Not getting better with your present treatment Q and A
Something is not right here, Why am I not getting better, is it me?
It may not be you, but it could be the Wrong Diagnosis or Treatment, or both? Not sure, then read on!
Now you may have added a new problem to the original one, treatment failure, you ask “What is wrong with me?” This happens much too often in mental health diagnosis and treatment and could be avoided if you just knew a little more about the most common mental health problems, especially those with a biological basis with medication responsiveness. But first a brief discussion on the importance of the right kind of comprehensive multifaceted bio-psychosocial diagnosis and its importance in choosing the right treatment.
Something is not right-Why am I not getting better?
There are many possible reasons but two possible reasons that should be first explored are is the right thing being treated and second is it the right treatment. Diagnosis and treatment are interconnected having three basic parts, history of the problems, the symptom expression of the problems and the response to a treatment, all three should fit together and reinforce each other.
What specifically should be done?
If you not getting better either more history personal, family and environmental is needed to clarify everything, or the target symptoms you hope to get better may not be the ones suited for the treatment, or the treatment is the wrong one, not of sufficient intensity, or duration, or needs an adjunct.
How do you approach this?
I will use some common presentations seen in children, adolescents and adults to illustrate the problem and the solution. Emphasis will be on matching the right diagnosis , with the right target symptoms, with the right treatment. For some problems this will be relatively easy , for others this can be very complex, sometime it is quick, sometimes because of the nature of the problem it may take much time, either because it is a complex multifaceted problem or it has not matured, peaked, to show its full diagnostic features which is often the problem especially younger the patient.
What do you mean?
A diagnosis like ADHD if it classical and uncomplicated should be straight forward, easy to rule in or rule out, while an Unstable Mood presentation, that may be Bipolar Disorder could be very complex, with certain anxiety disorders such as Panic Disorder in the middle. Some problems cut across diagnoses like ODD or Oppositional Defiant Disorder and require in depth analysis to see if they are connected with another diagnosis which is driving it or is its cause.
How do you generally start when you first hear a person’s history of their problems?
I start with no preconceptions, thinking any diagnosis and any treatment may be appropriate certainly with a new patient, but also try to keep this attitude with patients that have established diagnoses and treatments, because of the ever changing nature of the environment, brain chemistry and the minds response to everything. Everything changes and is interconnected especially dealing with the human mind. Then I start matching the history and symptom picture to possible diagnoses and medication responsive symptom diagnostic clusters, and the medications that might be helpful.
What are these groupings of medications and their responsive diagnoses or symptoms?
I will list these from the simplest and most predictable to the more complex: 1. The neurostimulants like Adderal and Ritalin, for the hyperactivity, impulsivity and distractibility of ADHD, 2. The SSRIs or Selective Serotonin Reuptake Inhibitors like Prozac and Lexapro for Anxiety Disorders like Panic and OCD- Obsessive-Compulsive, 3. SSRIs also used for Unipolar Stable Depressions, 4. Typical and atypical neuroleptics like Haldol and Risperdal for Impulsive Motor Tic disorders like Tourette’s, 5. Mood stabilizing medications having three classes a. anticonvulsants like Depakote and Lamictal, b. Neuroleptics like Risperdal and Haldol, and c Lithium in a class by itself, for Unstable and Aggressive Mood Disorders, like Atypical Mood Disorder and Bipolar Disorder. 6. Neuroleptics for Thinking and Atypical Relatedness Disorders like Schizophrenia , other Psychotic and Psychotic like disorders 7. An Atypical group of symptoms or problems that don’t fit into the previous groupings and has unpredictable and at times changing brain chemistry, and may respond to any class of medication or none in an atypical manner.Diagnostic Symptom Clusters or Groups
I noticed ODD was not mentioned in the groupings above , why is that?
Some problems or diagnosis are only descriptive labels pointing to no biological or other cause, and ODD is one of these. A disorder like ADHD which it often occurs with is the opposite, though in its symptom picture no causation is implied or suggested, but in fact classic uncomplicated ADHD is very biologically caused with a very specific treatment response to neurostimulants medication.
Why is it important to know if symptom or problem clusters have a biological basis and medication responsiveness?
So you can have the optimal treatment for symptom control, elimination of symptoms, and to prevent relapses and complications. For example a person can be in treatment for years for ODD with little help, is this because the non biological treatment like counseling or psychotherapy is not effective or is it the wrong treatment. It could be the ODD is caused in part or most of it by some biologically based problem like ADHD or a Mood Disorder and the medications for them would lessen the ODD or make it much better. ODD,ADHD or Mood
Do specific symptoms, or symptom clusters or problems have a specific treatment like ADHD ?
