ExcitableBrain, Mood,DxGroups
Excitable Brain and Mood Disorders < xml="true" ns="urn:schemas-microsoft-com:office:office" prefix="o" namespace="">
A person who has a mood disorder has a brain that is in a state of over excitability. This similar to a person who a seizure disorder who also has a brain that is over excitable. When either brain is further excited a certain threshold is reached, and there is a point of no return. In a seizure brain it results in a seizure, in a mood disorder person it results in some sort of mood melt down, that can be emotional, cognitive or a physical equivalent. This much like a seizure once started must run its course. The course is similar to a wave in that in mood disorder there is wave of mood instability, with high energy and low energy phases, corresponding to the elation of mania, followed by the depression of the depressed phase.
There are three phases, i) stable energy phase, ii) high energy and iii) low energy phase, corresponding to euthymia, normal good mood, mania followed by depression, as the brain recovers back to euthymia. Again similar to the preseizure, seizure, post seizure states. Another presentation In mood disorder would be the excitability showing it self with irritability growing in a three phase wave like way i) to anger, continuing to grow to the, ii) peak of the wave, the point of rage that runs its course, iii) followed by physical exhaustion, and then when the brain recovers back to base line of normal excitability or “normal irritability”. Both the person experiencing and observing this progression and the rage attack describe its seizure like quality, where they can no longer control the strong feeling, or thought process, or impulse, and it then controls them, until it runs its course , much like a seizure. Often in the example of irritability, anger , rage what pulls the trigger, or flips the switch to get to the point of loss of control is the frustration of hearing the word no or its equivalent, something small or large frustration that causes the threshold to be reached.
Treatment or both seizures and mood disorder is based on making the brain less excitable, more stable so there less intensity or amplitude or height of the waves, high and low, and less frequent wave formation, the time between the waves or episodes is increased. Another factor is the waves are organized resulting in organization of mood, thinking and behavior. If there is extreme and frequent mood instability the wave become disorganized resulting in disorganized mood, thinking and behavior.
An effective treatment should do at least four things, i)modulate and dampen the highs, ii) dampen the lows, iii)stabilize the highs and low, making them less frequent, and iv)keep them connected and organized. That is treats the ups, the downs, stabilizes, and organizes. These four effects would minimize the effects of stimulation like the word no or the frustration or whatever the stimulus, for it could also be too much of a good thing, a pleasurable thing, to further excite the brain. This would keep the anger at a minimum , the low energy depression, sadness, or say migraine also at a minimum, hopefully stabilize the wave of excitability enough so there would not be a rage attack or a meltdown, and if it did occur it would be less intense, less frequent , and of lesser duration, and not lead to massive seizure like disorganization.
Like seizures , each wave of excessive excitability lowers the threshold so that it even more likely for the next to occur , but with more intensity and of greater duration, and harder and harder to treat, thus illustrating the importance of early and adequate treatment. Treatment is not only symptomatic but preventative. This treatment model helps whether, it is the up and down of manic excitement and depression, or that of irritability, anger, rage, rage attack, melt down, exhaustion, fatigue , recovery,, or mild excitability, high energy, insomnia, migraine, sleep, recovery, to use just three of many possible examples.
Wrong diagnosis will lead to the wrong medication and can make matters worse, by fueling the wave of excitability , or cycles which are at the core of the unstable mood disorder. Common example would be misdiagnosing as Unipolar depression, or an anxiety disorder and using an antidepressant like an SSRI or tricylic, both of which can escalate the cycles to the point of psychosis, and violence to self and others, though they may show a too quick initial good response. This occurs because these medications increase the serotonin, norepinephrine, and dopamine, which may already be in excess, rather than re balancing them. Another example is the misdiagnosis of ADHD with the use of a stimulant that increases dopamine, making the person more irritable, angry, nasty, and more prone to depression and rage, slightly more prone to mania and psychosis. Two reasons why the effects aren’t as bad as the antidepressants are that the stimulants are very short acting, 3 to 12 hours, only have effects for that length of time, and work more specifically on parts of the brain rather than the wide global action of the antidepressants, which can have effects for weeks, good and bad. One has to be much more careful in using an antidepressant than a stimulant for these reasons.
This same worsening of the symptom or the disorder can occur with migraines, thought to be serotonin responsive, Imitrex and Prozac are used, and yet don’t get better, because in fact they are caused by the same brain chemistry problems as in mood instability, and a mood stabilizing medication is needed, like Risperdal, Depakote, Lamictal, perhaps Lithium, to rebalance the brain and stop the cycle of say irritability, excitement, lack of sleep, headache, severe migraine, to the point of needing to go to bed, totally exhausted from the migraine attack, and then recovery.
