By Erik Messamore
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The podcast currently has 13 episodes available.
This episode deals with the question of weight gain from antipsychotic medication:
I'm on 20 milligrams of olanzapine. It's helping me and I don't want to change it. The only thing is that I've gained a lot of weight that makes me feel very unattractive. I’ve spoken to my psychiatrist about it, but I haven't gotten any guidance on the matter. Are there any solutions to weight gain from this kind of medicine?
Modern antipsychotic medications can be very helpful for some people. And they are less likely to cause neurological side effects, compared to their first-generation predecessors. However, many of these newer medicines can cause someone to gain significant amounts of weight.
This is a serious problem that the psychiatric profession (in my view) has been very slow to address.
In this episode, Dr. Erik Messamore describes several strategies that can reduce the risk of medication-related weight gain or that can reverse weight gain once it has started.
Strategy 1. Choose antipsychotic medications with low weight gain risk
Different antipsychotic medications come with different degrees of weight gain risk.
Table 1 in this open-access medical journal article lists medications with higher or lower risk of weight gain. The graph in this article also illustrates the differences in weight gain risk among the various antipsychotic medications.
Strategy 2. Switch to an antipsychotic medication with lower weight gain risk
People who have gained weight from higher-risk medications – like quetiapine (Seroquel) or olanzapine (Zyprexa), for example – may lose weight after switching to a lower-risk medication.
On the other hand, some people (like the person who sent in today’s question) might mostly like their current medication, or may not want to take the risks involved in medication switching (e.g., the switched-to medication might not work as well, or might have other side effects). In situations like these, there are several weight loss options worth considering.
Strategy 3. Diet and exercise to reduce weight from antipsychotic medication
Many studies show that antipsychotic-induced weight gain does respond to standard diet or exercise interventions. A relatively small reduction of 150 calories per day can lead to about 16 pounds of weight loss over a year. For many people, that can be achieved by sticking to natural, whole foods and avoiding processed foods with a lot of carbohydrates or added sugars.
Exercise and physical activity can enhance weight loss. And numerous studies show that exercise can improve mood, reduce anxiety, increase cognitive performance, and reduce symptoms of psychosis.
Very low carbohydrate diets like the ketogenic diet are popular these days. These diets are designed to reduce insulin levels, which can make it easier to lose weight (because insulin is a fat-storage signal). Many people who undertake these diets can maintain calorie deficits without feeling hungry. Several case reports and a small clinical study suggest that the low-carb/ketogenic diet might help some people with schizophrenia, psychosis, or bipolar disorder to experience fewer symptoms.
Strategy 4. Metformin to reduce weight from antipsychotic medication
Metformin is a widely-used treatment for type-2 diabetes. It improves the body’s insulin signals and reduces spikes in blood sugar. Metformin can also help people without diabetes to lose weight. And there are many studies showing the metformin can reduce weight in people who have gained weight from antipsychotic medications.
Strategy 5. GLP-1 Agonists to reduce weight from antipsychotic medication
GLP-1 is an abbreviation for glucagon-like peptide 1. The GLP-1 agonist drugs mimic the action of natural GLP-1. They optimize the body’s insulin responses and reduce appetite. Some of these medications – liraglutide (Victoza, Saxenda); semaglutide (Ozempic, Rybelsus, Wegovy) – even have FDA approval for treating obesity.
Lirgalutide has been studied in weight gain from antipsychotic medication and appears to produce more weight loss than metformin.
Strategy 6. Melatonin might reduce weight gain from antipsychotic medications
This episode mentions that some studies show that melatonin might reduce the amount of weight gained from antipsychotic medication, while at the same time helping to further reduce symptoms of psychosis.
The studies referred to are:
Summary and suggestions
Although the psychiatric profession has been slow to respond to the problem of antipsychotic-related weight gain, there are several options that can reduce the risk of weight gain or that can help someone lose weight.
Many psychiatrists are aware of these options and are willing to help.
But in cases where the psychiatrist does not know about these options or does not have experience with prescribing medications to assist with weight loss, it’s likely that a general practice doctor or an endocrinologist does.
The goal of treatment is always to maximize improvement and to avoid side effects whenever possible. And in cases where side effects are unavoidable, the goal should be to minimize them as much as possible.
