Dr. Barry Dworkin » Mental Health

“It must be my fault”

Dr. Barry Dworkin — Mon, 23 May 2005 03:33:42 +0000

Originally published in The Ottawa Citizen, May 22, 2005
Originally titled “Too Many Children Suffer in Silence”

Although many people are aware of the effects of alcohol abuse on family and friends, missing from this equation is a child’s reaction to a parent who drinks too much.

Young children have a difficult time understanding why their mother or father’s behaviour and actions can be so hurtful to them. Their questions and concerns often go unanswered because often alcohol abuse remains a family secret that no one wants to talk about.

The child’s fears and worries grow when no answers are forthcoming or the information provided to them is incomplete. The Centre for Addiction and Mental Health (CAMH), affiliated with the University of Toronto, cites research that shows children have many questions about their parents’ substance use or mental health but there is a lack of resources to help explain these problems to them.

A new storybook produced by CAMH entitled Wishes and Worries: A story to help children understand a parent who drinks too much alcohol, was released in April 2005 and written for five to ten year-old children.

Dr. Bruce Ballon, a psychiatrist in CAMH’s Youth and Addiction program and part of the writing team states that most children think that they cannot talk to anyone about their parent’s drinking problem. However, it is a subject that should be talked about and there is support available.

The storybook’s premise is to help children understand that they are not to blame for their parent’s drinking problem and behaviours. Children, for lack of information and understanding will usually blame themselves for the problem; they must be doing something wrong. They will come to the conclusion that somehow they must have upset their mother or father or that they are unlovable. If left to fester, it can affect their self-esteem and mood potentially leading to other problems later in life.

Indeed, Ballon points out that some may develop problems forging strong and healthy relationships or end up blaming themselves for other people’s actions because of the environment they grew up in. They also may be predisposed either genetically or due to their environment to use drugs or alcohol in response to stressful life events. Early intervention or prevention is the key to address these issues.

Wishes and Worries tells the story of Maggie, an eight year-old girl, who has experienced one disappointment and embarrassment after another because of her father’s drinking. With her ninth birthday coming up, she is worried that he will ruin her party as he did on her eight birthday. She feels quite sad and unsure of what is happening and blames herself for his behaviour. Throughout the story she learns that there are friends, family members and professionals who are available to help her understand her father’s alcohol abuse.

The book is beautifully illustrated and well written. Prior to the story’s introduction there is a page that contains information for parents about the book and they can use it to help their children understand alcoholism. The following page is designed for children and provides information about a parent who drinks and lists the different people they can talk to about their fears and concerns.

It will generate a good discussion between you and your child.

The storybook can be purchased from CAMH by calling 1-800-661-1111 or on-line at www.camh.net.

Club Drug Use Carries Uncertain Risks

Dr. Barry Dworkin — Tue, 26 Apr 2005 03:29:58 +0000

Originally published in The Ottawa Citizen April 25, 2005
Original Title: Three More Members of the Club

Part One
Final of two parts

When discussing the potential side effects of drugs, risks must be viewed within a realistic context. Indeed, my last column on Ecstasy, or MDMA, and today’s on GHB (gamma-hydroxybutyrate), Rohypnol (flunitrazepam) and ketamine, contain information that is factually correct.

Each person reacts differently to the effects of a drug.

GHB, developed in 1960 by the French as an anesthetic, is a salty powder that is dissolved in water. It is manufactured from common industrial chemicals that can be purchased with home-production instruction manuals from websites.

It is structurally similar to a naturally occurring central nervous system transmitter, gamma-aminobutyric acid (GABA). GABA is believed to regulate sleep cycles, body temperature, memory and brain glucose levels. Its unpleasant salty or soapy taste can be masked by mixing it in flavoured or alcoholic drinks.

GHB’s effects are dose-dependent. The initial euphoria occurs about 15 to 30 minutes after ingestion, reaching a peak in 20 to 60 minutes. This effect can be tempered if taken with food. The use of alcohol or other central nervous system depressants can increase GHB’s potential toxic effects. The drug’s concentration within the powder is not known, increasing the risk of overdose.

The signs and symptoms of GHB intake that can precede overdose are dizziness, increased salivation, muscle relaxation and amnesia. There is evidence to suggest that as the level of consciousness wanes, the risk of a slower heart rate (bradycardia) and low body temperature (hypothermia) increases. Overdose might lead to abnormal and ineffective breathing patterns, seizures, coma and death. Recognition of the early signs and symptoms can help prevent this outcome.

Long-term regular users of GHB might develop drug dependence. The withdrawal syndrome can include insomnia, tremors and anxiety.

The drug Rohypnol, also known as the date-rape drug, is the same class of medication as Valium: It is a potent benzodiazepine. This prescription drug is available in many European and Latin American countries for use as a preoperative anesthetic, sedation, and as a treatment for insomnia. Being a prescription drug, there is quality control in its manufacturing process.

Rohypnol can induce sleep (hypnotic), reduce stress, inhibition and anxiety through sedation, and is a muscle relaxant at doses of one to two milligrams. The onset of action is about 30 minutes after ingestion, with a peak effect occurring after two hours. The drug’s effect can last up to 12 hours.

Exceeding the recommended dose can lead to loss of memory of events occurring from the time of ingestion onward (anterograde amnesia), lack of muscle control and loss of consciousness. Users who consume alcohol can increase the drug’s effect.

Depending on the dose and other concurrent drug use, some users can develop low blood pressure, confusion, dizziness, aggressive behaviour, urinary retention (inability to urinate) and visual disturbances.

Benzodiazepines are not usually recommended for long-term use because of the high risk of drug dependence. Some prescription benzodiazepines can cause dependence with two to three weeks of daily use. Withdrawal must be medically supervised in order to prevent seizures.