They may or may not, take ODD it doesn’t, yet some forms of ADHD may or almost do. It is best to assume at the onset that any symptom picture can represent any diagnosis and have multiple treatments until your clarify the diagnosis and its possible biochemical causation that may represent some specific medication responsiveness. Do these problems have a single diagnosis?
Not only can a problem or symptom cluster be due to multiple diagnoses, within a single diagnosis there are at least four interrelated things to consider, or the same thing can be looked at on different level of knowledge or conceptualization. One has to make a diagnosis on at least four levels, 1. Descriptive- description of the actual problems or symptoms as they show themselves in the present by behavior, thinking, and bodily symptoms this represent the labels we use without implication of causation as are classified in diagnostic manuals, the next three levels play a part in causation, 2. Environmental- anything outside the brain chemistry yet having an influence on it, including family and relationships, this would also refer the role general body health has on brain chemistry, all of this would have to considered to be adding or subtracting to the symptom picture, 3. the Biochemical diagnosis-that is what is the theoretical brain chemistry problem and its possible medication responsiveness, and 4. Psychological or the role of the mind itself as it influences the mental health problems, symptoms or its disorder.
You are saying all of this should be considered in making the complete diagnosis and a treatment plan?
Yes, a diagnosis is more than a descriptive label, but to have meaning to be applied to treatment one has to have an understanding of the forces driving and causing what is described in the symptom picture and its history, which include the external environmental factors, the internal environment of the body in which the brain and its chemistry reside, the effects of the brain chemistry itself, and lastly and perhaps most importantly and least understood , though we fool ourselves into believing we know more than we really do the effect of the mind on all of this. Do not confuse the descriptive symptom picture and its history with what may be causing, driving it and maintaining it, only by know the causes can we effectively treat. One does not treat a description one treats its causes. How to make a Diagnosis
Considering this complexity how do you know what kind of treatment to use?
Treat by the what may be causing, driving and generating the symptoms or problems. If it is environmentally caused or conditioned, remove or modify those stresses, for example if the person is in a toxic environment, work with the environment, if it less than adequate parenting , help the parents, if it is too much stimulation from excessive use of video games or TV or Internet , then help that, if in an abusive family work with that, if it’s the work or school help that. If it is the mind itself putting up difficulties and fueling the problem then traditionally counseling therapy, like psychoanalytic or relational, or cognitive behavioral may be indicated. If it is the internal environment of the body, the body is sick then treat the sick body. If it turn out it is mostly brain biology driven then use the appropriate medication, if it is all three which it always it, the work with the environmental factors, the brain chemistry and the mind, putting the emphasis on what is needed in the present, and tailoring and sculpting the approach based on the individual unique needs and responses of the person.
How do you know it the treatment is working?
I use a simple rule, the person should be getting better, not staying the same or getting worse, or getting new symptoms, some of which may be side effects from the treatment, whether it is biological or not.
Wait your saying non biological treatments can have side effects not just medications?
Yes for example your treating a child for ODD who is angry, irritable, and prone to brief bouts of depression. Say the counseling , therapy, or behavior modification is putting requests or demand on the child or teen which he cannot meet because perhaps, his already unstable mood which is the cause of the ODD, is at its breaking point so to speak, and he is already operating on reserve frustration capacity to control anger, and the treatment is in a sense pushing them over the edge, week after week. Perhaps the ODD is due to ADHD and the person cannot concentrate because of on the therapy or home work assignments of the therapist, how could they not get more irritable, frustrated, and angry. Further they may begin to wonder why can’t they comply though they are trying very very hard, and start to feel like a failure, for failing at therapy. Now new treatment caused problems are added to the original problem. In cases of Anxiety disorders treated with non biological treatments the anxiety can get worse and lead to depression if not recognized. Here the treatment itself can be considered to be sick and is in need of its own diagnosis and treatment , it needs to be fixed before the patient can get better, yet the parents may blame the child, and the child may blame themselves.
This is turning out to be much more complex than I imagined, what is the solution to all of this?
If one is not getting better, go back to where we started this discussion, perhaps the diagnosis in its truest complex multifaceted self, descriptively, environmentally, biochemically and psychological is not right, and/or the treatment is not appropriately addressing the various facets with the proper therapeutic modality, not strong enough, not done long enough, or needs help from some other treatment. This is best understood and applied by looking at the various disorders, symptom clusters, and their treatment responses specifically, starting with their description and then looking for their environmental, brain chemistry and psychological causations, one at time.
Where is it best to start?
Start with the problem that means the most to you.