likely to blame that on other people or life circumstances. Consequently when they first seek treatment – they only profess to the depression as that is most bothersome.

Bipolar disorder looks like anxiety – in actuality, many, if not most bipolar patients also have some type of anxiety disorder. Consequently it may be very difficult for mental health professional to root out bipolar disorder. If patients are seen as agitated, hyperactive or fidgety, they may be only asked about anxiety or given a self-rating scale for anxiety. This would immediately lead the practitioner to diagnose an anxiety disorder – unless careful investigations were done.

Substance abuse can be complicating the issue – many bipolar patients spend years self-treating with substances of abuse. This includes prescription medications, recreational drugs and alcohol. There is not any particular drug that is more often abused by bipolar people as a whole – some will choose alcohol, some will prefer stimulants, some will choose pain medications – all of which will mask the symptoms to some extent. In some cases, the substance abuse appears to be more problematic than anything else and in cases of addiction; the substance abuse must be treated before an accurate evaluation can occur.

Denial is very common – Denial is a nice way of saying dishonesty. That would be lying. This sounds very harsh but in many cases, bipolar patients will not be honest about difficulties that they have had. It may be subconscious dishonesty in that they, themselves do not really know what the problem is. Lack of awareness is common but outright denial is also common. Many bipolar patients absolutely refuse to accept the diagnosis when it is first presented – even after years of not being treated properly. Oddly, this may make it more likely that the practitioner believes that the patient has bipolar disorder but such outright denial delays treatment.

These are just a few of the reasons why bipolar disorder is so difficult to pin down and, unfortunately, delayed treatment can have huge life implicationsBipolar disorder is one of the riskiest psychiatric illnesses to have and can have severe consequences for the patient who is not properly diagnosed and medicated – including job losses, family disturbance, institutionalization, jail and even death.

Bipolar disorder affects not only the patient himself – but family and loved ones as well.

Why is it so difficult to diagnose bipolar disorder?

Why do Bipolar Patients Quit Taking Their Meds?

Why do bipolar and schizophrenic persons quit taking medicine?

Talk to any medical professional about the trials and tribulations of dealing with bipolar patients and they will tell you that the single most bothersome thing is the frequency with which manic-depressives quit taking their meds.

This problem isn’t unique to bipolar patients, but it is more insidious and often more surprising.  Schizophrenics, who quit taking their meds, are identified fairly quickly.  Those with depression who quit taking their meds stay in their houses – this is troublesome but not a public nuisance.

People with bipolar disorder are usually quite memorable both at the best of times and the worst of times.  They are vivacious; they are shining; they are exasperating; they are amazing, and they are irritating.  Generally in order to be diagnosed, a bipolar patient will present one of two ways – either severely depressed or psychotic but their illness has gone unnoticed or unaddressed for a long time.

To be fair, psychiatric patients of any type may quit taking their meds for a number of legitimate reasons.  Well, semi-legitimate.

Mood DisordersLegitimately, a psychiatric patient of any type will have consulted with his or her physician before quitting can be medically supervised while doing so.  Even with medical supervision, the only really legitimate reason for a psychiatric patient to quit taking their meds completely is a person who has been taking anti-depressants for a short period of time (less than one year) who has only had one episode of clinical depression.  In this case, a psychiatrist would agree that a patient who does not have a long term history of depression can taper off the medication because they may not need it forever.  This patient is rare. Once another episode of depression or mood disorder occurs, virtually everyone will agree that it is a chronic problem that should be addressed with medication.  Permanently.

One legitimate reason for temporarily discontinuing use would be pregnancy, to avoid potential harm to the fetus.  In most cases, the medication would be re-started as soon as the patient is able.

Patients may also approach their physician about discontinuing a specific medication to switch to another.  Reasons for this might be ineffectiveness, intolerable side effects or cost.

Unfortunately, for most psychiatric patients there is no legitimate reason to discontinue medication altogether.  The physician will suggest or even prescribe an alternative medication.  The patient may feel that they have been unheard by their physician and while this may be the case, for most patients who “quit”, it is actually more likely that they have not talked to the physician at all.

Bipolar patients and those with other psychiatric conditions most often quit taking their medication without medical supervision or intervention in secret.  Oddly, this is because the brain is a tricky thing – most often they quit when they are doing well.  When the medication is working, they begin to believe that they do not need the medication – that they are “OK”.

Most psychiatric patients don’t want to have a mental disorder – or more likely they don’t want to be told that they have a mental disorder.  This may be in part due to the social stigma, but it may also be because they really like the way they are.  Medication often takes away the “spark” that has made them vivacious, memorable, brilliant and even irritating or dangerous.

It is very difficult to go from “outstanding” – whether it is good or bad to normal.  Bipolar patients in particular also quit taking their medication because their brains are bored.  The brain is used to go up and down, backwards and forwards, in and out.  When medication is working, the roller coaster goes away.

This may be good for a while, after the crisis because life has gotten way out of whack, they need time to recover, rest, and breathe.  But when the fires are put out, and the dust clears, the brain begins to crave the excitement.

Again, this really means the medication is working, and they will quit, yet again, starting the cycle all over again.

So, what can a caretaker, a parent, a spouse, or a friend do?  Likely any attempt at supervision or intervention will be met with anger, avoidance or outright denial.

Bipolar CaosAs bipolar disorder, and schizophrenia most often emerges in the late teens or early adulthood, is should be predictable that they do not want supervision.  They do not want to be told that someone else knows best.

When confronted or even questioned, the bipolar will almost always say that everything is OK – even if it is far from OK.  In short, they will lie.

Again, what can a caretaker, a parent, a spouse, or a friend do?  In short, especially in the newly diagnosed (and for a bipolar or schizophrenic the definition of newly would be likely less than 10 years), there will be no opportunity for supervision.  They will be secretive and untruthful.  You must wait for the crash and be there to assist with the crisis and recovery – only to repeat it again in a few months or years.

The good news is that eventually, the periods between “the crashes” will likely lengthen. When they are thinking clearly, when the medication is working – ask them why they do it.  Encourage them to participate in therapy, join a bipolar or mental disorder group. Realize they may not always go.

Over a period of years, perhaps decades – the patient may eventually become to accept that they truly do need the medication.  Likely they will never be completely compliant but one can always hope.

A caregiver, a parent, a spouse, a friend can look for signs – if you are close, you may be able to keep track of their medication, physician visits, refills but you may not be able to.  You should prepare yourself when you see signs: a developing increase in communication, vivacity, anger – likely followed by erratic behavior and hiding.

Intervene as much as you can but know that your may not be able to stop them.  They quit medication when it is working because it makes them….normal.

Melissa Lind