Dr. Raj,

A close friend of mine has been seeing the same psychologist every other week for over 4 years.  This friend is college educated and intelligent. He does not abuse drugs or alcohol.  He has a problem with anger management, often reacting out of proportion to events.  His reaction can range from melancholy to temper tantrums that include shouting insults.  He can go up to six weeks without having what I call a “melt down”.  How do I know this?  Because I have actually tracked his mood swings on a calendar over 12 months.  The melt downs can last 2 days, 1 week or he may have one very few days for 2 weeks.  Then, he will recover and appear happy and content for 2 to 6 weeks.  I know this is probably bipolar disorder.  Or maybe it is post traumatic stress, since he grew up with domestic violence between his parents.  The point is…my friend does not appear to be “getting better” in light of all the therapy he has gotten.  I can see no changes in his behavior!over the 3 1/2 months I have known him.  I know my friend speaks openly to his doctor and is honest to a fault.  He does realize he has problems with self esteem, depression, mood swings and handling his anger.  I know not every doctor is the same caliber, too.  What type of therapy should my friend be getting? Talk therapy? Cognitive behavior therapy?  What strategies can you suggest?

Answer:

Dear iNTj,

It does seem that you have a lot of insight into your friends problems and that you genuinely care about his well being.  You mentioned that he see’s a therapist every two weeks, how often is he seeing his psychiatrist?  What is the working diagnoses that his psychiatrist is treating?  Is he on any psychiatric medications and have any helped?

We now know that the most effective treatment will address the Biological-Psychological-Social domains individually.  What this means is that once, the presenting problem is understood, a health care practitioner should address each of these domains to get the most effective treatment response. The Biological domain usually involves medication management, the Psychological involves getting into psychotherapy and the Social domain involves looking at and understanding social factors that are contributing to the persons presenting complaint(s) i.e. family dynamics.

Remember that it takes time to correctly diagnoses and understand the dynamics of human behavior.  I know this can be frustrating for many individuals but the number of diagnostic tests in psychiatry are limited.  Our most useful tool is obtaining a through history from our patients and their families in order to come up with a working diagnoses and over time it is verified or adjusted.  Many times I hear from people, “My Psychiatrist only spent 2 minutes with me, how could he have correctly diagnosed me?”  My response to them is usually to find someone else who will spend the time obtaining the proper history to properly formulate a treatment plan.

As far as therapy goes, I think going every other week is not as effective as going every week.  In my opinion, much happens in two weeks and the session usually becomes about “catching up” versus working on insight.  Their are also many different types of therapy that range from working on supporting the individual to working on insight around internal conflicts.  Their are also therapies that focus on one’s thoughts (Cognitive Behavioral Therapy) as well as being more mindful about one’s behaviors (Dialectic Behavioral Therapy).  Which approach is best is dependent on the individual who is entering it.  As a general rule of thumb those in treatemnt do better than those who are not in treatment.

Thus, I commend your efforts in understanding your friend’s current challenges but remember that he must make the commitment to find the appropriate answers.  You can not do his work for him but only support him along the journey.  He’s lucky to have you in his life.

Hi Dr. Raj, I recently enrolled in a Master’s in Human Services program (online). However, I have already missed the dead line for the first assignment. It has been about 7 years since I have been in school and was really looking forward to starting and completing this course well. I’m not sure if I should withdraw from the program and complete it later or if I should take my losses and attempt to complete it any way.

Answer:

Dear Joy,

The first thing that comes to my mind is that it is appropriate that you are having some anxieties about being back in school (it has been 7 years and being in school is anxiety provoking itself); a few questions come to mind:

• Can you turn in your assignment late?
• Can you contact the instructor and find out exactly what impact completing your assignment late has on your final evaluation?

Wanting to complete the course “Well” has many different meanings depending on the individual; it is understandable that you had set your goals high but don’t let that stop you from reaching your ultimate goal (completing your Master’s Degree); when all is said and done, if you achieve an “A” or a “B” will all be an after thought.

I hear about people who say they take a “xanax” pill when they fly so they fall to sleep. What is this and can anyone get it?

Answer:

Xanax is a medication that belongs to the class known as benzodiazepines.  The benzodiazepines are considered to be minor tranquilizers with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties.

I think great caution should be taken when using a medication from this class of drugs because of it’s addictive potential.  However, in an individual with minimal abuse potential short term use can be appropriate.  In some situations, such as in your question, some individuals can become very anxious when they fly and require a minor tranquilizer to be able to tolerate the flight.

One aspect that I find very concerning is inappropriate use of this class of medications.  Many persons will go to their physician due to situational anxiety (an anxiety related to a particular stressor in ones life) and want something to relieve their symptoms.  What often happens is the person will find effective symptom relief and begin to psychologically become dependent on the medication.  I have seen many cases in which “pill popping” becomes a coping strategy.  Remember, I said that this class of medications is addictive.  Thus, what would have been a good short term strategy has turned into something that the person is now dependent.

What I suggest is asking your physician about addictive potential for any medications that are prescribed to you (Benzodiazepines are only available by prescription from your physician).  Make sure you ask the questions up front so that you don’t find yourself with a bigger problem down the road.

I hear a lot about depression and bipolar disorder on TV commercials.  I feel very sad sometimes.  How do I know if I may have bipolar disorder or just depression?

Answer:

The NIMH describes a Depressive Disorder as “an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression”. Depressive disorders come in different forms that include Major Depression, Dysthymia and Bipolar Disorder.  When someone is depressed, they may experience symptoms which include:

• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, being “slowed down”
• Difficulty concentrating, remembering, making decisions
• Insomnia, early-morning awakening, or oversleeping
• Appetite and/or weight loss or overeating and weight gain
• Thoughts of death or suicide; suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Dysthymia is a mild to moderate depression versus a Major Depression is a severe depression.  Dysthymic Disorder lasts longer than a Major Depressive Episode but is not as disabling with regards to work, school and pleasurable activities.  The third type of Depressive Disorder is Bipolar Disorder.  In Bipolar Disorder, not only does the individual experience the symptoms of depression (lows) but also experiences symptoms of mania (highs).  Symptoms of mania include:

• Abnormal or excessive elation
• Unusual irritability
• Decreased need for sleep
• Grandiose notions
• Increased talking
• Racing thoughts
• Increased sexual desire
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

A few gender differences that I think are worth mentioning: depression is twice as common in women than in men; about 6 million men in the US are affected by depression and many go undiagnosed; depression in men may not present with feelings of hopelessness but rather irritability and discouragement; lastly, depression has shown to be associated with a higher risk of coronary artery disease both in men and women.

If you feel that you have symptoms of depression or mania, make sure you discuss it with your physician to properly formulate a working diagnosis and treatment plan.  There is good treatment available and you don’t have to suffer needlessly.