If you’re concerned about weight gain, there are options and solutions. Your health care provider should be able to address them, or refer you to someone who can.
Topics
0:44 This episode’s question is about weight gain from antipsychotic medication
1:20 – How common is the weight gain problem?
5:49 – Which medications are more likely (or less likely) to cause weight gain?
12:38 – How to these medications lead to weight gain?
15:27 – What are some strategies to prevent or reduce weight gain from antipsychotic medications?
20:56 – How effective is diet and exercise for antipsychotic-related weight gain?
26:28 – Suggestions for someone who is concerned about weight gain from antipsychotic medications.
About the Podcast:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Send us a question
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel
What is akathisia?
Akathisia is a relatively common medication side effect. Akathisia is a feeling of restlessness that many people find difficult to describe. Many people with akathisia say that it makes them feel like they would like to crawl out of their skin.
What does akathisia feel like?
Akathisia can be just an uncomfortable feeling. But for many people that feeling of restlessness translates into not being able to sit still. (Akathisia comes from Greek words that mean “not able to sit down”). It can involve fidgeting, or not being able to sit down or lie down for very long without having to move. Akathisia can manifest as walking or pacing as well.
What causes akathisia?
Akathisia is sometimes a symptom of neurological illnesses (like Parkinson’s disease), but most of the time akathisia is a medication side effect.
Medications used to treat psychosis or schizophrenia are the most common cause of akathisia. But antidepressants can cause akathisia. So can some treatments for nausea or vomiting.
Akathisia treatment
Akathisia is relatively easy to treat. The most common treatments for akathisia are: reducing the dose of the medication that’s causing it, or getting rid of the medication and switching to a different one. The most common medication treatments for akathisia are propranolol or lorazepam. Other treatment options that have been studied include: cyproheptadine, vitamin B6, benztropine (Cogentin), or diphenhydramine (Benadryl).
In this week's episode, Melissa and Dr. Erik answer questions like:
Topics covered:
0:44
What is Akathisia?
02:11
Akathisia can consist of feelings or of movements.
3:32
What causes Akathisia?
6:36
Akathisia is a frequently missed or unrecognized side effect.
7:59
Why is Akathisia an often-unrecognized side effect?
10:40
The feeling of Akathisia is hard to express
14:25
A description of what Akathisia looks like
20:20
What to do when a medical problem does not respond to textbook solutions?
23:59
Antidepressant medications can cause Akathisia
26:17
Some medications for nausea or vomiting can cause Akathisia.
28:25
A tragic story of missed Akathisia in the emergency department
30:18
Advice and possible solutions for someone who might be experiencing restlessness
33:07
Weighing your options and choosing the right medications
About the Podcast:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Send us a question
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel
This week’s listener question was “is there any new research about curing anosognosia?”
Anosognosia is a medical term derived from Greek root words that mean “lack of disease knowledge.”
Although anosognosia started off as a neurological concept, it's also very common for people with psychiatric conditions to have no awareness that their symptoms are unusual, or that they could indicate the presence of a mental illness. Emerging data suggest that impaired insight in mental illness might -- like neurological anosognosia -- involve those outer layers of the right side of the brain.
It turns out that a unique form of brain stimulation that activates the right brain can temporarily reverse anosognosia in people who have had strokes... and in people with insight-impairing bipolar disorder or schizophrenia.
The studies are small. And the findings are preliminary. But the results open the possibility of treating bipolar disorder or schizophrenia without medications. And the data also suggests very strongly that insight impairment in psychosis is more like the anosognosia typically seen in neurological disorders than the commonly assumed psychological denial or willful disregard.
Companion YouTube video about vestibular stimulation as a possible mania-reducing, psychosis-reducing, and insight-improving treatment in bipolar disorder or schizophrenia.
Topics covered
1:01 – What is anosognosia?
1:45 – Is anosognosia a form of psychological denial?
3:19 – Psychological defense mechanisms versus willful denial of illness?
4:15 – The difference between denial and anosognosia
4:40 – History of the anosognosia concept
7:28 – What types of brain injury can cause anosognosia?
10:05 – What are some functions of the cerebral cortex?
12:03 – Can anosognosia be a feature of psychiatric conditions?
12:30 – Lack of illness awareness is common in psychiatric conditions
15:08 – An example of insight impairment in schizophrenia
18:26 – Can psychiatric treatment improve insight or illness awareness?
