Thursday, August 28, 2008

Scaled-up Structure of a Neuron

I'm always interested in analogies & thought experiments. One of them last year was to consider the following:

What would a brain cell (neuron) look like on a vastly expanded scale, where the body of the cell (cross-sectionally) would occupy an area about the size of a small urban residential lot (let's say about 10 x 40 metres, or 35 x 120 feet)?

Interestingly, it took a fair bit of effort to get an accurate picture of this (and even now, I'm sure I could get into a lot more detail). Advanced textbooks of neuroscience may be good at describing a lot of fine details, but they tend not to give the reader a good visual picture of what the brain -- or a neuron -- in action -- really looks like. In order to do this research, it involved digging at length into the neuroscience literature (full references are available to the interested reader).

Here are some of my findings:

A typical neuron cell body is about 20 microns in diameter (about 1/50 of a millimeter). If the cell body were made into a giant which occupied a whole city residential lot, we would be scaling upward by a factor of about 1.85 million.

At this scale, a single atom would be about 0.2 mm wide (well within visual resolution). At this scale, your head would be about 340 km in diameter. This is about the size of a U.S. state such as Ohio, Pennsylvania, or Louisiana; or almost as large as the Canadian provinces of New Brunswick and Nova Scotia combined.

Dendrites are arm-like extensions of a neuron's cell body. Dendrites can be up to 600 microns long, and on our scaled-up neuron, this makes the longest dendrites about 1 km long. Each neuron can have about 20 dendrites. Each dendrite in our model would be about 5 meters wide. In our model, dendrites are similar to the width of streets or alleys coming away from the yard (remember this is really in 3 dimensions), and each street or alley would extend to some outer reach of your local neighbourhood. Inside each dendrite are many mitochondria (the "power plants" of the cell), each of which about 4 x 1 meters in size (each about the size of a hippo).

There are fibers holding the whole cell together (and serving other functions), called neurofilaments and microtubules. They are typically about 10 mm in diameter in our model (like a medium-sized rope), and are spaced about 100 mm apart (so the inside of a neuron could get quite tangled up were it not for the fact that these "ropes" guide everything along smoothly, acting as miniature pulleys and motors).

A synapse is an area where two neurons communicate chemically. There are thousands of synapses on each neuron. In our model, each synapse area would be about 1 meter wide. The distance across the synapse (between neurons) in our model is about 180 mm (6 inches). Nerve cells release vesicles into the synapse containing neurotransmitters such as serotonin and norepinephrine. In our model each vesicle would be about the size of a small grapefruit. Each time the neuron is fully activated, about 300 of these grapefruit-sized vesicles would be released. Smaller activations of the neuron would cause only 5-10 vesicles to be released. After release, the vesicles are "recycled" within about a minute.

If there is a drug such as an antidepressant affecting the neuron, its size on our model would be something like a grain of sand. Concentrations of antidepressants in the brain are something like 1 in 6 million. This corresponds to one, or just a few, molecules of antidepressant -- each one the size of a 1 mm grain of sand -- in every cubic foot in our model. This shows us visually that just a tiny amount of something in the brain can have a powerful effect.

In the actual brain, neurons are "packed" with a density of about 100 000 per cubic millimeter. In our model this corresponds to neurons packed roughly equivalent to how the city lots are "packed" in a residential neighbourhood (but in 3 dimensions).

The brain's surface area, scaled up for our model, would occupy an area about the size of Washington state, or of southern British Columbia, all of which occupied by "houses" or "yards" corresponding to individual neurons (but in the real brain, there are 3 dimensions, of course). The "houses" would be locally connected through dendritic connections in areas corresponding to residential "neighbourhoods". And there would be many axonal connections linking these neighbourhoods to the far reaches of the brain's territory.

The total population of neurons in the brain is about 100 billion, which is 15 times the population of humans on the earth.

Thursday, August 21, 2008

Financial Metaphor

Managing your emotional life can be compared to managing finances.

"Investments" need to be made. Investments of emotion, attachment, time, energy. And money too.

It is much easier to "invest" when you have a bunch extra to work with. Wealthy people have an easier time putting money aside into new profitable ventures.

When you are using all your resources just to survive, it can be insulting and frustrating to be asked to "invest".

Sometimes, especially in depressive states, people are operating in a state of continuing, advancing debt. Emotional debt. Energy debt. Time debt. Relationship debt.

In addictive states, there is a neurophysiological debt that has to be "paid off" in order to get out of the addiction -- the price is in the form of acute and chronic withdrawal symptoms.

There are books out there about how to invest or manage money wisely.

I don't tend to like these books, in part because I think our culture has a very unhealthy preoccupation with financial wealth. Those who manage the economies of nations also perhaps consider financial wealth or growth a higher priority than a more basic good, such as "well being".

But I think that economists, marketers, and business managers can have excellent ideas, and I have to remind myself to keep an open mind.

How IS it possible to "invest" when you don't have very much?

Most financial advisors would say to automatically squirrel away a little bit every month, and stick it in an RRSP or something like that.

The key is -- consistency, regularity, and automaticity. A little bit each month--or every day--wisely invested, can add up.

In depression, such investments might take the form of "automatically" spending a little bit of energy or time exercising every day (even a minute or two). Or working on relationship-building. Or looking into a new activity. Or meditating.

If there is a state of "indebtedness" then making a plan to pay off the debt in an organized way, and to make a budget, etc. is necessary. But sometimes, external "debt relief" is needed. This may require reliance on external help for a time.

Another thing most financial advisors would say is that one should "diversify". Investing in only one thing makes you vulnerable to having a huge loss if the market changes suddenly. Investing in several different areas protects you, and insulates you, from environmental change. This could apply to relationships, activities, and therapeutic resources. Of course, if you "diversify" too much, it leaves your energies so diluted that it can be hard to appreciate or grow from your involvement in any one thing.