Ketamine is a derivative of phencyclidine (PCP). It prevents brain cells (neurons) to reclaim various neurotransmitter compounds that are released by one neuron to communicate with another. The neurotransmitter levels can build up and overstimulate certain brain areas. This effect can cause hallucinations and strange thoughts and ideations.

Ketamine is difficult to produce in a home lab because it requires a specialized manufacturing process. Most of the supply is taken from veterinary and human anesthesia products. Pharmaceutical grade ketamine comes as a liquid that can be swallowed or injected. Club users will allow the liquid to evaporate in order to collect the powder. The powder can be mixed with tobacco or cannabis and smoked or snorted.

Ketamine has a rapid onset of action that lasts 30 to 45 minutes. It can cause a dreamlike state or a feeling of floating outside the body. Increasing doses can lead to confusion, anterograde amnesia and delirium. Depending on the dose, other drug and alcohol ingestion and the person’s ability to metabolize the drug(s), some can develop hypertension, rapid heart rate (tachycardia), palpitations, a reduction in breathing effort (respiratory depression) with periods of apnea (no breathing).

Chronic users can become addicted. Withdrawal can be severe and require medical supervision to assist in the detoxification process.

The purpose of this series was to provide information about what is known about these drugs and not to be interpreted as scaremongering.

Information should be provided within a frame of reference or context that provides the reader with a means to gauge true risk. To wit, some users will not experience the severe side effects of club drugs; others will.

More research is required to provide people with an accurate assessment of their chances of experiencing these harmful effects. Until then, the user is travelling through uncertain risk territory.

The Club of Tortured Souls

Dr. Barry Dworkin — Tue, 05 Apr 2005 03:27:11 +0000

Originally published in The Ottawa Citizen April4, 2005

First of two parts

Recently, one of my patients with bipolar disorder took Ecstasy at a rave. Within 60 minutes she had collapsed on the dance floor from dehydration.

After a thorough assessment in the emergency room, she was given intravenous fluid replacement and sent home. The following day she came to my office for a follow-up visit, experiencing a precipitous decline in her mood.

This two-part series will look at four commonly used club drugs: Ecstasy (3,4-methylenedioxymethamphetamine or MDMA), GHB (gamma-hydroxybutyrate), Rohypnol or the date-rape drug (flunitrazepam), and ketamine. How do these drugs work and what are the health risks?

The club drugs stimulate the release of the neurotransmitters serotonin, norepinephrine and dopamine from brain cells. These neurotransmitters are intimately involved with mood stability. People use club drugs to enhance social interaction: They feel less inhibited and experience increased empathy, physical closeness and euphoria.

MDMA is the drug of choice at a majority of raves. It is an amphetamine derivative originally developed in 1914 for use as an appetite suppressant, but it never got past animal testing. Its chemical structure is similar to the hallucinogen mescaline. MDMA is addictive but less so than amphetamine, and it does not cause psychosis as often as LSD or other hallucinogens.

Many of the illicitly manufactured MDMA tablets are not pharmaceutical grade. They can contain “binders” or extra ingredients such as caffeine, dextromethorphan (cough suppressant), pseudoephedrine (decongestant), or hallucinogens like LSD or other potent amphetamine derivatives. The latter two ingredients in combination with MDMA can have strong unpleasant hallucinogenic effects.

MDMA’s effects occur 30 to 60 minutes after ingestion, faster if it is crushed or if its powder form is snorted. The effects can last up to eight hours. Serotonin, dopamine and norepinephrine flood the synapses or spaces between the nerve cells. This effect is enhanced by MDMA’s ability to block a brain enzyme that breaks down these neurotransmitters.

The euphoria occurs after a brief feeling of agitation, time disorientation, lack of appetite and reduced thirst. Some people may experience a mildly locked jaw (trismus) or will grind their teeth (bruxism). Both of these side effects can be tempered by sucking on a lollipop.

The overstimulation of the brain and central nervous system can lead to a serious life-threatening condition. The heart rate and blood pressure can increase above acceptable limits. Some users will experience tremors, seizures, clinically significant irregular heart beat (arrythmias), parkinsonism, esophoria (the eyes turn inward — cross-eyed) and an inability to urinate (urinary retention).

The most serious side effect of MDMA ingestion is an elevated core body temperature (hyperthermia) due to serotonin syndrome. This syndrome can lead to muscle rigidity and seizures, muscle breakdown (rhabdomyolysis), acute kidney and liver failure, adult respiratory distress syndrome, and blood clotting abnormalities.

MDMA also stimulates the pituitary gland in the brain to release antidiuretic hormone (ADH). This hormone will reduce the kidneys’ ability to produce urine in response to an increased fluid load; they cannot excrete water into the bladder.

This creates a ‘perfect storm’ of pathology. The body overheats from dancing and the effects of the drug. The kidneys shut down. The user will dramatically increase his or her intake of water and other fluids in response to increased body temperature. Without the kidney’s ability to excrete water, the fluid overload reduces the blood sodium concentration (hyponatremia) through dilution. Low sodium concentration levels coupled with high body temperatures can cause confusion, delirium, paranoia, headache, anorexia, depression, insomnia, irritability, and a rapid, involuntary, oscillatory motion of the eyeball (nystagmus), all of which may continue for several weeks.

Several days after using ecstasy, the effects of serotonin depletion can cause depression, and for some it is severe. People who repeatedly use MDMA increase their risk of cognitive deficits and potentially permanent memory impairment.

MDMA does change the brain’s normal function. Indeed, studies indicate that long-term use in typical recreational doses can lead to a paranoid psychosis that cannot in practice be distinguished from schizophrenia. Prolonged drug abstention will lead to a reversal of the psychosis.