22:36 – What can family or friends do?
22:52 – The controversy of involuntary treatment
26:00 – Strong caring relationships are better than strong logical arguments
28:23 – Do neurological factors contribute to lack of illness awareness in psychiatric conditions?
29:45 – A simple procedure that can temporarily reduce symptoms and improve insight
34:13 – The possibly paradigm-shifting significance of vestibular stimulation studies
Quotes
Resources
The book I Am Not Sick, I Don't Need Help! How to Help Someone Accept Treatment by Xavier Amador is one of the most helpful resources for friends or family members to understand anosognosia/illness unawareness and how to befriend, support, and effectively encourage someone to accept treatment.
About the Podcast:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Send us a question
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel
Can Antidepressants Reduce Self-Harm?
Self-harm is a common behavior. About 1 in 8 children and up to 1 in 5 adolescents will deliberately injure themselves without suicidal intent. But even without suicidal intention, self-harm is an alarming and potentially dangerous behavior. Self-harm is a sign that something is wrong… but what’s the best way to help?
It’s not uncommon for someone with self-harming behavior to be prescribed an antidepressant. Most of us would think that someone who is repeatedly harming themselves is very sad or depressed. So, it’s not surprising that doctors might prescribe an antidepressant. But it raises several questions like:
Melissa and Dr. Erik address these questions and more in this episode of Ask A Psychiatrist.
Episode highlights
2:10 – What do antidepressant medications do?
3:34 – The types of conditions that “antidepressants” can be useful to treat.
4:36 – Conditions that might be worsened by antidepressant medications.
5:35 – Some less-publicized side effects of antidepressant medications.
7:00 – Why it’s useful to know about the possible side effects of any medication.
8:32 – How feelings of numbness happen, and how numbness can drive self-harming behavior.
10:13 – Differences in medication response speak to differences in the cause of the symptoms that the medication was prescribed to treat.
11:36 – What we diagnose as “depression” has many different underlying causes.
12:59 – Are there differences in how children or adolescents respond to antidepressant medications?
14:13 – Antidepressant use in children or adolescents is associated with slightly but significantly increased risk for suicide.
16:04 – Could antidepressant medications increase self-harming behavior risk?
17:46 – What are the causes of self-harming behavior?
19:30 – Self-harming to regulate emotions.
23:09 – Self-harming to change the flow of a discussion or the power in a relationship.
24:49 – The limitations of antidepressant medication as a treatment for self-harming behavior.
26:10 – Are there ways to treat self-harming behavior that don’t involve medication?
Notable quotes
“I sometimes say that drugs don't know what they're supposed to do… It turns out that drugs like the antidepressant medications do many things beyond just maybe treating depression.”
“It's really helpful to know what the potential downsides are so that you don't mistake a side effect for the symptom of some illness and then get more medicine instead of less medicine.”
“If the room is dark, it could be because somebody turned off the light switch… it could be because there's no electricity running into the building… it could be because there are dark curtains over the lights and the windows. There are many pathways to darkness in a room. And there are probably equally many pathways to depression in a human being.”
“What we call depression is almost certainly a whole bunch of different underlying processes that have similar top-level symptoms. That the diversity is the most likely explanation for why some people get great results from a particular medicine while others get no results and others get worse.”
About the Podcast:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Send us a question
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel
Cannabinoid Hyperemesis Syndrome (also called CHS) is the topic of this week’s episode.
Melissa and Dr. Erik answer the question “How can something that’s an anti-vomiting medicine be the cause of a vomiting illness”?
Cannabinoid hyperemesis syndrome involves symptoms like loss of appetite, stomach pain, nausea, and vomiting. Vomiting attacks come in waves or cycles. A vomiting attack can last many hours or several days and can be severe enough to cause dehydration or a host of other serious complications.
Cannabinoid hyperemesis syndrome affects some people who use cannabis regularly. The typical CHS patient will have used cannabis nearly daily for several years. However, there are cases of CHS developing in people who have used it as little as once per week for 6 months.
Time and topics
1:41 -- What is cannabinoid hyperemesis syndrome?