A final note I would make in this analogy is to observe that most financial advisors are actually salespeople, and not true unbiased advocates. While they may be sharing good advice with you, they will also profit from you investing with them. This automatically biases their advice. Perhaps not everyone is interested in building a big RRSP fund to pay for their retirement years; perhaps not everyone cares if they miss out on "market growth opportunities". It may be more important for many individuals to put more of their resources into the here and now.

So I encourage you to be well-informed about your "investments". Receive advice, but also research your choices independently, then decide.

Sometimes the best time for "investment" is when you are already feeling better, when there is an abundance of emotional resources again. Remember then, to put aside a little bit each day, this may protect you during a future drought or famine. Things like CBT, exercise, etc. sometimes work better when you are already feeling better, and you are using them preventatively. Even medications may sometimes work better as preventative agents than as acute treatments.

Wednesday, August 20, 2008


I should caution the reader that this particular post is less directly related to psychiatry--it's more of what I would call a "philosophical musing". So you may want to skip over this post if you're not in the mood for it. But it's something I've thought about for a long time, and I find themes pertaining to it coming up frequently in my daily work.

Consciousness is miraculous.

It may be (actually this is exactly my view), that from a scientific point of view, consciousness is the product of chemical and electrical signals in the brain, influenced by both internal and external stimuli, forming an integrated network with numerous complex feedback loops. Regardless of the causes of consciousness, it remains miraculous that any physical process could give rise to a subjective experience of awareness.

The issue of free will is related. Even if we claim that free will is an illusion, that all choices are determined by the existing structure of the brain in combination with environmental events, and furthermore that brain structure and environmental events are themselves determined by historical precedents (perhaps with a degree of true randomness at the core of physical phenomena rendering all of these processes imperfectly predictable), the awareness of having -- or seeming to have -- free will is also miraculous.

Clearly there are "degrees" of consciousness. Human awareness can vary--or be changed pharmacologically--from full alertness, or hyper-alertness, to many degrees of sedation, to unconsciousness. Apparently absolute unconscious states may only be relatively so, since some degree of stimulus may produce a response even in people who are sleeping deeply, anesthetized, or comatose. As we agree that there are degrees of consciousness, how sure can we be that there is an "absolute zero" where there is no consciousness at all?

If awareness or consciousness is the product of the brain, and the brain's function is a property of a network of chemical and electrical connections, then it may follow that any system in which there are chemical or electrical connections carries a form of consciousness. It seems grandiose -- on the part of humanity -- to claim that the human brain is the only structure capable of conscious awareness or the perception of will.

Most people would have no difficulty asserting that higher animals are conscious, though most (I included) would say that the consciousness of animals is "lesser" than that of humans. At the most obvious level, we can say that the intellectual and language feedback which enriches our conscious experience is much reduced in animals, such that very little cultural development over different generations is possible in non-humans. Another "thought experiment" type of question would be, who is MORE conscious, a fully alert dog, or a heavily sedated human? I guess many would say that there are "types" of consciousness, and that the "human" type is qualitatively different than "non-human" types, irrespective of the degree of alertness or sedation, etc.

Fewer people would claim that simpler animals are conscious.

Very few people would agree that plants are conscious.

Almost nobody would agree that rocks are conscious.

I claim that all of the above may be "conscious" in a way. I do not mean to sound mystical at all here, just extending the logic that if chemical or electrical connections in a network give rise to consciousness, then perhaps any systems of chemical or electrical connections that form feedback networks are also conscious. Therefore, all of the universe could be considered "conscious". A rock could be considered "conscious" since it is intimately linked -- chemically and electromagnetically -- to its environment, and both disintegrates and incorporates environmental elements continuously during its lifetime (obvious changes in chemistry and magnetism perhaps taking place over thousands or millions of years--an example of how some forms of "consciousness" may involve different time-scales than what we are used to).

A corollary of the above could be that since consciousness is a product of networks of chemical interaction, then all conscious beings are "interconnected", perhaps part of a higher-order consciousness. A simple example of this would be to look at politics. Often times we refer to nations as though they are people. We talk about "what Russia is thinking", or about "U.S. arrogance", etc. While this is figurative language, there is a level of literal truth, I suppose, to consider that a nation itself represents a higher form of consciousness, or could at the very least appear to be a higher form of consciousness to an external observer (i.e. someone who did not realize they were communicating with a nation instead of with a person).

I am not saying that this therefore makes it rational to start singing songs to the rocks to soothe them, or to embrace some kind of animistic belief system where we deify or personify plants, mountains, planets, gemstones, etc.

But I hope this line of thinking may cause us to extend respect and caring to all things. Fellow humans. Fellow animals. Fellow living things. Even inanimate objects. The earth. The air. The soil. Your home. Your room. Your belongings. Other people's belongings. Objects that have been thrown away. And, going inwards, to all the different parts of our body (many of which, ironically, are as inert or "dead" as stones, but still require care -- for example our teeth, hair, epidermis, or nails). Going inwards further, on an even more abstract level, your feelings, your thoughts, and your life history, all deserve respect and caring.

The act of respecting and caring for ourselves is part of healthy living. I think this respect and care can be extended to all aspects of the environment around us.

And, on a slightly mystical note I suppose, I wonder if there is something about respect and care that is always mutual--so I wonder if the universe can, on some level, always perceive, understand, and reciprocate such care. This is sort of a "karma-like" idea.

Stepping back from a mystical note, though, I think there is solid psychological evidence to support the idea that caring and respecting as a way of life is part of staying healthy and happy.