There are some animal and human studies that indicate that MDMA use (possibly in conjunction with cannabis) can lead to cognitive decline in otherwise healthy young people.

My patient with bipolar disorder experienced a precipitous decline in mood because the MDMA depleted the serotonin stores in her brain. People with mental illness are more vulnerable to the deleterious effects of MDMA and other club drugs. It is akin to a patient with asthma or chronic lung disease who smokes. They will tend to have more severe disease and attacks than someone who does not smoke.

These drugs are adulterated with other chemical additives and, although most club drugs look like prescription medicines, they are illegally made and can cause harm even in small doses.

I will return to the club in my next column to review GHB, Rohypnol and ketamine.

Painful to lose independence

Dr. Barry Dworkin — Mon, 14 Feb 2005 22:38:54 +0000

Originally published in The Ottawa Citizen February 14, 2005

Watching someone we love lose their sense of self has become an all-too-common occurrence in Canada and, indeed, in many parts of the world. Even as adults, our childhood image of our parents is firmly imprinted into our minds. The piece-by-piece loss of this image is painful to witness and frightening to the afflicted.

Although we associate dementia (the loss of intellectual capacity, gradual loss of memory, mood swings, changes in behaviour and inability to perform daily tasks) with the aged, Alzheimer’s disease, the most common form of dementia, occurs throughout adulthood.

How many Canadians suffer from Alzheimer’s? How do you recognize it? What have we learned about this disease? What treatments are available and what progress can we expect in the future?

The most common form of Alzheimer’s disease is Sporadic, involving 90 to 95 per cent of all cases. There is a rare genetically inherited form called Familial Autosomal Dominant that accounts for the remaining five to 10 per cent. Two-thirds of the 280,000 Canadians afflicted are women. One in four Canadians has a family member with the disease. Within the next 25 years, as baby boomers age, the number afflicted will increase to 750,000.

Today, $5.5 billion a year is spent providing nursing-home care, medications and community support services for people with dementia. Annual per person costs proportionally increase with disease severity: $9,541 for those with mild disease to $36,794 for those with severe disease.

We know the disease causes gradual unrelenting brain injury and damage. The brain is organized into different zones, each responsible for a specific function. For example, short-term memory loss, loss of vocabulary skill, and the inability to recognize familiar faces is associated with damage to the temporal lobe and hippocampus.

Despite these changes, people still appreciate, respond to and experience a full range of emotional responses.

Brain tissue becomes damaged because too much beta amyloid protein is secreted into the region. The carrier molecules that usually transport the protein away from the area are overwhelmed. As a result, plaques form and destroy the brain cells (neurons). In addition, twisting choking stringy material within living neurons (neurofibrillary tangles) destroy more of them.

Patients and their family and friends have difficulty pinpointing when the symptoms began because of the slow, progressive nature of the illness. Indeed, many of the treatments available work best in those with mild to moderate disease. An early diagnosis is essential to try to limit the speed of disease progression and improve quality of life.

Although there is no cure for Alzheimer’s disease, there are three cholinesterase inhibitor medications, donepezil (Aricept), rivastigmine (Exelon) and galantamine hydrobromide (Reminyl), available for people with mild to moderate disease that can help improve or slow the decline of cognitive tasks such as memory, language and orientation (knowing the date, time, and who you are). They can stabilize the person’s ability to cope with the responsibilities of daily life.

Notable in Alzheimer’s disease, many of the neurons that are destroyed produce acetylcholine, a neurotransmitter linked to learning and memory. When a neuron activates, it will communicate with the adjacent neuron by sending acetylcholine to it. The acetylcholine in turn will activate the next cell to keep the message going.

These cholinesterase inhibitor medications increase the amount of acetylcholine in the brain by blocking cholinesterase, the enzyme that breaks down acetylcholine, leading to an improvement of some symptoms.

Recently, mamantine (Ebixa), a different class of medication, was approved for use for people with moderate to severe disease.

Cessation of therapy results in symptom relapse after a few weeks. It requires about three months of therapy to see peak improvements. Over the next nine to 12 months, there is a slow return to the original starting point. Thereafter, the decline is slowed compared to those who do not take the medication.

New research is promising. A new drug called Alzhemed, currently in clinical trials, appears to prevent the formation of amyloid plaques and encourages the mopping-up of the beta amyloid before it reaches threatening levels.

Recently, an antibody vaccine against beta amyloid was injected into the brains of mice, and reduced plaque formation.

Although there is no known means to prevent Alzheimer’s disease, there are lifestyle measures that can reduce the rate of onset of the disease: exercise (walking has been shown to delay cognitive decline), smoking cessation, controlling high blood pressure and elevated cholesterol levels, moderate alcohol intake, and healthy eating habits.

Advances will continue as researchers gain more insight into the mechanism of the disease. This is happening now and offers hope to those suffering with this disease and to their families.

The Alzheimer Society of Canada website, www.alzheimer.ca, contains a plethora of information about the disease.

The betterment of one’s life

Dr. Barry Dworkin — Tue, 27 Jan 2004 22:49:53 +0000

Originally published in The Ottawa Citizen January 27, 2004

Original Title: The betterment of one’s life

A common student question asked at Canterbury High School focuses upon the melange of moral, ethical and consequential aspects of smoking cannabis.A previous column focused on the physiological and psychological effects of drug use, especially marijuana/cannabis. After my column about the latest research on the effects of cannabis, many readers wrote to express their opinion about the issue. One e-mail caught my attention.

Deborah is a 37 year-old single woman with three boys aged 10, 12 and 14. She first tried marijuana at age 11 and started regular use by the time she was 15. She quit during the five years encompassing her pregnancies but restarted after her youngest son’s first birthday. She smokes an average of four to 10 joints daily. She does not drink or smoke cigarettes.