2:53 -- Symptoms are often relieved by hot water baths or showers
04:30 -- The first report of cannabinoid hyperemesis syndrome was published in 2004
05:45 -- Cannabinoid hyperemesis syndrome might have been around longer, but not recognized
06:29 -- Cannabinoid hyperemesis syndrome might be the result of stronger cannabis being easier to get and use regularly
07:12 -- Why has CHS not more widely known?
08:41 -- It’s not profitable to publicize CHS
10:48 -- Why don’t cannabis companies warn consumers?
14:00 -- Cannabis prohibition was a bad policy
15:16 -- State governments are mostly silent about CHS
18:40 -- Knowing about risks is important for consumers to make informed decisions
22:29 -- Is CHS dangerous? What are the possible complications of CHS?
26:26 -- How often and for how long before cannabis use poses a risk of CHS?
28:49 -- Treatments for the active phase symptoms of CHS
31:55 -- The definitive treatment for CHS
33:51 -- What to do if you think you might have CHS
34:59 -- The leading theory about what causes CHS
36:51 -- Tips for stopping cannabis use
Notable quotes
“If you don’t know that something exists, it’s hard to see it.”
“This could be a newly-recognized fallout from greater access to higher strength, longer-term use of cannabinoids.”
“There can be extremely important medical information that gets published, that probably everybody ought to know about. But there’s just not a mechanism to disseminate the kind of information to people… Absent funding to disseminate knowledge at scale, knowledge dissemination happens at a trickle”
“Because of prohibition, we know relatively little scientifically about marijuana’s risk profile. Through prohibition policies, you’ve made cannabis way popular. And through prohibition policies, you’ve made its safety profile a subject of debate”
“States, in my view, have done a good thing by trying to make a substance available that might help people… But the idea of having a state government endorse marijuana as a medicine, display medical benefits on their website, and not say one word about risks is irresponsible”
“You’re not supposed to feel nauseated. You’re not supposed to have unexplained appetite loss. And you’re certainly not supposed to be vomiting a lot. So, if you have any of those things, do get checked out.”
“It can become very confusing. How can something that is supposed to help with vomiting cause vomiting? The answer is because the body develops tolerance, and the body wants to kind of fight back against whatever the drugs are making it do. So, if you take a drug constantly, which turns down the vomiting response, the parts of your brain that regulate vomiting, are actively pushing back against the action of the drug. In chronic suppression of the vomiting system, the vomiting system like builds muscle and gets stronger.”
“You might be one of these people for whom the body has just revved up its vomiting machinery. The only way to get back to normal is to put a pause to cannabis use and let the body’s vomiting machinery get unwound back to its normal state.”
“Recovery is not a solo sport. Recovery is a team effort. So, if you put a pause on cannabis and your stomach is feeling better, then do get friends, get family, get new friends, find online support groups, find a new team, or enhance your current team to help you to support you, so that you can try to figure out other things to do what cannabis used to be doing for you.”
“A whole lot of people who are in recovery have been where you're at. And they will lend you some confidence and probably all sorts of love and support in trying to help you to get to a better quality of life.”
“Nobody wants you to stop weed and suffer. Everybody wants you to stop weed and to have, you know. a more awesome life as a result.”
About the Host:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Send us a question
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel
In this episode, Melissa and Dr. Erik discuss Alzheimer’s disease and address the question of whether it’s possible to prevent Alzheimer’s disease.
What is Alzheimer’s disease?
Alzheimer’s disease is one of several causes of dementia. The American Psychiatric Association has renamed “dementia” and now refers to this type of condition as “Neurocognitive Disorder.” Either name refers to a decline in cognitive performance. “Cognition” is a broad term which can include things like: attention, decision-making, recognition of language, faces, or situations, learning, or memory.
Dementia (or “neurocognitive disorder”) can have many causes and can involve many different facets of cognition.
What are the symptoms of Alzheimer’s disease?
The most common early symptoms of Alzheimer’s disease are memory loss or confusion. The tricky thing is that everyone can have memory issues or become confused from time to time. Alternately, it’s also possible to have frequent forgetfulness that is entirely benign.
Alzheimer’s disease is a concern if memory loss happens often enough or is severe enough that it starts to interfere with daily life.
Early-onset and familial cases of Alzheimer’s disease
Dr. Erik explains that some cases of Alzheimer’s disease can begin when a person reaches their 50s. Most people who develop Alzheimer’s disease at this age have a form of illness that is strongly determined by genes. The most well-known Alzheimer’s disease genes cause brain cells to produce a protein called beta amyloid, which appears to be toxic and is associated with cell death in memory circuits.