Monday, August 18, 2008

Types of Alcoholism

The term "alcoholic" has been used frequently in contemporary culture. Often the label itself may carry a certain "shock value", which, I suppose, could lead to a recently-labelled "alcoholic" contemplating more seriously a reduction in alcohol use. I always worry about labels, though, because I don't like the idea of being or sounding judgmental or critical (there is enough judgment and criticism in the world today, and in psychiatric illness a lot of extra judgment and criticism comes from one's own mind). Yet I do believe in the value of attempting to fearlessly speak the truth about things, even if they are truths that we don't necessarily want to hear.

Each person who has a drinking problem may have unique factors that have contributed.

Some researchers have categorized "alcoholism" into two types. Type I alcoholics may use alcohol as an attempt to treat anxiety, and are less likely to associate alcohol with thrill-seeking or fighting. Type II alcoholics may use alcohol spontaneously for thrill-seeking, and are more likely to have had alcohol-related problems with fighting, etc.

In my opinion, there is some support for subtyping alcoholism this way, but of course I think there is a much wider range of contributing or causative factors. I can think of some people who started out with a "type II" pattern as a teenager, but ended up in a "type I" pattern later on. Others may have a sort of mixture of "type I" and "type II" characteristics. For both subtypes there is probably a robust hereditary predisposition, some of the predisposing factors being direct (i.e. a predisposition to use alcohol excessively when available or a predisposition to react to alcohol in a certain way), and some of the predisposing factors being indirect (i.e. anxiety for type I, high thrill-seeking for type II).

Type I is more common, and is probably easier to treat, I think because there are underlying issues and needs that can be met in other healthier ways (e.g. treating anxiety, building healthier relationships, engaging in psychotherapy). Type II can be more challenging to treat, particularly because those with this type may be less likely to want treatment or change.

Here's another useful link with info about alcohol and addictions, from the Centre for Addiction and Mental Health:

Friday, August 15, 2008

Real vs. Perceived Alcohol & Drug Use in University Students

I always ask patients about drug and alcohol use.

Often times, someone will tell me that they drink alcohol or smoke marijuana "socially" or "on weekends" or "average". I always follow this up with more questions about how much this really amounts to.

Often times, this amounts to a pattern of either daily use, or quite frequently of having binges at least once a month, sometimes once or more per week.

It is quite clear from a medical point of view that binge drinking is psychologically harmful: not only does it place someone in a position of higher risk for physical accidents (I do not have to search my memory far to think of tragic alcohol-related deaths or severe head injuries among young students in the prime of their life), the pharmacological effect of this type of usage will exacerbate all mood and anxiety problems. It will interfere with normal sleep for long periods of time after the binge is over, and if there is a mood-related or anxiety-related sleep problem already, it can push the symptom intensity up much higher and make it much more difficult to treat.

I have found that many people, upon describing their pattern of binge drinking or marijuana use, will say that their behaviour is part of normal, ubiquitous university culture, i.e. "everyone does it."

Here is what some statistics show from a local part of a large recent continent-wide survey of university students:

Percentage of students who actually have never used marijuana: 63%
Students' belief about what percentage of fellow students have never used marijuana: 16%

Percentage of students who actually use marijuana daily: 1 %
Students' belief about what percentage of fellow students use marijuana daily: 16%

Percentage of students who have actually never used alcohol: 16%
Students' belief about what percentage of fellow students have never used alcohol: 3%

Percentage of students who have used alcohol daily: 0.1%
Students' belief about what percentage of fellow students have used alcohol daily: 30%

All of these above figures show that students greatly overestimate how much their fellow students are drinking and using marijuana. Because of how powerful the influence of social pressure is, especially to young people, it is important to be reminded of the facts. It is much more the "norm" for students to drink or use marijuana rarely, if at all. And it is common -- not rare -- to be completely abstinent.

However, one concerning figure from the same study shows that about 40% of male students, and 30% of female students, have had 5 or more drinks in one sitting at least once in the past month. This is a binge. And this is associated with the greatest risk of physical and psychological harm. For almost 10% of students, binge drinking occurs 3-5 times per month, which is more or less on a weekly basis. This type of behaviour is certainly a prelude to a more severe future of alcoholism, with all its physical and psychological sequelae.

Based on my reading of epidemiological studies, it is clear to me that 2 drinks per 24 hours is the maximum quantity of alcohol reliably consistent with good health (it may be that this level of alcohol consumption actually confers health benefits compared to abstinence, at least for some people).

I am not convinced that any amount of marijuana use is consistent with good health, except perhaps for some people who may have used it just a few isolated times in their lives, in a good mood, in a pleasant environment, which may have helped them relax some of their inhibitions or gain some other insight about themselves or the world. It is more often the case, though, that such experimentation leads to negative health effects.

Thursday, August 14, 2008

Internet Addiction

It has come to my attention, both in my practice, and in a recent review of results from a large survey, that many people are using the internet so much that other areas of their life are suffering.

For university students in particular, a high percentage of individuals report that their internet use is adversely affecting their grades.

The internet can gobble up time in numerous ways: if you are bored, you can find an endless stream of connections that can keep your mind absorbed with new tangents.

Many people use the internet to communicate with others. The internet can be a wonderful technological aid which fosters closeness, expands our community of friends and peers, etc. But it can also cause us to be so absorbed in the activity itself -- of talking to friends, or perhaps to strangers -- that hours of time pass by. Sometimes these hours are spent online when they might otherwise have been spent visiting a friend in person, doing a healthy activity outside, studying, etc. Sometimes these hours are spent in the middle of the night, instead of sleeping.

