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Neuro Alignment: A Monoamine Treatment Approach JOSH SIZEMORE, RN, MN, PMHNP ORCA FALL CONFERENCE 11/05/2016 Disclaimers • I love coffee, if a drug rep brings me one, I drink it. Presentation Goal TO CONSIDER DIFFERENT WAYS OF LOOKING AT SYMPTOMS, DIAGNOSIS AND TREATMENT TO ASSIST IN CONCEPTUALIZING THE MOST COMPLICATED OF PATIENTS. INSTEAD OF FOCUSING SOLELY ON CHIEF COMPLAINTS, SYMPTOMS AND DIAGNOSIS IT TEACHES A WAY OF ROOTING OUT THE UNDERLYING CAUSES OF THE SYMPTOMS WHICH ALLOWS FOR RICHER TREATMENT OPTIONS AND IMPROVED OUTCOMES. Does psychiatry need a different way of looking at things? Does psychiatry need a different way of looking at things? How do we do it now? Symptom * Symptoms ** Symptoms *** Symptoms **** **** Symptom Pattern **** **** **** Symptom Pattern **** **** **** Symptom Pattern **** **** **** Major Depressive Disorder Symptom Pattern ***** *** * * *** ***** Symptom Pattern ***** *** * * *** ***** Symptom Pattern ***** *** * * *** ***** Bipolar Disorder Symptom Pattern * * * * * * * * * * * Symptom Pattern * * * * * * * * * * * Symptom Pattern * * * * * * * * * * * Attention Deficit Hyperactivity Disorder Symptom Patterns * * * * * * * * * * * * * * * * * * * * * * * * * * * * Symptom Patterns * * * * * * * * * * * * * * * * * * * * * * * * * * * * Symptom Patterns * * * * * * * * * * * * * * * * * * * * * * * * * * * * Obsessive Compulsive Disorder Uh Oh? **** **** **** * **** **** **** * Major Depressive Disorder with Moderate to Severe Anxious Distress What about this? What about this? Major Depressive Disorder What about this? Major Depressive Disorder Adjustment Disorder What about this? Borderline Personality Disorder Major Depressive Disorder Adjustment Disorder What about this? Borderline Personality Disorder Major Depressive Disorder PTSD Adjustment Disorder What about this? Borderline Personality Disorder Major Depressive Disorder Disruptive Mood Dysregulation Disorder PTSD Adjustment Disorder The 5 Core Areas of Focus 1) Nature - Biological predisposition – The way each individuals brain was naturally made 2) Nurture – Non genetic influences 3) Limbic System activation/response 4) Sensory integration 5) Medical/Somatic signs and contributors 1) Nature - Biological Predisposition Problems vs Disorders Everyone has problems: Which accounts for most of what we encounter when working with children and adults. Psychiatric disorders are rare – most “true” psychiatric disorders have an underlying organic cause or component which when understood can lead to the best treatment options and outcomes. Monoamine Neurotransmitters 5HT Serotonin NE Norepinephrine Da+ Dopamine Theoretical Monoamine Model Bipolar I Schizophrenia + + Bipolar II + Psychotic Process/ Bipolar Episode + Bipolar Brain Bipolar 5HT NE Mood/Anxiety ADHD - - Severe Mood & Anxiety, OCD - + DA+ ADHD - Severe Mood/Anxiety Fibromyalgia/Aspergers Autism/DD/TBI - - Medication Side Effects Medication side effects correlate (for the most part) with underlying brain pathways (except for odd metabolizers and certain gene mutations – it is still true in these cases, just unpredictable unless you have obtained and understand genetic testing). Medication Side Effects Discussion Bipolar I Schizophrenia + + Bipolar II + Psychotic Process/ Bipolar Episode + Bipolar Brain Bipolar 5HT NE Mood/Anxiety ADHD - - Severe Mood & Anxiety, OCD - + DA+ ADHD - Severe Mood/Anxiety Fibromyalgia/Aspergers Autism/DD/TBI - - 2) Nurture – Non Genetic Variables Other variables that were not related to the way we were biologically made. * Trauma * Attachment * Sleep/Insomnia/Sleep Deprivation * Nutrition, * Medical problems (some crossover with 5th core area, hypothyroidism, Vit D deficiency…) * Social Relationships * Coping skills * Drugs * others? 3) Limbic System Response (& Limbic Irritability) Focus, Cope, Adapt & Learn React Anxiety PTSD, Fight or Flight 3) Limbic System Response (& Limbic Irritability) Focus, Cope, Adapt & Learn React Anxiety PTSD, Fight or Flight 3) Limbic System Response (& Limbic Irritability) Focus, Cope, Adapt & Learn React Reactive anger, reactive emotions, reactive bonds, reactive hopelessness, reactive si/sib/hi, etc. Anxiety PTSD, Fight or Flight 4) Sensory Integration Two main processes (therefore 2 ways of evaluating & treating). 1: The amount that gets through (dependent on level of dysfunction). 2: Our ability to process what gets through (dependent on ability to focus, concentrate and organize). 5) Medical/Somatic Contributors Many medical problems are psychosomatic in nature or found to be comorbid with psychiatric contributors with the underlying causes being the same for both (example MTHFR gene defect, chronic pain, migraines, seizures, histaminosis…) Case Study 1 17 year old male, past diagnosis: MDD w psychotic features, GAD, high functioning Aspergers and ADHD. Hx of suicide attempts and sib, multiple past hosp. CC is anxiety, depression and poor focus. MH tx for 2 years. 