She comes “from a good upper middle class family.” Her father was in the armed forces and her mother worked for the government. Her sister works at the Department of National Defence and is active in her church. Deborah works for several physicians and was a registered practical nurse for 15 years.

Deborah says, “I have always been very ambitious, adventurous and seemed to have excelled in everything I have attempted; drama, track and field, horseback riding, skiing, skydiving, rock climbing, guitar, keyboards, drums and singing.”

Her concern was that her marijuana use was jeopardizing her health. Her feelings of shame prohibited her from discussing this issue with her family doctor. She feared “what she might think of me, as a person, a mother, and a professional.”

She often feels pressure or pain in her chest and cannot breathe as easily as before. She worries that she may have cancer of the mouth, throat, lungs or stomach from her smoking.

She asked if I might help her quit using cannabis. (There was no precondition that her story would be published.)

She had three goals: to show teens the long-term physical and psychological effects of cannabis; to discourage its use; and to “get some much needed help so that three beautiful little boys will have a mom around for a long time.”

In addition to her desire to quit her cannabis use, she wanted a full physical exam and tests to determine whether she suffered any deleterious health effects.

During her first visit last October, she stated she was experiencing mild, manageable mood swings. She could concentrate and functioned well at work. She had normal sleep patterns and appetite.

She stated she was a high achiever with many goals and dreams. She expressed frustration that she could not sing as she once could or motivate herself to achieve her goals.

She smoked outside of the house and never in front of the children. However, they knew what was going on. Her guilt about the message she was sending to her children was unbearable.

Her physical exam and blood tests were normal. A lung function test indicated the smaller airways were becoming blocked. The chest X-ray was normal.

The question “why does she continue to smoke?” does not necessarily have a straightforward answer. We know she started at age 15, the middle or tribal stage of adolescent development. In this stage, there is a consolidation of body image and sexual identity. The school environment is comfortable. Peer groups become their new family and safe haven and are a form of tribalism with all its rituals, markings and lingo. Peer pressure becomes the dominant behavioural influence. In the quest for independence they test their limits and compare themselves to their friends. Paradoxically, they conform to their peer group in order to feel more independent.

Drug abuse during adolescence will arrest or hinder progression through the developmental stages that lead to independence and self-awareness. Indeed, Deborah readily admits she has difficulty defining who she is. At 37, she remains stuck in her adolescent middle stage. Although she appears to be coping with many of her responsibilities on an adult level, her sense of self remains undefined.

I usually give my adolescent patients some “homework” after the preliminary evaluation to better understand their concept of friendship, relationships and their self-image. These questions are part of the Adolescent Toolkit (http://members.rogers.com/barrydworkin/help_teens_tune_in.html) and are germane to Deborah’s situation:

- What do you like and dislike about yourself?

- What are your good and bad qualities?

- What are your definitions of a friendship and relationship?

The goal for Deborah is to understand why she smokes, gain control over her behaviour and achieve true independence.

Next week’s column will review Deborah’s progress.

Dealing with depression

Dr. Barry Dworkin — Thu, 30 Oct 2003 00:20:50 +0000

Originally published in The Ottawa Citizen October 29, 2003
Original Title: Melancholy Blues but the Roses are Still Red

It is not a human weakness, and taking medication is not an admission of failure.

Although great strides in public education about depressive illness has led to better treatment and less suffering, I think we must prevent the pendulum from swinging too far whereby people lose their innate ability to distinguish normal grief from clinical depression.

There are people who give of themselves without any thought of reward. Mr. Rock (not his real name), went to England to care for his ailing father. He took charge of his father’s care. Shortly thereafter his father succumbed to his illness. Mr. Rock had to organize the funeral arrangements.

On the day of the funeral, he drove around the countryside picking up many his father’s elderly friends so they could attend the funeral service. He provided emotional support for many of them. He was the only family member left alive.

Out of concern for his health he came to see me. In telling this story he started to cry; the first time he had had the opportunity to do so. In his desire to help everyone else and the whirlwind of activity ensuing after his father’s death, he did not take time for himself. He put his grief on hold because others needed him.

He could not sleep or focus on his work. He felt that he should be able to continue as he always had done.

He was aware of the normal grieving process but failed to recognize he was just as deserving of support as anyone else. Sometimes even the most stalwart and stoic need a hug.

It is not a sign of weakness to experience and express sadness. He felt better knowing his was a normal human response that did not require medical therapy.

Another wonderful patient came to see me around Christmas. Inundated with responsibilities several weeks prior to the holidays, she continued to function well but she was unhappy and feared that this was abnormal. She wanted to know whether treatment was required. Family members and friends suggested she might need medication. She sought reassurance that her response was normal.

Indeed it was. The Diagnostic and Statistical Manual outlines specific criteria for clinical depression. Treatment is suggested when a person experiences at least five symptoms for more than two weeks (depressed mood, loss of pleasure or interest in all activities, suicidal thoughts, significant weight loss or weight gain, isolation from friends and family, feelings of worthlessness, guilt, poor personal hygiene, inability to concentrate, lack of motivation and fatigue, mood swings, poor memory, agitation or anxious mood, inability to sleep and poor or increased appetite).

One of the five must be depressed mood or loss of pleasure or interest in daily activities.

Depression occurs when one experiences profound loss: the death of a loved one, financial ruin, divorce, failing at school, relationship break-ups or losing one’s job, among others.

Some may have a genetic predisposition for major depression which is triggered by these events. These people can also experience depression without warning or notable cause.

People react differently in these situations. Some will go through the five stages of depression: denial, anger, bargaining, depression and acceptance and move on.

Denial is the antithesis of anger. The former is a defensive measure, the latter offensive in nature. At first, a person may deny a problem exists.