There are other addictive lures that may snag people's attention, including games, gambling, and porn. Perhaps all of these activities allow people to enjoy certain aspects of life with greater freedom and discretion. But they can be very addictive, in the sense that a relationship can be formed with the activity, at the expense of other life relationships (e.g. with other friends or loved ones, with work, with school, with other interests, with physical self care and exercise, etc.).

So I'm not saying that the internet is bad. But I encourage people to be careful not to be involved with a computer in an addictive way, in a way that is interfering with other life activities and relationships.

To some degree this is a cultural issue -- our modern culture is changing, and the computer is becoming increasingly a part of it. This may be integrated in a way that is healthy and part of a new "normalness", just as any new technological innovation changes behaviour and culture (from the invention of the wheel or of fire, to the printing press, to the automobile, to the TV, etc.). There are those who resist any cultural change, or pronounce it to be unhealthy. So the internet is here to stay, and I hope can remain an enhancement to our culture -- but we need to learn ways to participate in the culture in a way that is safe and healthy, and to be aware of its dangers (just as we need to be aware of the dangers of fire, wheels, or the automobile).

As a formal challenge, I encourage people to try a month without using the internet at all, and to assess how life is different during that time.

I have made a similar challenge to people about TV, to turn it off completely for a month, then to review any differences in the way they feel.

I recognize the irony that I am making these statements in a forum only available on the internet!

Tuesday, August 12, 2008


The feeling of boredom may be a signal to change what we are doing, to seek something more stimulating or pleasurable.

Many signals that the brain gives us are helpful guides, which lead us to make better decisions.

Other times, the signals the brain gives us are misleading.

In the case of boredom, the brain may be conditioned to expect a lack of stimulation or pleasure in a given activity. And it may be conditioned to expect stimulation or pleasure by leaving this activity. If this behavioural pathway is followed, it may further lead to a conditioning effect, in which the initial activity feels even more boring the next time round. It is like the forest path again, and each time you go down the path, it becomes more established.

I believe that in many cases the brain causes us to leave experiences prematurely. There might be much more pleasure, stimulation, and meaning in activities that are felt to be boring, but the brain is too habitually eager to get us out quickly, to the alternate activity.

As an exercise, I encourage practicing ways to discover interest, stimulation, meaning, and pleasure, in activities that you have pronounced to be boring (e.g. working through a textbook for school; getting through a work shift; commuting; conversing with someone who isn't your favourite person, etc.). It may require looking at the experience in a different way, with an eye to find significance, meaning, and interest, rather than focusing on the aspects that you find tiresome.

One very specific way to discover this change of perception is to take a class in drawing, painting, or photography -- often part of the experience is of learning to see things in a different way, to become absorbed with interest in something you thought was mundane. Another technique is to take courses in meditation, in which one can learn to be more at peace with the present moment, even while sitting quietly with almost no external stimuli.

In my work with students, I believe this is an extremely important issue. Many students have enrolled in a course of study that may last at least four years, or may lead to a lifetime career. Yet they are bored with what they are doing. I strongly encourage choosing courses (or other life decisions) that have a hope to be interesting, and coming to the work with an attitude of finding significance, meaning, and interest, rather than expecting or continuing an experience of boredom. Boredom leads to disengagement, a fractured relationship with what you are doing, and can be the beginning of lifelong unhappiness with the present moment.

While you may need to make external changes, it is important to make a strong effort to direct internal changes too.

Friday, August 8, 2008

Music & Repetition

Life is full of repetition.

Life problems, including many of those associated with depression, involve a lot of repetition, and monotony.

Symptoms recur. Relationship problems recur. Problematic themes recur.

We often seek to end the repetition.

Sometimes it is necessary to end the repetitive cycles, if we can see them.

Other times, I think one can work with repetition in a similar way as occurs in music.

Music is repetitious. The rhythm or beat may be constant. Various accompaniments may be the same throughout. Themes within a piece of music may continuously recur. Without some degree of repetition, a musical piece would seem confusing or aimless. Changes, colourations, variations, and harmonies can transform monotonous repetition into a beautiful and dynamic composition. Repetition itself may not be the problem.

I encourage the idea of managing some recurrent life themes in a musical way --your repetitive theme could be part of a meaningful composition. Also, a musical approach may permit you to work through the old theme, say goodbye to it, and introduce something new.

Activation Energy

In chemistry, there are atoms or molecules that can react very strongly with one another, perhaps leading to a new molecule, or to a release of energy.

Yet, these particles may not react, unless they have a sufficient energy, the "activation energy".
The activation energy is like a fence to climb over before you can ski down a hill. Often times, the reactions don't happen in our lives, because we do not climb over the fence, we do not reach the activation energy.

Some reasons for the activation energy phenomenon may be that some particles need to be "pushed together" energetically in order to react. You may need to push yourself sometimes into an action that ends up being extremely meaningful and self-sustaining.

Other reasons for an activation energy barrier could be "geometric". For example, a key or a puzzle piece may fit, but it has to be placed in just the right way, at just the right orientation or angle, in order to work. Pushing harder and harder will not solve this problem. Sometimes we push ourselves, things seem not to fit, but it is because we are approaching the problem at the wrong angle.

Catalysts are things that reduce the activation energy barrier. Sometimes the fence in front of the hill is too tall to climb. A catalyst is like a gate in the fence. Or it could be an environment in which things fit together more easily (e.g. it could be like having surrounding portions of the puzzle done for you, permitting you to more easily place your piece with more clues).

Behaviourally, we must be willing to invest "activation energy" into new actions and ideas. The resulting reaction may pay off, and return much more energy and meaning.

