Trauma/PTSD, psychosis, and antipsychotic drugs

Thunderwolf, MSN, RN · Mar 25, 2009

I understand and appreciate the confusion.

One thing to keep in mind, however, is that any illness taken towards its "Nth" degree may precipitate psychosis....depression and anxiety included.

It all depends on the individual, the illness, and its severity.

Looking forward to hear others' feedback.

Whispera, MSN, RN · Mar 25, 2009

I think that the practice of polypharmacy doesn't do much to help people. Sometimes prescribers forget that not everyone responds to medication and they keep adding things until the patient is on all sorts of meds. Whenever more than one med is taken, there's a chance for interaction. Add 5 drugs and you definitely increase the chance of increased interaction and more side effects.

If a medication doesn't help, after a long enough try and trying to tweak the dosage, or combining it with another medication, I believe it should be discontinued. Sometimes it takes a longggg time to get the right timing, dosage, and medication(s). Just adding and adding isn't the answer.

As for antipsychotics to traumatized, borderline, and PTSD patients, I think they could be helpful if the symptoms warrant them, but therapy should be implemented too, since the life experience needs to be dealt with for them to be well--no meds will make it all better for these diagnoses.

Thunderwolf, MSN, RN · Mar 25, 2009

I totally agree.

Polypharmacy has become a problem.

And.............There is NO magic pill or pills.

I am a firm believer in the use of therapy or counseling.

To be honest, in many many cases, I would like to see more of a push in a different direction...if you need a medication, the use of active therapy/counseling to address it must be evident to secure a med refill. If one has an issue or an illness, a pill prescription request is simply not enough. Addressing the illness/issue head on is what is called for...not jacking up or loading on more meds.

If a patient has been on several meds and they have proven not to work well (ie polypharm), maybe the issue of meds is NOT the issue. Maybe, it is something else or in addition...like current stressors and/or the lack of adequate supports. But, I agree, after a while, if the problem is still a problem, it makes no sense whatsoever to continue throwing more and more meds at it, hoping that something will stick. That is plain foolish. And you are correct, the more meds that are added increases the risk of side effects and adverse effects. Not good. And you are also correct, sometimes the answer is not more meds...but less.

It is a big problem.

However, what continues to fuel the problem is:

Many folks don't want to work on their issues/illness...just numb it away. Not the answer.

Many in the Pharmaceutical Industry are encouraging polypharmacy. That has to be addressed.

Many physicians are honestly caught between a rock and a hard place...from customer service departments in their facilities (to give the customer anything they want to keep the customer happy and returning...even if it is wrong).

Many physicians/physician groups allowing access aplenty to addictive meds to folks who have now become addicted to them...guaranteed revenue. Free flowing addictive meds only fuels the pathology.

Many community mental health centers/programs (located within our communities) have been left frail and underfunded for too long. This also needs addressed.

Polypharmacy is only a symptom of the bigger picture.

Unfortunately, the forces that be have turned it into our current "opiate of the masses."

The masses have tasted it and often times feel entitled to it.

inthesky · Mar 25, 2009

thank you!

This does give me some perspective on why the Doctors polypharm patients. The average IP stay is 3-7days. The patients see a doc every morning and say "this med isn't working" and the doc increases the dose or adds something else. The docs are responsible for a psychotic suicidal patient to be safe to leave in a week. They constantly have the state behavioral health agencies reading all the charts and threatening not to pay when they believe that a patient no longer needs to be here.

Patients often feel an antidepressant placebo affect when they 'feel' SSRIs work within a few days when I think it is more of a discovering hope within themselves dynamic.

I question our doctors, but I think the therapists are amazing and aside from acute mania and psychosis, their therapy and groups are the bulk of treatment efficacy. The nurses don't run any groups and don't have the time to attend them. I do spend a lot of time trying to reinforce coping skills (even most of the time I don't even know what was discussed in group) and talking patients out of instant gratification ativan =P.

I just don't know if the behavioral community thinks deeply enough about actual neurochemical mechanisms and interactions. What happens if you suppress too much dopamine? What happens when wellbutrin or etc actual increases dopamine levels whereas navane decreases them? We give a ton of trazodone. Couldn't trazodone mixed with other ADs increase risk of seritonin syndrome? What happens when there is too much seritonin floating around? Doesn't it need to be reupintaked to a certain degree? There are tons of studies that combining SSRIs with anticonvulsants might not be effective with bipolar disorder, but this is done all the time here. Maybe the doctors are working on these principles and I have no idea about what I am talking about, but they would never discuss with with a lowly med nurse without feeling threatened and insulted.