This short-term primary defense mechanism is a shield against potentially overwhelming pain. Once reality pokes through this shield, anger ensues to fight back the pain, “Why is this happening? This is not fair! I’ll show them. They can’t do this to me!”

Anger eventually subsides and bargaining follows. The person tries to alter the course of events by pleading their case to a greater power, “Please God, if you spare his life I will never speak ill of him again.” They think by altering their behaviour they can bring about positive change, “If I show her I love her, she will see I am a good person and she will take me back”.

Depression begins once bargaining has run its inevitable course. Most people begin to recover after several months. Their appetite returns; one of the first signs of recovery. Sleep habits improve, energy levels and motivation to participate in cherished activities increase, loss of pleasure wanes, work or school functioning improves and concentration and memory sharpen. They begin to laugh again. They accept and adjust to what has happened.

The past decade has seen the emergence of grief counselors. They provide comfort and counsel to those affected by sudden unforeseen traumatizing events.

I wonder if the individual’s ability to experience and adapt to adversity is compromised by this well-intentioned effort. Should adults be given time to think about what has happened to them?

Many people would rather talk to a family member or friend rather than a complete stranger. Should an individual have the opportunity to ask for help when they want it?

Depression and sadness are not human weaknesses. Taking medication, if indicated, is not an admission of failure.

Rather, those individuals who recognize it and do what is appropriate to help themselves are in control of their lives. They learn about their personal limitations and grow from their experience.

Ask questions, take control and ease the suffering.

© Dr. Barry Dworkin 2002

Bipolar disorder tough to diagnose

Dr. Barry Dworkin — Thu, 30 Oct 2003 00:16:56 +0000

Originally published in The Ottawa Citizen October 29, 2003
Original Title: Polar Opposites

Mr. S. was visibly upset about his wife’s behaviour and mood swings. Her “gambling addiction” playing the slots accumulated $40,000 in debt. Mrs. S. admitted gambling was a problem but continued to do so because of the exhilaration of knowing she would win the big prize. There were other notable behaviours.

She would lock all the doors within the house 15 times per day and awake at night to ensure they remained locked. Her screams at night that demons were under the bed terrified her family. She would talk about one subject and rapidly switch to another in mid-sentence. She experienced bursts of energy lasting several days. She would obsessively clean the entire house and cook a month’s worth of food.

Then her mood would crash. She would socially isolate herself for weeks on end. With the prospect of a marriage breakdown, bankruptcy, loss of their home and 30 years of mood instability she had hit bottom.

Mrs. S. has Bipolar Disorder (previously termed manic-depressive disorder). Bipolar disorder is an under-diagnosed and under-recognized condition. Indeed, an average of eight to ten years passes from the time of initial symptoms to diagnosis and treatment. It usually appears between the ages of 18 to 24 but can appear at earlier and later stages of life.

Bipolar disorder is an inheritable illness that leads to extreme mood swings. One study revealed a 13 percent risk of bipolar disorder among children of biological parents with the disorder. Indeed, Mrs. S.’s alcoholic father had similar mood swings problems.

About one in 100 Canadians suffer from this condition over their lifetime. The World Health Organization identified it as the sixth leading causes disability-adjusted life years in the world among 15 to 44 year-olds.

Drug and alcohol abuse usually accompanies this condition. Twenty-five to 50 per cent of people with bipolar disorder attempt suicide and 15 per cent will die. Ninety per cent will be admitted to hospital for at least one psychiatric assessment and treatment and two-thirds will have two or more hospitalizations in their lifetime

The characteristics of mania, a psychotic condition, include feelings of inflated self-esteem, grandiosity, invincibility and irritability. The manic person may think they are Jesus Christ or other famous person or deity capable of fantastic powers and brilliant ideas. They speak rapidly often changing the content of their discussion in mid stride and are easily distracted. Physical activity increases and the need for sleep decreases. They may exhibit hypersexuality and act impulsively (e.g. go on extravagant spending sprees) without reflecting upon the consequences of their actions. They have poor judgment and do not recognize their condition.

People with hypomania are not psychotic. Their behaviours are similar to mania but without the psychotic traits, poor judgment and impulsivity. They tend to be more irritable and impatient but are able to function without impairment. Indeed, they may function at a superior level in the short-term.

There are several types of bipolar disorder distinguished by whether there is true mania (Bipolar I) or hypomania (bipolar II) in conjunction with bouts of major depression. The Bipolar II person experiences frequent periods of severe depression interspersed with hypomania.

Diagnosing bipolar disorder is problematic. Most patients will come to see their doctor only when they are in the depressed phase of the illness. They rarely come in when they are manic or hypomanic because they feel good. Indeed, when they are depressed they do not report instances of feeling well or view these fleeting short episodes as inconsequential since their focus is on their depressed mood.

This situation leads to the diagnosis Major Depressive Disorder instead of Bipolar Disorder.

Further compounding the problem is the initial dramatic improvement in symptoms in the first two weeks after starting an anti-depressant medication. However, by week four they revert to their depressed state. Increasing the medication dose or changing it to another product may not result in any improvement. Indeed, a “clinically depressed patient” who does not respond to three different anti-depressants should arouse suspicion they have bipolar disorder.

The Mood Disorders Questionnaire (http://www.dbsalliance.org/questionnaire/screening.asp) is a tool available to patients and physicians that helps differentiate between bipolar disorder and depression. It contains a series of statements that checks for characteristics inherent in bipolarity and the degree of impairment experienced by the patient. A positive screen for bipolar disorder is accurate nine out of ten times.

If you know of a family member or friend who is irritable or angry, thinks and talks so fast that others cannot follow them, sleeps excessively or not at all, feels very powerful and important, has trouble concentrating, has thoughts of suicide or death, spends too much money, abuses alcohol and drugs, is obsessed with sexual activity and suffers from severe mood swings, they should be evaluated for bipolar disorder.