We must also search for, and be willing to use, catalysts. A social catalyst might be a friend, who could help introduce us to new friends. Or it might simply be a place where you feel comfortable -- such as a community centre, school, coffee shop, church, etc. The physical place may be a catalyst to help you meet a new friend, or attain greater social comfort.

I think therapy is a catalytic process in many ways, in that it may not always provide energy for action directly, but could help provide a "surface" in the form of a therapeutic frame, a place to re-organize our orientation to things, permitting reactions to more easily occur.

Tree Metaphor

Imagine your self as a tree. You require soil, water, and sun.
How does water ascend from the soil all the way up to the tips of your leaves?
A small portion of the energy may come from your roots.
The pathways inside of you are mainly conduits for the water to rise, and cannot really pump the water upwards.
Most of the energy comes from the sun, from energy that causes evaporation in our leaves. This creates suction. This energy is so powerful that it can draw water up to the top of a 100 metre redwood tree.

I see this as an analogy to energy and motivation in our lives. We can't provide all of our own energy and motivation. We must be involved in external things which draw action out of us, as the sun and its evaporative effects draw water all the way up a very tall tree. This leads to continuous "columns" of action, beginning at the roots, ascending to the outer portions of our selves. Others (other relationships, other involvements in community) are necessary to keep this cycle going. It is very hard to generate your own motivation all alone--"root pressure alone" can only go so far.

Many of my patients with low motivation and energy try very hard to initiate activity. A turning point can often be when they become involved with others, or with a community, or with some other external structure, that can help keep this "column" of motivation rising to new heights.

Tuesday, August 5, 2008

Discontinuing Benzodiazepines

Benzodiazepines are common sedative drugs which are prescribed to treat anxiety symptoms and to treat insomnia. The most common of these are lorazepam (ativan), clonazepam, temazepam, diazepam, and many other drugs ending in "pam". Some of the newer sleep medications such as zopiclone are quite similar pharmacologically to benzodiazepines, and in my opinion may as well be included in this discussion, despite their supposed reduced risk for dependence problems.

These drugs can be powerful life-saving agents, in treating seizures, in treating alcohol withdrawal, in surgical anesthesia, and for numerous other applications.

For insomnia and anxiety they are best used for very short periods of time, usually only for days or a few weeks.

It is very important to note that there are some people, in my opinion, who do better to continue taking benzodiazepines on a long-term basis to treat chronic anxiety symptoms. There are some "anti-benzodiazepine" groups out there which I think fail to acknowledge that some people really do benefit from long-term benzo treatment. There are many more people, in my opinion, who do well to use benzodiazepines repeatedly, for brief periods of time, during symptom exacerbations. The "anti-benzodiazepine" groups are too dogmatic, in their criticism of this class of medication.

Yet, for many people, longer-term benzodiazepine use does not help, but instead causes more problems. The benzodiazepines cause more physical and psychological dependence than most people realize, and therefore can be difficult to discontinue.

If you want to discontinue a benzodiazepine, here are some of my suggestions (once again, all of these ideas need to be employed in collaboration with a trusted prescribing physician):

1) Do it extremely slowly, especially if you have been on it for a long time. Do not stop suddenly. I would suggest 5-10 % dose reductions every 1-2 weeks. I have recently discovered that so-called "compounding pharmacists" are available who will prepare individualized doses of medication--for example in a liquid form --so that you can do tiny dose reductions of benzodiazepines very conveniently and precisely.

2) Consider switching over to diazepam (Valium), at a dose which has an equivalent effect for you to start off with. (there are tables to refer to, which show approximately how much diazepam is equivalent to doses of other sedatives or benzodiazepines). The advantage of valium is its much longer period of metabolism in the body, which can then soften the effect of small dose changes.
Once again, 5-10 % dose reductions every 1-2 weeks (you can use the higher reduction more frequently if you are tolerating the taper more comfortably).

Addendum: a recent review in the Cochrane database (an excellent collection of evidence-based research studies) suggests that switching to long-metabolizing benzodiazepines such as diazepam may not be necessary. However it is pretty clear that tapering slowly is important. (Denis et al, Cochrane Database Syst Rev. 2006 Jul 19;3:CD005194)

3) Often times, the first 50% of your dose reduction will be easier and quicker, and the last few milligrams of your dose can be hardest to taper. So you may need to taper more slowly during this final stage. Once you get down to about 0.5 - 1 mg of diazepam daily, you can discontinue entirely (diazepam comes in 2 mg and 5 mg tablets).

4) Sometimes an adjunctive drug such as an anticonvulsant can make the tapering process a little easier, although the evidence is weak and shows that the benefits are not consistent or robust for everyone. It may help a particular individual though. Examples of suitable anticonvulsants are carbamazepine, gabapentin, pregabalin, and others. The usefulness of carbamazepine was affirmed in the above-mentioned study by Denis et al.

5) Antidepressants such as SSRI's may be helpful to treat the underlying anxiety or other symptoms that the benzodiazepine was prescribed to treat in the first place. However, one should not expect that SSRI treatment will treat or reduce benzodiazepine withdrawal symptoms. Sometimes the SSRI may actually increase some of the withdrawal symptoms, if the SSRI is itself slightly interfering with sleep or causing physical side-effects such as restlessness or nausea.

6) I would like to emphasize that, in most cases, all other available treatments for anxiety, agitation, irritability, or insomnia should be optimized before resorting to benzodiazepines. These include healthy lifestyle change (e.g. moderating stress, exercise, eating well, etc.), cognitive-behavioural therapy, meditation, and non-addictive medication (e.g. SSRI antidepressants). The only exceptions to this would be in cases of alcohol withdrawal, seizures, or highly agitated acute manic or psychotic states, in which benzodiazepines (sometimes at high doses) could be extremely important and necessary.