I'm starting my psych DNP program in the fall and I am really hoping this program gives me the education to start understanding these questions.

Whispera, MSN, RN · Mar 26, 2009

patients often feel an antidepressant placebo affect when they 'feel' ssris work within a few days when i think it is more of a discovering hope within themselves dynamic. ssris have what some call a "zing ring" in their structure. they can give a patient an energized feeling after a few doses even though they're not totally effective yet.

what happens if you suppress too much dopamine? you get parkinsonian/eps symptoms

what happens when wellbutrin or etc actual increases dopamine levels whereas navane decreases them? they somewhat cancel each other out

we give a ton of trazodone. couldn't trazodone mixed with other ads increase risk of seritonin syndrome? yes

what happens when there is too much seritonin floating around? serotonin side effects--nausea, dryness, etc.

there are tons of studies that combining ssris with anticonvulsants might not be effective with bipolar disorder, but this is done all the time here. maybe they don't read the research and are doing things the traditional way

medication is very very tricky, requires lots of tweaking, and what works with one person may not work with the next. docs are under pressure to get results, so they do what they can within the hospital stay, and hopefully follow up during an appointment the patient would have after being discharged.

Whispera, MSN, RN · Mar 27, 2009

I need to correct my former posting. You don't get EPS from too little dopamine! duhhh...I was sleepy!

Mr Ian · Mar 28, 2009

okie diddley dokie... you've stumbled on another pet topic of mine... Messycation.

The science in psychiatry is - "Give it a go - what's the worst can happen?"

Of course there's some "worsers" worserer than others - like Clozapine/Clopine/Clozaril - or Lithium.

My biggest bother with psychiatric medications is the counter-therapeutic effect (not side effect) - and they can actually reduce the efficacy of psychological therapies.

Brief explanation: Two main things we need to 'improve' (with or without mental illness - think of when you've been on a training course instead of someone being mentally unwell) -

1. Ability to learn

2. Energy to learn

In (1) learning we rely on things like dopamine (see here) to make things 'stick'. So knocking out those NTs is going to make learning impossible. (Helps understand why some patients never seem to learn or remember huh?)

In (2) the brain needs energy to work - (see Ego Depletion - Roy Baumeister) and medication that produces a brain-lethargy is going to impact on the ability to regulate itself. (So no wonder why some have a short fuse or assault peope huh?)

These are the two main things about psychiatry that I dislike. We do (A) - while not thinking/caring about (B) - and then wondering why this stuff aint working. (Or we drug-induce diabetes and then we have the hypoglycaemia issue - which is IMO another ego-depleting cause of compromised self regulation... that's why hypo's tend to get aggressive - limited ability to regulate)

But I've never really been into "psychiatry" anyhow - I'm into Mental Health. And there's a significant difference. Psychiatry is about the neurobiological working of the mind and how to alter it with drugs. Mental Health is about psychiatry - and the lived experience (to give a broad title to a complex matter).

I accept a place for medication in providing mental health care but I cannot abide polypharmacy. It's only excuse for use is a complete lack of skilled 'other' interventions/interventionists.

I like Thunderwolf's preferred options - and stuck with that for a long long time; until more recently and I've started to meld a little more psychiatry into my mental health work by new understanding of brain function.

I read a theory called Neuroanalysis (Avi Peled, MD; Isreal) - I think I mentioned it before? - which essentially considers the tri-play of neuroscience, psychology and psychiatry in mental order and disorder.

I believe there is a synergic effect of medication and psychological therapies that brings about more significant and lasting change.