Slowing down the production of the beta amyloid protein is a promising opportunity for Alzheimer’s disease prevention and clinical studies of drugs that may slow down beta amyloid production are underway.
Brain health tips
Although we are still waiting for proven ways to prevent Alzheimer’s disease, we can definitely improve our cognitive health at any time. And some of the most useful ways to protect our brains as we age revolve around reducing the risks of strokes, including so-called “mini-strokes” and what Dr. Erik calls “micro-strokes.” Any type of stroke – whether big or tiny – causes brain cells to die. Preventing strokes is therefore a good way to preserve brain tissue. Meanwhile, exercising the brain is a good way to preserve brain function.
Here are several ways to prevent strokes:
Head injuries can also contribute to cognitive decline. So reconsider your involvement in contact sports, hear head protection when needed, and try to avoid situations that might expose you to unnecessary head injury risk.
The bottom line about preventing Alzheimer’s disease is this…
It’s hard to identify surefire methods for Alzheimer’s disease prevention. This is simply because we understand relatively little about what causes it. And it’s hard to design robust prevention strategies for things whose cause isn’t all that clear.
There are some treatments being studied currently that might be truly effective at preventing Alzheimer’s disease risk. But we will have to wait and see what clinical trial tests show.
In the meantime, focusing on whole- body health is probably the best way to promote long-term brain health.
The Paleo lifestyle
What Dr. Erik calls “the paleo lifestyle” might be one of the best ways to promote whole-body health and mental well-being.
Extending the concept of the “paleo diet,” which suggests that the optimum human diet would be similar to the diet humans were genetically designed for, the ideal human lifestyle is designed around things that human beings were designed for: eating natural, minimally-processed foods; living in tightly-connected social groups; being physically active; and doing things that contribute to the welfare of others. These are all linked to long-term cognitive health, and are the best path to resilience, contentment, and happiness.
Alcoholism is an all-to-common problem. Achieving recovery from alcohol use disorder is an important therapeutic goal. There are many causes of alcohol use disorder, including genetic and biochemical contributions. Unfortunately, most alcohol treatment programs today focus exclusively on social, psychological, or spiritual factors.
There are three FDA-approved medications that can help someone with a drinking problem to improve their odds for success. Medications should not be the only part of treatment. But they should at least be considered.
Even though potentially helpful medication options exist, only 1 in 10 people with alcohol use disorder are offered evidence-based medications for alcoholism.
In this podcast episode, Dr. Erik and Melissa discuss how to get through alcohol withdrawal, being successful in recovery, and the FDA-approved medication options that can help.
In today’s episode you will learn:
“Recovery from addiction is not a solo sport”
Key Timestamps
[00:43] This week’s question: Will it be hard to quit drinking?
[02:02] Statistics around problematic alcohol use.
[02:40] How does your life improve after quitting drinking?
[03:45] How can you SAFELY start your recovery from alcohol?
[04:59] How does the body become physically addicted to alcohol
[08:30] 100 mg of THIS vitamin prevents amnesia and other side effects of alcohol withdrawal.
[10:53] Why you might need valium and other drugs to adjust to alcohol withdrawal.
[13:50] Why do people consume alcohol?
[15:13] Is it possible to become sober ONLY by taking meds?
[19:35] The 12-step Alcoholics Anonymous approach: strengths and weaknesses.
[22:34] An alternative to AA (without the seemingly religious stuff).
[23:36] Why medications are only a tool in your recovery journey.
[24:55] 3 FDA approved medicines that help you recover from alcohol addiction (and how they work).
[35:29] A message to everyone who wants to quit alcohol.
4 Key Highlights
Links
Support groups for people who are addicted to alcohol: SMART Recovery | Alcoholics Anonymous
Ask us anything: Ask a Psychiatrist Website
Connect with Dr. Erik Messamore: Website | Twitter | LinkedIn | Facebook
Keywords
Medication for alcohol addiction, alcohol addiction treatment, alcohol addiction doctor, alcohol addiction help, how to start quitting alcohol, what do i do if i am addicted to alcohol, alcohol addiction recovery, alcohol addiction psychiatrist, addiction medication names, is there a cure to alcohol addiction, anti-addiction medication, anti-addiction meds, recovery from addiction with medication, recovery from addiction, overcoming alcohol addiction, medication for sobriety, sobriety, medication for alcoholism
This week’s podcast episode focuses on borderline personality disorder.