Discontinuing Antidepressants

Antidepressants usually should never be stopped suddenly. Also, if you are taking an antidepressant it is important to take it daily without skipping doses.

If the antidepressant level in your body drops suddenly, it will not cause a sudden plunge into depression as a result -- the impact of antidepressants on mood disorders occurs over a period of weeks or months.

But if the level drops suddenly, it will cause a withdrawal syndrome. Symptoms include nausea, anxiety, insomnia, abnormal physical sensations in the body, and a variety of others. For some people these symptoms are no more than a nuisance which passes easily after a week or so. But for others it becomes an intolerable syndrome, which furthermore can magnify previous symptoms of depression and anxiety. The withdrawal syndrome may fool you into thinking that you require the antidepressant on an ongoing basis (since you feel awful when you stop it), when in fact you may be ready to discontinue as long as you do it gradually.

--by the way, I am not advocating that people try to discontinue antidepressants if the medication is helping--in most cases I advise people to stick with an antidepressant that works for them, and if their symptoms are recurrent or chronic to consider a long-term course of the medication--

Most of the SSRI antidepressants (e.g. paroxetine, fluvoxamine, sertraline, citalopram, escitalopram) and other antidepressants such as venlafaxine, can cause a withdrawal syndrome. Paroxetine and venlafaxine seem to be particularly notorious.

There are various reasons to discontinue a medication. Sometimes people want to stop because they have been feeling better for a good long time, and want to see if they can stay well without a medication. For others, the medication is not working, or is working questionably well, and it is time to make a change in plan. For others, they are simply fed up with taking pills, and want to stop.

If someone does want to discontinue, I have a set of suggestions that makes the process easier (these are ideas that need to be applied with guidance from your prescribing physician):

1) if the medication has only been taken for a short time (a few weeks or less) usually it can be discontinued very quickly, and a problematic withdrawal syndrome is not very likely
2) if the medication has been taken for a long time, then I recommend an extremely gradual tapering. Most tablet sizes permit easy dose changes of only 25-50% at a time. These changes are too large. I suggest shaving off tiny amounts, and sticking with the new lower dose for up to a week at a time before reducing the dose further. Sometimes, a 10% dose reduction every week is best tolerated. For a tablet, this may mean cutting off about 10% of the tablet with a sharp knife. Fortunately, with antidepressants, the EXACT dosage is much less critical than for other medications (such as hematological drugs, etc.), so this relatively imprecise method of dose reduction is appropriate for this purpose, in my opinion. Some antidepressants come in capsule form (e.g. venlafaxine and sertraline). In these cases, I have recommended that people take the capsules apart, to carefully remove a small percentage of the contents, during their taper (venlafaxine XR 75 mg capsules have approximately 200 little granules inside; one could take out 20 granules for a 10% dose reduction).
3) If this process--of gradual tapering--is not working out, I have a second method which can often help: fluoxetine (Prozac) is the one antidepressant with an extremely long period of metabolism in the body. So it does not have a sudden withdrawal syndrome. Fluoxetine can be added to another antidepressant regimen, at which time the other antidepressant can be tapered much more easily. After this, fluoxetine itself is much easier to taper and discontinue, as it "tapers itself" out of the body gradually over about 4 weeks. Once again, this would have to be attempted only with close guidance from your doctor, because sometimes (rarely) adding a second antidepressant can cause other problems (e.g. a "serotonin syndrome").

Sunday, August 3, 2008

Forest Paths Metaphor

One's life, or mind, or brain, is like a forest with many paths.

There is some literal truth to this metaphor, in that the connections in the brain that form memories and patterns of behaviour, most likely exist as pathways between many different neurons, with the pathways consolidated and strengthened further every time they are activated.

Some of our forest paths may be well-trodden, but lead us into dangerous territory every time (maybe into poor relationships, addictions, recurrent self-destructive thoughts, depressive symptoms, or other harms to self).

But it is not easy to navigate new paths. The familiarity, ease, and convenience, of the old paths makes them the most likely to take.

You may need to do hard work forming new paths in your forest, resisting the urge to take the old familiar ones.

The old paths may never "close up" entirely. Look at the paths in a literal forest outside. Even paths that are overgrown for years are still apparent, and if someone was to make a new path in that area, chances are they might choose that same old overgrown one.

But old paths gradually weaken, if they are left untrodden. You may need to leave them dormant for years (imagine those protective fences they put up in forests to protect "ecologically sensitive areas" from being trampled by hikers--put some of those up in your own mind and in your own life).

What to expect from an antidepressant

Here is what to expect and to watch for when starting an antidepressant:

1) some people will have an immediate positive effect from an antidepressant, they will notice improvement in mood or anxiety right away.

2) most people, though, will notice very gradual improvement, and it will require at least two weeks at a full dose to have a substantial change in symptoms. Some people may require a longer period of time, up to 2 or 3 months or longer, to notice a benefit.

3) many people have their worst side-effect problems in the first 1-2 weeks of starting an antidepressant. Side effects might include sleep problems, nausea, sweating, or increased anxiety (there can be many more side-effects too). Usually these side effects settle down after 1-2 weeks.
To reduce the likelihood of this being a problem, I usually start most people on a tiny dose of an antidepressant (for example, 1/4 tablet daily), to allow people to adjust more gradually. The advantage of this is less side-effects, but the disadvantage is that it could take longer to experience a benefit. Studies show that the most significant and consistent positive effects of antidepressants begin at a full daily dose (usually one tablet daily of most antidepressants).

4) Some people may have severe side-effect problems. If this happens, I usually recommend that they discontinue the medication, so that we can make a new plan. People who have bipolar disorder, or who may have a higher risk (e.g. through family history) of developing bipolar disorder, have a higher risk of severe side-effects from antidepressants, and have a higher risk of experiencing a manic episode as a result of taking an antidepressant.