A month after beginning treatment, Mrs. S. no longer had any desire to gamble. Her mood swings resolved. She functions well at work, her marriage is stronger, the debt is consolidated and her life is back to normal. Thirty years of suffering has ended.

For more information: The Mood Disorders Society of Canada http://www.mooddisorderscanada.ca/bipolar/bst/

© Dr. Barry Dworkin 2003

Students stressed, desperate for help

Dr. Barry Dworkin — Fri, 28 Mar 2003 04:34:34 +0000

Originally published in The Ottawa Citizen March 27, 2003
Original Title: What society has wrought

One of the more difficult aspects of answering teen questions is the degree of angst and pain that spills from them. Although the majority of our teenage children progress through adolescence to become well-adjusted, productive adults, a substantial minority is desperate for help during life’s stressful events.

A recent annual Academy of Child and Adolescent Psychiatry meeting supports this view. A U.S.-wide survey of 3,242 teens and young adults indicates one-third experience a bout of depression. Two-thirds of this group fail to seek professional help.

The survey indicates that 36.4 per cent of teens between 15 and 19 experience a bout of depressed mood lasting two weeks or longer, at least once in their lives. About seven per cent have symptoms that suggest a major depressive disorder. Depression is a major health risk to teens.

The incidence of teen suicide climbs. “Less than 20 per cent of teens will tell a doctor about their (depressive) symptoms,” reports Dr. Stephanie Riolo of the University of Michigan.

“Of those who tell, girls seek help more often than boys do.”

This is similar to my experience at Canterbury High School clinics. Many teens are reticent and intimidated from seeking medical attention; they fear their family doctor will breach confidentiality and inform their parents. Some seek solace from friends or acquaintances, only to find the support underwhelming or ineffective.

The teen years are a time for personal growth and development. Adolescents develop different areas of interests, life and educational goals, and a sense of self through the three stages of adolescence. Although dating and social interactions are an important element of adolescent development, for some it becomes an all-consuming process. They can become stuck in a particular stage of development.

Drug use poses a similar threat. One observation made by the guidance counsellors and our medical centre at Canterbury is that many teens become trapped within destructive relationships. Friends and family are forgotten.

Some lose themselves in the relationship; their moods and actions are influenced by the actions of their partner. The dynamics of their relationship change if they become sexually active. There is the anxiety of infidelity, sexually transmitted diseases, pregnancy and the consequences of any of these concerns.

There are many reasons why this occurs: parental strife, divorce, laissez-faire approaches to discipline, lack of parental involvement and support, lax enforcement of the rules of the house, poor sense of self and depressive illness among others. Sometimes, there’s no apparent explanation.

This is not an indictment of parents but based on direct observation and interviews with the students.

Here, the students have their say:

Grade 9

“What do you do when you get so upset that you think people would be better off without you?”

“If my boyfriend has slept with another girl before, is it best to have him tested? And why?”

“If I had a friend who I thought was being abused by her father, should I come to you or what should I do?”

“A friend of mine is really depressed. And, he wants to die although he said he could never go through with it. He says that he can’t live like this any more, and that he won’t tell anyone until OAC, when he won’t see any of us again. I hate to see him like this. How can I persuade him to get help?”

“Depression and suicide run in my family. I’ve heard that it can be caused by a chemical imbalance and is curable. Is that true?”

“A close friend of mine has had a hard life. She’s been anorexic and bulimic for eight years now. She’s 5-foot-2 and 75 pounds. I’ve tried to get her help but they say she’s not ready for a program yet. I’m really worried about her.”

“I have a lot of problems and things going on in my life and I don’t feel like I have anyone to talk to. I’m worried that my problems are going to start taking control of my life and I don’t know where to turn. How do I get help and who do I go to?”

Grade 10

“I used to trust everyone but within the past two years three guys (who I was serious about) cheated on me and friends have betrayed me. Now I can’t trust anyone at all. Even friends I’ve known since I was a baby. How can I get over this trust issue and trust again?”

“Is there such a thing as a social anxiety disorder — when you are so wrapped up in what other people think of you, you don’t enjoy your friends or whatever.”

“I have a friend who is a frequent self-mutilator. I’m afraid her cuts will get infected. I’m not worried about suicide because she only cuts her legs but I’d like to know what is the risk factor of infection. She uses razors mostly but scissors sometimes. What can I do?”

“I started having sex a year ago when I was 15, and my vagina was very tight. My boyfriend could not reach full penetration, and once I blacked out. Why is this and what can help?”

Grade 11

“For years, my dad’s girlfriend hated me. She used to insult me and tell me my real mother hated me. She tried to run me over with her car. I told myself I didn’t care but I guess I really did. This I guess went on for four or five years and I’ve never talked about it. My new stepmother says that because I was older (11+), it didn’t affect me, but it does.”

“I’m very shy and am always trying to make people happy. I want to talk to someone but I’m afraid. I find that I get excessively angry and violent at times. When I feel this way, I feel like hurting or destroying someone or something. Is there something wrong with me?”

One is struck by the concreteness of some sexuality questions. There is little emphasis on the appropriateness of the activities described. Should our children have to worry about these issues? How can we prevent this behaviour?

Many teens are adrift, lacking direction and focus. Once they find someone they trust, they tend to stick with them. Trust provides the ability to influence a teen’s life. The goal is to minimize and if possible eliminate behaviours that are inherently self-destructive.

Survey shows youth drug use up in past decade

Dr. Barry Dworkin — Thu, 27 Mar 2003 04:36:40 +0000

Originally published in The Ottawa Citizen March 26, 2003
Original Title: What teens want to know: Drugs

In this continuing series based on teens’ questions asked at Canterbury High School, today’s column looks at the drug issue, which is all too often intertwined with the issue of sex among teenagers.