Borderline personality disorder is a common condition
Borderline personality disorder is relatively common. It’s a condition that currently affects about 1 out of every 60 people (Lenzenweger, 2007). Up to 1 of every 20 people may be diagnosed with borderline personality disorder at some point in their lives (Grant, 2008).
“Borderline personality disorder” is a terrible name
Dr. Messamore starts off by pointing out that the name of this condition – “borderline personality disorder” – is long overdue for change. It is based on 1930s-era psychological concepts. The psychological concepts have been updated over the past 90 years. Tragically, the name of this condition has not.
Modern neuroscience has revealed a lot about the underlying causes of borderline syndrome. Biochemical studies, genetic studies, and brain imaging studies point to biological and neurological factors as the primary cause of “borderline” symptoms.
Considering all that we’ve learned about this condition, it would be easier to understand – and scientifically more accurate – if we retired the term “borderline personality disorder” and replaced it with “emotion regulation disorder.”
What causes borderline personality disorder?
You can think of the brain as having an emotion-generating part and an emotion-checking part. The “borderline” syndrome happens because the engine and the brake are out of balance.
The engine
Emotions are your brain’s way of influencing your behavior or decisions in ways that the brain thinks will benefit your survival. The job of the limbic system is to generate emotional reactions to events (or ideas). The limbic system is just the generator. It does not have the ability to decide if its reactions are useful or not. That’s the job of the prefrontal cortex.
The brake
The part of your brain that does the things you recognize as thinking… that region is called the pre-frontal cortex – the PFC. One of the many important functions of the PFC is to analyze whatever situation you find yourself in. (For us human beings, creating an explanation is as fundamentally important as food or water). Whenever the limbic system generates an emotion, the PFC is supposed to check it out. (Remember the limbic part is just the generator – not the evaluator). The PFC is supposed to determine of the emotional response is appropriate for the event. If the emotional response is out-of-proportion to the event (or if the emotional response is interfering with other important decisions), then the PFC can talk back to the limbic system.
Overactive engine, inefficient brake
Numerous studies have shown overactivity in parts of the emotion-generating limbic system among people with borderline personality syndrome. Meanwhile, studies have also shown that the activity in the PFC braking region is under-active, or that its connections with the limbic system are inefficient.
The result: the brain generates emotion signals that are either not needed in response to some events, or that are unnecessarily strong. That’s why I think that “emotion regulation disorder” would be a better term for this condition.
How overcharged emotions are at the heart of many “borderline” symptoms
So now consider what happens when you, or someone you know, is feeling extremely uncomfortable. The strong emotion constrains your options. You can’t think about things that are not in line with what your emotion makes you think is true. You’ll do almost anything to feel better. Maybe even things that others would call “reckless” or “impulsive.”
In fact, most of the symptoms of borderline personality can be easily understood as attempts to change emotions that feel too strong.
What are the symptoms of borderline personality disorder?
The diagnostic criteria for psychiatric conditions are listed in the DSM-5, which is published by the American Psychiatric Association.
The DSM-5 describes borderline personality disorder as “a pervasive pattern of instability of interpersonal relationships, self-image, and emotions, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following:”
Calling it a “personality disorder” slowed down biological research about borderline personality syndrome
I think that coming up with “borderline personality disorder” as the name for the syndrome of emotion regulation struggle was a horrible idea from the very beginning. One of the many very negative effects from this naming decision is that the American Psychiatric Association seemed to be telling the world that we’re confident that we know the cause is “personality.”
This declaration apparently signaled to the world of biomedical scientists that there is little point in studying its biochemistry. I think that’s the reason why borderline personality has been so poorly studied (from a biochemical basis) compared to other major psychiatric conditions.
Take a look at the number of scientific articles from 1946 to 2015 that address the possible biological causes of schizophrenia, depression, bipolar disorder, and borderline personality (BPD).
What’s the best treatment for borderline personality disorder?
While biologically-focused scientists seemed to stay away, the psychologically-focused scientists have done a lot of very good work understanding how emotions work and how they can be harnessed.