5) In all cases, I like to see and hear from people frequently whenever a new medication is started, so that any possible problems can be addressed early. Sometimes side-effects can quietly pass, other times it might be best to back off, stop the medication, and try something else.

6) The benefits of antidepressants can sometimes be subjectively obvious, other times they may be quite subtle. Others around you may notice beneficial effects before you do yourself. It may be only after a few months that you can look back and see (and feel) that things are better.

7) There is evidence that antidepressants reduce the risk of relapse in recurrent depression (probably about a 50% reduction). For some people, even if they may not need the antidepressant to treat current, acute symptoms, they may benefit from continuing the medication so as to prevent relapse. Of note, studies also show that psychotherapy (CBT in particular) reduces relapse rate by about 50% as well in recurrent depression. And there is evidence that the combination of medication + psychotherapy is synergistic, and may reduce the relapse rate by 75%. Reference:

8) Sometimes you need to try several (or many) different antidepressants, before finding the one that suits you best. Different medications in the same class (e.g. the various different SSRI's) can sometimes "suit" people quite differently. For many of my patients, a combination of two antidepressants, or sometimes more complex combinations of other medications, ends up helping best. In these situations, I do think it is important to give each medication trial a good, thorough try (usually at least two months) before making major changes.

Soothing a Crying Baby metaphor

When a baby is crying, it is important to assess what might be the problem:
-is the baby hungry?
-is the baby having some pain?
-is the baby medically ill?
-does the baby need to be changed?
-does the baby simply want affection or human contact?

It is important to meet the baby's needs.

Sometimes, though, the baby may continue crying, despite you addressing and ruling out the various possibilities described above.

What can you do?

I think it is important to be present with the baby. Be soothing and calm in your voice and touch and movement. Try not to react with frustration or anger or fear at the baby's continuing cries. But simply be present, gentle, and calm. Dance. Sit. Rock gently. Massage. Sing.

If you need to take a break, have one briefly, or have someone else take over for a while.

But return, continue, be present, be soothing, be calm, try not to let the agitation of the baby cause you to be agitated (if you become agitated or tense yourself, it may lead to a vicious cycle, and the baby may continue to cry with greater distress).

The baby will eventually stop crying. And it will learn over time that crying or distress may come and go like waves, but that there will be always someone calmly present. It is like the baby will learn -- with a guide (you) -- how to swim in stormy waters. The baby will eventually "internalize" the external guide, and this calming presence will become part of the baby's self.

I consider this to literally be part of healthy parenting and healthy infant development.

But I also consider it a metaphor for managing one's feelings and emotions at any time in life. Your emotions may be like the crying baby. The rest of your self is confronted with the task of handling the crying baby. So, be present, listen and attend to what the need may be; be soothing, be calm, try not to let the agitation of your "crying baby" cause the rest of yourself to be agitated. And you too may need breaks -- just like a tired parent -- and may need someone else to help out for a while.

Stellar Formation metaphor

Developing in life reminds me of stellar formation:

Things start with a thin cloud of dust (the dust may be so thin as to consist only of individual atoms).

There is just enough gravity to cause the huge, thin cloud to pull together slightly.
(this may take millions of years)
Eventually the cloud is dense, and is even getting warmer in the middle.
The gravity continues to act, the density increases, until the cloud is very dense and much more compact.
When the middle of the cloud is dense enough and hot enough -- an incredible qualitative change happens, one of the miracles of physics and one of the outstanding phenomena of the universe:

nuclear fusion spontaneously begins. The energy from this is tremendous, and a star is born.

Dust turns into a star. The requirements are time and gravity.

We all have time, and we all have gravity. Our lives may be full of dust. Don't let that discourage you. Gather what you can together. A powerful qualitative change can happen even after a long, long, period of waiting and working.

Saturday, August 2, 2008

Swimming Metaphor

Learn to swim.

Symptoms are waves and storms that hit us. These waves and storms may cause us to panic, to flail and struggle in the water. This causes exhaustion and can cause us to drown. It even makes us harder to rescue.

Learn to float. Let the waves come, float with them, let them go. Learn how to avoid flailing against the waves, and instead try to ride neutrally with them. Learn how to use your energy well in this type of situation.

It is like what I've read about being swept out to sea by a rip current. It will exhaust you to struggle against it. You may have to float with it a while until you have an opportunity to move laterally, all the while allowing more time for someone to help you.

In swimming you need to be willing to put your head under the water. In this position you cannot breathe, and you cannot see clearly. Yet in this position you can swim much more efficiently. There are reflexive, self-protective instincts that sometimes need to be over-ridden in order to progress.

I've always liked this metaphor but ironically I literally swim (in the water) very poorly. I need to take more lessons myself. Actually, I think one can apply this metaphor in general more easily if you literally do swim, and take swimming lessons (in real water!).

Friday, August 1, 2008

Canvas Metaphor

Your life is like a canvas, on which life experiences are painted.

If parts of your life have "gone wrong", or if there have been terrible injuries and painful experiences, these will permanently be part of the canvas.

Yet, the ongoing process of life, starting every morning, gives a daily opportunity to add more to the canvas. Part of the "painting" is outside your control, but part of the "painting" is controlled directly by your will.

Paint well. Learn new ways to paint. Learn from books, learn from other people, learn from children, learn from the elderly, learn from animals in nature. Be willing to use new tools or brushes or pigments. You may need to take a colour mixing class, so you can get just the right hue that you want. The canvas is large, and expanding. The painful areas may not disappear, but their relative size on the canvas will diminish as you add more to your painting each day.