One can minimize the wrong treatment medication by not responding to symptoms or cluster of them no matter how dramatic or pressing for relief, but to try to see the bigger diagnostic picture not only by descriptive category but also by likely biochemical cause, which point to the correct choice of medication. To do this one has to familiar with the major diagnosistic categories, their symptom presentation, their history, and their medication responsiveness based on biochemical causes. In all of medicine no matter how available or sophisticated diagnostic tests may be , the diagnosis is ultimately made clinically. Clinically means using three basic sets of data, i) the symptom presentation of a disorder, ii) the history of that disorder, and lastly and sometimes least appreciated and used correctly is iii) the expected treatment response. All three are interrelated, have an internal consistency, and must be understood, used to ensure the right diagnosis.
Many errors are made because the basics are not understood, and applied on a consistent basis. The understanding and application of the clinical method as exemplified in the making a clinical diagnosis is one, if the most basic of all basic procedures.
The basics of the disorders symptom presentation can be partly understood by using diagnostic and symptom screen lists appropriately, which means by also using information from history and treatment response to clarify the diagnosis.
Paper and pencil screening tests are just that, they are screening tools, they do not in themselves make the diagnosis, no more than a very sophisticated lab or imaging test in the rest of medicine make the diagnosis. They only begin to point the way, and the information they gather must be added to by knowing the history or the disorder, the history if the individual, the history of the family, and the treatment response of all to begin to make and confirm the diagnosis. Again this is one of those very basic facts and procedures. Below are some diagnostic and symptom lists that can be used as screening tools.
Decision Tree Screening Clusters for Biologically Based Mental Health Disorders
One first have to rule out the following , before ruling in the mental health disorders as causes:
A) Medical Disorders- examples would be seizures, sleep apnea, thyroid, head trauma
B) Substance Induced- such as drugs of abuse, many prescription and non prescription drugs
C) Environmental - examples would be abuse, neglect, trauma, natural catastrophes
The following six symptom cluster can be used to quickly screen for the other disorders that may present with the certain core symptoms of a biologically based mental health disorder .For example the symptoms of hyperactivity, impulsivity and inattention found in many disorders including ADHD. They are listed in order from the relative most severe and complex, to more mild and least complex with ADHD itself last to emphasize the fact that all that precedes it need to be ruled out and treated first. If the symptoms still are present and impairing after the differential diagnostic process and possibly after medication treatment trials, then there are two diagnoses, the primary diagnosis and ADHD may be present.
Brief Medication Responsive Symptom Clusters
A) [ ] Mood swings, angry, aggressive, bossy, bullies, little sleep, high energy, racing thoughts
B) [ ] Hearing, see things that aren’t there, thinking illogical, bizarre odd disorganized behavior
C) [ ] Tics, motor movements of face, eye blinking, twitches, sniffing, snorting, throat clear
D) [ ] sad, depressed, tearful, little energy, motivation, don’t care, negative, suicide thoughts
E) [ ] Worried, fearful, easily embarrassed , rituals like counting, panic attacks, fear of being alone
F) [ ] Poor concentration, distractibility, overly active , doesn’t think before talking or acting
Mood Cluster- A Expanded Medication Responsive Symptoms
1) [ ] Too happy, cheerful, enthusiastic, silly, giddy, goofy, overly friendly, even with strangers
2) [ ] Brief periods of sadness, irritable and whiny, cries over small annoyances and hurts
3) [ ] Often unpleasant, nasty, mean, irritable, excitable, short fuse, easily made angry
4) [ ] Demanding , defiant, hard to please, difficult to live with, like walking on egg shells
5) [ ] Quick, frequent , intense, mood changes , with ups and downs like Dr. Jeckle & Mr. Hyde
6) [ ] Tantrums, can’t calm self down in 20 minutes, seizure like rages lasting minutes to hours
7) [ ] Injures self on purpose, self mutilates, bangs head, hits and bites self, punches wall
8) [ ] Verbally - physically abusive ,aggressive to others, violent, destructive to property
9) [ ] Thinks too highly of self, unrealistic big ideas, need to be boss, in charge, bullies peers
10) [ ] Needs very little sleep, yet seems rested, too much and fast emotionally charged speech
11) [ ] High physical -mental energy, doing more and more with goals at home, school, work