The 2001 Ontario Student Drug Use Survey, a study conducted by the Centre for Addiction and Mental Health (CAMH) every two years since 1977, looked at legal and illicit drug use by more than 4,200 students from Grade 7 to OAC.

“The 1980s were a period of decline of drug use, the ’90s had a resurgence and in 2001 the good news is that illicit drug use among youth isn’t growing — the bad news is it’s still higher than it was in the early ’90s,” according to Dr. Edward Adlaf, the senior scientist at CAMH and associate professor at the University of Toronto who conducted the study.

For the first time since 1991, the survey did not show any year-over-year increase in drug use. However, most measures continue to be significantly greater than the 1993 rates. Alcohol remains the top dog in this department. In 2001, 63 per cent of students drank, versus 57 per cent in 1993.

Further, binge drinking — defined as downing five or more drinks at one time — was reported by 25 per cent of youth in 2001, compared with 18 per cent in 1993. Inebriation rates increased from 17 per cent in 1993 to 27 per cent in 2001.

Between 1999 and 2001, cigarette use declined from 29 to 24 per cent, solvents from seven to six per cent and LSD from seven to five per cent.

The student drug-use survey highlights include:

Students today are not using alcohol, tobacco or cannabis at an early age.
The percentage of new users has not increased over time.
Although rates of drinking and driving among licensed students remained stable at 15 per cent, about 32 per cent of all students report being a passenger in a vehicle driven by someone who had been drinking, and 19 per cent of drivers reported driving after using cannabis.
Perceptions about the risks of using cannabis, cocaine and LSD seem to be weakening over time.
Toronto students use alcohol at a lower-than-average rate, while western Ontario students report above-average use of cannabis, heroin, methamphetamine, cocaine, crack, hallucinogens and ecstasy. Northern Ontario students have a higher rate of alcohol and binge drinking.
Females reported higher rates of non-medical stimulant use, while males reported higher rates of heavy drinking, cannabis, glue, methamphetamine, LSD and hallucinogens.
Drug use was lowest among 7th-graders and highest among 11th- or 12th-graders — with the exception of inhalants, that showed greater use among younger students.
These statistics correlate with the questions students pose in the classroom. Teens want to know what drugs will do to them. Their questions are to the point and reflect an interesting dichotomy between immediate versus long-term harm.

They seek a frame of reference to compare the risk by invoking another drug or activity for risk assessment comparisons.

These Grade 9 questions reflect a desire to understand the issues:

“What are the side-effects of the drug mescaline? What is it?”

“My best friend used to be anorexic and bulimic and now uses a whole bunch of drugs. Her parents know, but they refuse to take action. All of her friends are the same way. What do I do?”

“How fast will smoking kill you, ’cause I don’t want to die?”

“Is it true you lose brain cells if you do drugs? If so, what exactly do drugs do to you?”

“How do I tell my parents about my drinking problem?”

“My friend throws up every time she gets drunk. This is normal, but the same things happens when she smokes marijuana. Is she allergic? If so, how can she find out the consequences of trying acid or other drugs?”

“Does alcohol stunt the growth of your boobs or anything else? Also, if you drink a lot as a teen but stop after a few years, will you have liver problems?”

“I’ve been doing drugs for a while and probably done just about every drug you can think of. I also get depressed a lot and I find drugs help me to escape for a while. I don’t want to quit drugs, but I want the depression to go away. What should I do?”

“I heard that smoking pot does not harm you at all because it is a natural drug, but all that is harmful is the smoke. Is this true?”

“Is there such a thing as a weekend alcoholic?”

“If one of my parents is an alcoholic, what are my chances of being an alcoholic?”

“Some of my friends that smoke weed, their grade-point average is going down. I smoke about two to three times a week, but it hasn’t really affected my school work. Why is that?”

“If you do drugs and have a high tolerance level, does it have the same effect on the body and mind?”

“What effect does cocaine have on a person if they done it just once? Or more?”

“What would be the difference smoking weed or smoking weed laced with cocaine?”

“How long do drugs stay in your bloodstream? If the doctor takes a urine sample, can they detect drugs?”

“When my friends are talking about drinking or getting drunk, it makes me feel very uneasy. What should I say to them? I don’t want them to get drunk. I feel very scared about alcohol and what it can do to you.”

Our teens want our help. Their questions call out for guidance through the maze of half-truths and peer pressure. Most parents have the unique opportunity to guide their children through the morass.

How do you get herpes?

Dr. Barry Dworkin — Wed, 26 Mar 2003 04:27:39 +0000

Originally published in The Ottawa Citizen March 25, 2003
Original Title: What teens want to know: Real Questions, Real Answers

How have society’s changing attitudes about sexual activity and responsibility affected our teenage children?

The Medical Institute for Sexual Health, a U.S. non-profit group promoting sexual abstinence outside marriage, lists the devastating toll laissez-faire attitudes have had on our teens.

Its data are supported by similar reports by the U.S. Centers for Disease Control.

The medical institute raises concerns that providing sexual health information without moral context and consequence is harming our children.

The institute’s review of the data indicates that our children’s emotional and physical health is at risk.

Half of all 13- to 17-year-olds will become sexually active. Twenty-five per cent of all sexually active teens have a sexually transmitted disease.

Over 20 years, the prevalence (number of existing cases in a given population) of genital herpes in children 12 to 19 years old increased by 500 per cent. Chlamydia, a leading cause of infertility in women, occurs in one in 10 teenage girls, half of all cases in 15- to 19-year-olds. Human papilloma virus, a leading cause of cervical cancer, is reaching epidemic levels in the teen and young adult age group. Teenage girls with the virus are more susceptible to cervical cell changes that lead to cancer, compared with adult women.