You may find that your painting intersects or resonates with other people's paintings. That can be a great joy of life. Or you may find that your painting stands alone. There is room for every style in the great art gallery here on the earth.

Reading List

Here is a set of books that can be worthwhile to read, dealing with mental health & self care issues. I think I will try to update this list regularly as I stumble upon new titles.

1) The Feeling Good Handbook by David Burns. An overview of cognitive therapy ideas, with lots of exercises to work through, pertinent to anxiety, depression, relationship conflict management, procrastination, among other things. Sometimes the book may come across as saying (imagining the smiling face of the author on the cover of the book): "if only you did my exercises properly or more thoroughly, you too could have a happy life". I think this is a weakness of the book--it is important to acknowledge that cognitive techniques can help, and they require a lot of work, but they may not help all symptoms, sometimes they may not work at all, the exercises often may not be pertinent, some of the content may seem trite; and the style of the book may be annoying to some. Yet I do think it is quite a comprehensive overview of some cognitive techniques, and it is worth looking at; the author validly challenges you to actually work through all the exercises with pen and paper, cover to cover, before judging the book. While cognitive therapy can help during a bout of severe depression, I think it is most useful when you are actually feeling better already, or only feeling mildly symptomatic. The cognitive therapy can help prevent relapses, help you stay well.

2) Against Depression by Peter Kramer. A very good defense of biological psychiatry. Also some interesting ideas about how quite severe depression, with its associated severe suffering, may have been "normalized" in current and past culture, in the arts, etc. It is an interesting and thought-provoking idea. I personally agree with many of his points.

3) An Unquiet Mind by Kay Jamison. Her other books are also worth looking at. She tells her personal story of dealing with manic depressive illness. From an interesting perspective, in that she is a famous research psychologist who has co-authored one of the major textbooks on the subject of manic depression.

4) various of the books by Irvin Yalom. Enchanting and delightful at times. Some might find him annoying. But an example of what psychotherapy experience can be like. He has a very open and liberal style (perhaps too liberal for some).

5) various of the books by Oliver Sacks. Interesting to learn about the different experiences and phenomena associated with the brain and its disorders. In this way a commentary on the human experience in general.

6) I encourage people to visit an academic library, and browse through some of the major psychiatry and psychology journals. Look through them as you would copies of waiting-room magazines. You'll get a sense of what's going on in research, what some of the new treatments are, and how psychiatrists and psychologists think. Many of the articles are pedantic and questionably relevant, but others are more readable, pertinent, and interesting. The biggest psychiatry journals are The American Journal of Psychiatry and Archives of General Psychiatry. Another good large journal is The British Journal of Psychiatry (more of a European perspective). Journals devoted specifically to the latest medications and other technologies for treating mental illness include The Journal of Clinical Psychiatry (this journal seems quite influenced by industry, but has good updates about medication treatments), The Journal of Clinical Psychopharmacology, and Biological Psychiatry (this journal can be very technical). There are lots of interesting journals devoted specifically to psychotherapy as well, and in the psychology literature there is a wealth of other perspectives to look at (however, many psychology journals contain articles that are full of technical jargon).

7) Read a textbook of social psychology. A wonderful field, very interesting. The textbooks are easy to read. And presents a rich body of evidence about social factors in personal psychological experience that we often neglect to consider in managing emotional problems.

8) Yoga for Depression by Amy Weintraub. This was recommended to me. As I scan through it I see good things. If not this particular book, I do think that at least something in this genre deserves an important place on your bookshelf.

9) The How of Happiness by Sonja Lyubomirsky. The author is a psychologist who has researched happiness, and the factors that contribute to it. An important subject, often neglected by the majority of us who focus on the factors that contribute to negative states or disorders, rather than the factors that contribute to health. However, the book, in my opinion, while having some good practical suggestions in it, is fairly weak and limited in its usefulness in its approach towards managing major mental illnesses. It is most useful for those who well, or who are recovering from their illness already, and want to consider some changes that could help them stay healthy and happy. It is also helpful, I think, for those who are chronically demoralized, moderately unhappy, but not clinically depressed.

10) Influence: the psychology of persuasion by Robert Cialdini. A useful book by a social psychologist, looking at the factors that persuade us to buy something, do something different, or change our mind. I think that being more aware of these factors -- often used in advertising or by salespeople -- can protect us from being persuaded to do things that we don't really want or need, and can therefore help us to make healthier decisions.

11) How to Start a Conversation and Make Friends by Don Gabor. So many of us struggle with shyness, or find it difficult to make new friends, or hold a conversation, etc. Here's a book that gives a lot of practical suggestions on how to approach these things more easily. I realize that many people believe a "how-to" book would not do much for them, or that the ideas in the book are things that are already very familiar or obvious to some, but I think that working through the book can only help, at least as a frame to contemplate and plan ways to make things better. There is a wide variety of books on this subject, and I invite people to check out numerous different titles--some people may need to check out numerous titles to find a book whose style and content suits them best. A search on a bookselling site such as Amazon, looking for "social anxiety" or "shyness" books will yield a nice variety to choose from.

12) Find a newspaper with a large collection of daily cartoons. Read them regularly. If you have a favourite cartoonist or humourist, get an anthology (e.g. I always liked The Far Side). A lot of other stuff in newspapers has a negative impact on mood, in my opinion, since newspapers focus on disaster and conflict in the world, rather than on things that are going well. We have to find a balance between staying well-informed and involved in debate or activism, etc. while not allowing the terrible stresses of the world to damage us. Of course, when depressed, it may be that nothing seems funny at all--and reading cartoons may just be an irritation; if this is the case, I'd advise you to give it a break until you're feeling better.