12) [] High energy person, only low energy is by severe headaches, stomach-intestinal problems
13) [ ] Excessively involved in pleasurable things with potentially painful consequences
14) [ ] Not thinking about consequences of behavior, speech, goals, plans, or relationships
15) [ ] Concentration changes excessively with mood, easily distracted by minor & irrelevant things
Thinking-Reality Testing-Cluster B
1) [ ]Hallucinations- hearing, seeing, tasting, feeling, smelling or sensing things that aren’t real
2) [ ]Delusions – believing things that aren’t based on reality, like one is god, the famous, very bad
3) [ ]Paranoia - reading hidden meanings into things, people out to get, hurt, deceive, harm you
4) [ ]Oddness – being peculiar, different, strange, bizarre, eccentric, unusual in behavior
5) [] Illogicalness – thinking and behavior doesn’t make sense, is disorganized
6) [ ]Disconnectedness- a disconnect, or loose connection between thoughts-feelings-behavior
7) [ ]Blocking – thinking gets stuck or blocked, so there is inability to finish or start a thought
8) [ ]Psychomotor Abnormalities – mind-body is too slow, too fast, mind fast body slow, vice versa
9) [ ] Repeating – repeating what is done [echopraxia] or said [echolalia] like an echo
10) [ ] Negativism- motiveless resistance to directives, being physically rigid, Mutism
11) [ ] Posturing- peculiar postures, movements , mannerism, grimacing, but not tics
12) [ ] Emotionless- diminished, blunted, inappropriate emotional responses and reactivity
13) [ ] Anhedonia - diminished , little or lack of interest or pleasure in most things
14) [ ] Avolition- lack or diminished drive , very difficult if not impossible to start and finish things
15) [ ] Alogia – diminished or lack of speaking, or thinking, or representations of such like writing
Movement-Impulse-Cluster C
1) [ ] Simple Motor Tics- rapid meaningless muscle contraction of few muscles like eye blinking
2) [ ] Simple Vocal Tics - sniffs, snorts, clicks, throat clearing, grunts, coughs, barks, yelps, giggle
3) [ ] Complex Motor- touching, squatting, twirling & retracing steps when walking, repeating
4) [ ] Complex Vocal- saying and repeating words, phrases, part of songs
5) [ ] Motor Driven Compulsions- doing things over and over, rituals driven by tics
6) [ ] Motor Driven “ADHD type symptoms”- over active, impulsive, inattention driven by tics
Depression-Cluster D
1) [ ] Depression- sad mood, tearful, whiney, easily cries, irritable, feels empty and alone
2) [ ] Interest- diminished pleasure and interest in most things, don’t care, too bored attitude
3) [ ] Body Weight- significant weight loss or gaining, eating too much or too little, not dieting
4) [ ] Sleep- sleeping too much, too little, waking up cant fall back to sleep, never feels rested
5) [ ] Mind/Body Energy- as observed by others either too slowed down or speeded up
6) [ ] Fatigue- loss of energy, always tired, fatigued, no motivation, drive, ambition
7) [ ] Negativity- worthless, guilty, ashamed, negative about self, present , past and future
8) [ ] Concentration- diminished ability to think, remember, concentrate, mind goes blank
9) [ ] Hopelessness- hopeless , recurrent thoughts of death, dying, suicide ideas, attempt, plan
Anxiety-Somatic- Cluster E
1) [ ] Worried all the time, poor sleep, restless, keyed up, on edge, easily fatigued, irritable
2) [ ] Fear , embarrassment of social, performance situation, with unfamiliar people scrutinizing
3) [ ] Worry of not doing rituals, hand washing, checking, ordering, counting, repeating, praying
4) [ ] Panic attacks, heart pounds, shaking, short of breath, dizzy, lightheaded, losing control fear
5) [ ] Worry over losing & leaving loved one or home, or going to work/ school, sleep alone
6) [ ] Extreme fear, numbing, avoidance and re-experiencing trauma, abuse, neglect, catastrophes
7) [ ] Frequently ill, “always sick”, severe headaches, stomach/intestinal problems, rashes, allergic
Attention-Impulsive –Cluster F
1. [ ] Always moving, on the go, into everything, frigidity, can’t be or sit still, even when sleeping
2. [ ] Can’t pay attention, focus, concentrate on boring stuff for 15 minutes when left alone
3. [ ] Doesn’t slow down, to stop and think or, to focus on consequences before talking or doing
The Atypical Child-Person – Cluster G “Group 7”
This is the 7th Cluster for people who don’t fit into the other groupings, having some aspects of more than one yet not fitting into any one grouping. Often the Atypical Child-Person is inaccurately put into another grouping and doesn’t have the expected biological treatment response to the usual medication of that group. These people often have unusual sensitivities to medications and may need multiple trials to determine the proper medication and dosing. The rule of diagnostic uncertainty , and using the rule of starting very low and going very slow and cautiously with any medication applies very strongly to this group of people.