1) Nature - Genetic diathesis: Paternal: Anxiety, Depression, Social Skill Deficits (suggestive of Aspergers). Maternal: Anxiety, Depression and ADHD. Presents with vibrating keen anxiety, non stop motion, bouncing leg, distractible, verbally impulsive but pleasant and likable. Highly intelligent in electronics... 2) Nurture – Negative trauma hx, social skill deficits, mild hx of being bullied, trouble falling asleep, anxiety leads to poor school attendance. Past medication trials: 4 SSRIs, partial response, excess physical and mental sedation at moderate doses. Stimulant led to increase in anxiety, anger and irritability but helped focus. Clonazepam helpful, not fully effective – only current med, can’t be without. 3) Limbic Response; reactive, poor ability to adapt, focus, cope and learn. 4) Sensory Integration: Mild sensitivity to noise, touch, texture & light which greatly improved since childhood, used to be moderate to severe. In quiet/neutral environment able to focus but only on things he enjoys. 5) Medical/somatic – diagnosis of fibromyalgia, chronic back, knee, joint pain, multiple MRIs with no findings, 1 unremarkable exploratory joint procedure, allergy to food dyes resulting in extreme behavioral reactions. Case Study 1 Results Treatment plan made to trial Cymbalta and/or amantadine with prior provider before I met client, however, medications not started until under my care – not instinct. Began Cymbalta and increased to 30 mg twice daily, within 2 months mood and anxiety stabilized, continued to struggle with ADHD symptoms, mild reactivity, pain, anxiety and mood symptoms. Began Amantadine and increased to 100 mg twice daily and started decrease in clonazepam, within 2 months (by month 4) all symptoms stabilized and rarely taking clonazepam. By month 6 off clonazepam. Remained psychiatrically stable on medications, without changes, for the past 1.5 years, no lasting pain issues. Full time college student, double majoring, working and involved with student clubs – purposeful sleep issues continue. Case Study 2 56 year old female, past diagnosis of: PTSD, Major Depressive Disorder and Bipolar Disorder. Hx of suicide attempt in early 20s during major depressive episode. CC is depression, med side effects and sleep. Most recent diagnosis: PTSD and Bipolar I Disorder (which was diagnosed when hallucinating and in a delusional state after being placed on a steroid). 1) Nature – Genetic diathesis – Maternal – all women struggle with depression and anxiety. Paternal – alcohol and substance abuse. Presents moderately depressed with mild anxiety and physically restless, needs to stand due to restlessness not anxiety. 2) Nurture – Hx of domestic violence, no ongoing trauma, extensive past PTSD treatment which she feels was as effective as it could be and denies any lasting concerns. Past medication trials: Was fully stable on Prozac for over 20 years but stopped working, on Zoloft for 2-3 years, helpful, not fully effective but stopped working. Changed over to Cymbalta which helpful but caused anxiety, then placed on effexor which has also caused anxiety and restlessness. Placed on Abilify when hospitalized and given bipolar diagnosis 5 years ago. Currently on Abilify and Effexor which is not working, causing weight gain, anxiety, irritability and restlessness. but has not been able to get off due to withdrawal side effects. Struggle falling asleep, tired but can’t shut down thoughts. 3) Limbic Response; Mild reactivity, surprisingly low given PTSD history. 4) Sensory Integration: Unremarkable. 5) Medical/somatic – Obesity, diabetes, chronic ankle, shoulder and back pain from past car accident, diabetic neuropathy, constipation. Case Study 2 Discussion autoreceptor Case Study 2 Results Treatment plan made to trial Viibryd and get off Abilify and Effexor (with assistance of Pristiq). Over a 2 month period used Pristiq to get off of Effexor which decreased side effects and minimally helped mood, then titrated over to Viibryd. Within 2 months (by month 4) depressive symptoms completely stabilized with only side effects being looser stools which was tolerated and even helpful due to hx of constipation. At 5 months decreased and discontinued Abilify with only side effect mildly worse sleep initiation which stabilized with use of Prazosin. Has been stable the past 2 years on Viibryd and Prazosin without any lasting side effects and has lost 30 lbs which helped to stabilize her diabetes. Pain improved through pain management and is more tolerable due to improved mood, coping and decreased med side effects. Look outside the box The brain is stupid, the mind is intelligent (example sleep deprivation). Try to look at symptoms from a more evolutionary standpoint (examples ADHD, melatonin). If you are following treatment recommendations for a given disorder and it is NOT working – DON’T keep doing it – reassess if you have the right diagnosis. (Examples; OCD vs ADHD, ADHD, True ADHD and an ADHD Brain) Perspective Questions? [email protected]