I wrote about this on another blog site - here's an extract:

I subscribe to the theory that the brain is a functional object. It has bits and bobs that work together to make things happen. The way it works is a physiological action.
There are certainly cases of purely biophysical causation for mental problems - like syphillis or alcoholic psychoses - and all the CBT in the world is not going to make a huge - or as huge - an impact as treating the underlying condition - but by far and large the people that I see present with histories that reflect any, often most, of the following:
childhood trauma/abuse
drug use
pervasively poor social supports
socioeconomic difficulty
employment issues
event specific reactions
The effect of these on the person tends to be a negative one. The exposure to these issues appears to me to 'train the brain' to expect it to be ****.
On the techno side - thoughts and feelings that exist over time form neural networks that, as neuroscience supports in the theory of 'fire together; wire together', become highly fixed connections. So soon all events begin to go down this fixed neural network pathway - in depression, this demonstrates why things are perceived as a (potentially) negative event when they are often neutral or even positive.
We're not unique people. You must have met plenty of people for whom nothing seems to be 'right' or 'good'? Fixated in their trenchant ways, nothing deters them from their beliefs, no matter how much or how intelligent the arguments are presented. The neural networks seem to be stuck in one pathway only.
So if the pathway is set - there is a higher propensity to think, believe and feel that way. It's perfectly normal and it's based on experience and understanding.
Hence my preferred expression to anyone suffering a mental disorder -
It's a perfectly normal reaction to an abnormal situation.
So how does CBT help?
My opinion is Cognitive Therapy challenges the thinking pathways - to try and literally talk you out of a mode of thinking. But not just in the meta-physical; but in the real true and hard physical wiring of the neural networks in the brain.
The problems with 'entrenched thinking' - after a while the neurones firing together become harder to break and they lose 'synaptic plasticity' - or the ability to shift. Drugs that aid plasticity are next in line for development I think. And I can see LSD perhaps making a significant contribution to this.
Psych drugs screw with those networks. No one knows exactly what is meant to be happening to be happy - they just know what seems to be happening - neurotransmitters like norepinephrine, serotonin, dopamine, and acetylcholine being the primary targets for neurotransmitter research.
If Avi Peled MD had his way - we'd be researching the neural networks and profiling them in every neuro-lab in the world right now.
But with most the anti-p and anti-d drugs that work on these neurotransmitters there are changes not only to the increase/decrease in neurotransmitters activity - but there is also an increase in plasticity.
Having an increase in plasticity is great - it means we can literally change the neural pathways of the brain easier. But we're not sure how to drug the neurones to 'go make a happy network'. So we need a method to do that.
That's where CBT - and any of the other psychological therapies - comes in.
Most the stuff we learn to make the neural pathways is socio-environmental - it's experience. We take an experience and we create a feeling that lasts in memory. It becomes a belief - a way of interpreting our experience based on that memorised feeling - and our thoughts are pre-determined by that belief.
When the neural networks are fixed in one way - the best way to change them (in the absence of going in and rewiring the brain - an internal modification) is to apply an external modifier.
So talking about things can make us different. We can create different neural networks.... if you want to.

So my opinion is there is a clinical treatment pathway that isn't really considered or followed, but should be and suits for all cases from the raving psychotic* to the neurotic worrier:

1. Commence with psychological therapies - establish the person's own ability to bring about neural network change with external modification

2. If not successful (enough) add in some plasticity enhancing drugs - a kind of 'brain lube' if you will.

3. Retry psycholgical therapies

4. Revisit the drugs cupbaord - followed by psychological therapy.

Important considerations:

Balancing a drug that allows plasticity, reduces psychotic experience and yet doesn't deplete the ego or ability to learn - is a highly skilled job. Most psychs don't even recognise this - let alone attempt it.

Less is more. Using the least amounts of psych drugs leaves more option for the other therapies to work

*In psychoses I believe there is a much stronger dysfunction going on than can be ameliorated by talk therapy (the stress of the experience can be reduced, for sure - but not the psychotic phenomena) - it is highly likely that psychitic dysfunction has become extremely hard wired (?almost fused) so even tho the drugs are counter-therapeutic in some ways - again it becomes an skilled art of optimising the patient's opportunity to engage in fixing the neural networks to the best outcome.

Unfortunately the psychiatrists who would even consider this are few and far between - and then you need a ward full of health care staff who aren't just screaming for something to 'calm the patient down'.

One day we'll just sit under a machine that looks like a cross between an EEG and an AED - it will analyse the networks - tell us what's wrong and a couple of blasts from an rTMS and we're cured.

Beam me up Scotty.

inthesky · Apr 1, 2009

good info! I'm going to read it more in depth when I'm less tired =P I've thought about the 'thinking' issue as well. We keep some patients in constant ativan hazes to avoid agitation, but people can't go home, function, and keep a job like that. Very few really consider the plight of our patients and their ambitions.