Oral sex is a means for some girls to maintain they are virgins. Many do not see oral sex as being sexually active. Many teens do not even have a definition of what “sexually active” means.

As many as one in five of our teenagers are clinically depressed. Suicides have increased threefold in 30 years.

After nine years of giving health clinics at Canterbury High School, thousands of patient visits and hundreds of handwritten anonymous questions answered during classroom visits, these reports and statistics lead me to accept them for what they are: the truth.

Before writing me off as alarmist, please read what your children have had to say:

Grade 9

“What happens if when you’re having oral sex, you swallow sperm?

“If a girl swallows my sperm, will she be pregnant?”

“How is abortion performed?”

“What is the average of females being raped and beaten in the ages 14 to 16?”

“How does Viagra work?”

“As a male, if I impregnate a girl, what are my obligations?”

“Can you get pregnant without having sex?”

“My friend used to have a boyfriend who hit her and treated her like crap. He even used to use her for sex. Now he wants to get back together with her and she hasn’t made up her mind. As a best friend, what should I say to her to make the right decision without hurting our friendship?”

“Do males have to ejaculate or is it something they choose to do?”

“Can you arrange an abortion without our parents knowing?”

“Can a girl get pregnant if a guy ejaculates in a pool and she is near him?”

Grade 10

“Are there any risks for girls under 14 years other than pregnancy and STDs?”

“If you have intercourse with someone who has an STD, are you guaranteed to get the STD?”

“What is herpes? How can you get it? And how do you get rid of it?”

“My friend might be pregnant but she doesn’t want to have it. She doesn’t want to go to the doctor. She wants her friend to punch her in the stomach to kill the baby. I don’t think it’s right. What can I do to convince her to not do this?”

“Does the size of a man’s penis affect his personality?”

Grade 11

“Would it be safer to have sex now while we are younger, considering that the number of people who have AIDS is rising very quickly?”

“Is it illegal for a 15-year-old girl to be having sex with a 20-year-old guy? What if she’s 16?”

“Can you have an abortion when you are 16 without letting your parents know?”

“I just can’t handle it with the workload any more. I’ve had it trying to balance out school, homework, work, sports, friends and a boyfriend and especially parents. I’ve gotten to the point of nervous breakdown. I don’t sleep, hardly eat. I feel helpless. What can I do? P.S. What is hepatitis B and how do you catch it?”

These questions cut across all socio-economic and cultural strata. We must face this growing trend. We cannot ignore what is happening to our children. Many parents come into my office gravely concerned about their teen’s behaviour.

Teenagers, despite their protestations and efforts to act as adults, need guidance and support to become mature, caring adults.

The guidance centres on responsibility, respect, sexual behaviour and following the rules of the house.

Many parents try to be their children’s friend. The idea is the child will be more likely to accept you into their life. Parents hope they will have more influence on their child’s life decisions and actions.

This strategy, well-meaning and caring as it is, will not stand the test of time.

Friends do not tell friends when to go to bed. At some point, circumstances will dictate that parents will have to switch hats from friend to parent. Viva la revolucion!

Despite their challenges to your authority, teens do need their parents to be a foundation for morals, limits, rules, understanding and love, regardless of what the teens might say or do. Too many feel adrift in a sea of confusion. They need to know they can return safely to port.

As the questions above show, what possible benefit is it to a 15-year-old to have to worry about whether their boyfriend or girlfriend is cheating on them?

Why should they have to deal with the complications inherent in a sexual relationship on top of their educational, social and family responsibilities?

Why should they have to come into the office freaking out over whether they are pregnant or have an STD? Why are they worried about the effects of swallowing sperm? What can parents do? Quite a bit, but it is not an easy road.

Tomorrow night, Dr. Joanne Tannenbaum and I will present at the Citizen conference centre a forum for parents and teens called “What your teens want to know: Real answers to real questions.”

——————————————————————————–

Tomorrow’s column will look at teens and drugs.

Dr. Barry Dworkin is a family physician and an assistant professor of family medicine at the University of Ottawa.drbdworkin@hotmail.com

Read previous columns at members.rogers.com/barrydworkin/

Web Sites:

Medical Institute for Sexual Health: www.medinstitute.org

Centers for Disease Control: www.cdc.gov/nchstp/od/news/RevBrochure1pdf.htm

National Mental Health Association: www.nmha.org/infoctr/factsheets/24.cfm

Teen Sex: What You Need to Know

Saturday: The demise of dating: Why school kids have ‘buddysex.’

Sunday: In their own words: Students talk about hooking up.

Monday: In search of guidance: Health educators try to guide students through the morass and attempt to curb date rape by teaching the dangers of mixing alcohol and sex.

Today: Sex ed: What are they teaching our kids in elementary and high school? And Dr. Barry Dworkin on what teens really want to know about sex.

Tomorrow: High-school confidential: the Canterbury health clinic. And Dr. Barry Dworkin on kids and drugs.

Thursday: A look at what parents and teens have to say in Wednesday night’s public forum. And Dr. Barry Dworkin on the angst teens are dealing with on the subject of sex.

Friday: The consequences of the hooking-up culture: Where will society and divorce rates be in 20 years if we continue in this direction. And a reality check — teens are not the libertines they are portrayed as.

Public Forum on the Culture of Teen Sex

Parents, teens and others interested in the culture of ‘hooking up’ are invited to a Citizen-sponsored public forum held by Drs. Barry Dworkin and Joanne Tannenbaum, tomorrow at 6 p.m., at 1101 Baxter Rd. Register by e-mail at dworkinforum@thecitizen.canwest.com or by phone at 596-3664. Please include your name, phone number, and the number of people who plan to attend.