As a result, we now know about the important connections between the emotion-generating limbic system and the emotion-regulating prefrontal cortex. Not only do we know about these connections, we also have ways to strengthen them.
It turns out that learning to regulate emotion is a skill that can be taught and learned, pretty much exactly the way that learning to play the piano or to speak a foreign language can be taught and learned. The process is the same. You show the brain what it needs to do. You practice it, step by step. You make mistakes. You practice some more. You get a teacher, a coach, some fellow learners to help you practice, keep you on track, applaud your progress, and inspire you with theirs. You do this week after week and after a while, you start to get good at it. You keep practicing. You keep getting better.
Whether it’s learning to speak Swedish, learning to play harmonica, or learning to recognize and regulate emotion, the process is the same. They all rely on the brain’s remarkable and ever-present ability to literally re-wire itself to make easier any task we ask it to do for us.
Emotion regulation training works for people with the emotion regulation issues that are regrettably today still called “borderline personality disorder.” It sucks to have any sort of mental struggle. But the good news for people with emotion regulation struggles is that there are well-studied and effective training-type therapies that get close to correcting a root cause. Numerous modern brain-imaging studies have shown that these types of training therapies reduce the overactive limbic system and strengthen its connections with the emotion-regulating prefrontal cortex.
The silver lining of borderline personality
The thing with human beings is that our greatest vulnerabilities often provide clues about our greatest potential strengths.
Up to this point, I’ve been focused on the problems of intense or reactive emotion – about how the emotion engine revs too easily or to rapidly. On some levels, the brain is like a car. It has a lot of complicated parts that work together (behind the scenes, usually far outside of our awareness) to get us where we would like to be.
If the brain were a car, though, it would be a very high-performance vehicle – like a Lamborghini. The problem is – for all of us – we’re not given instructions about how to operate that magnificent machine. So most of us spend a good part of our lives driving from ditch, to post, to wall, to ditch – getting where we want to go in a halting, jerky way… and crashing quite often.
But once you understand how your brain really works – particularly the emotion pieces – and learn how to regulate it, you’ll find that it takes you far and fast, wherever you decide to steer it.
So you can think of emotion regulation therapy as a driver’s course.
The other thing about “borderline personality” is this: the ability to experience deep emotion is also a gift. It becomes possible to experience life in ways that are more vivid and more beautiful than others may ever have access to. When such a person is healthy, they can use their depth of experience to drive really great thought and have truly rich experience. The capacity for strong emotion can be difficult to live with, but it can also be a treasure.
Psychosis is a word that gets spoken a lot, but that gets discussed very little.
About 1 of every 11 people will experience psychosis at some point in their lives. But even though it’s a common experience, we hardly ever talk about it.
In this episode of Ask A Psychiatrist, Dr. Erik Messamore and Melissa Xenophontos discuss psychosis.
Dr. Messamore explains what psychosis is, how it happens, and what to do about it.
We learn that it’s easier to understand – and probably more accurate – to think of psychosis as a misperception syndrome.
Psychosis by itself is not a standalone diagnosis. Rather, it’s a symptom that can have many different causes.
It’s important that anyone experiencing psychosis have a thorough medical and neurological evaluation to look for the cause. A medical explanation needs to be ruled out before viewing psychosis as a symptom of a mental illness.
Mental Health America has an online questionnaire that can help someone determine if they are experiencing psychosis.
Dr. Mesamore’s website has a blog post that lists the recommended medical tests to rule out medical causes of psychosis.
Click here if you’d like to ask a question or suggest a topic to address in a future episode.
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KEY TAKEAWAYS:
QUOTABLE:
“The accurate way to think about psychosis is a misperception syndrome or a phenomenon, technically and realistically it is best to think about psychosis as a neurological symptom.”
“Conscious awareness is kind of like the dashboard of the entire brain processing.”
“Psychosis is fairly easy to recognize, but once it’s recognized, the next step should not be an assumption that there’s a mental illness. The next step should be the assumption that there’s a medical disease going on that needs to be figured out and treated quickly.”
“There are about 50 different diseases that can cause psychosis as a symptom… about 100 different medications or drugs which can cause psychosis as a side effect.”
“Nobody should assume that psychosis means schizophrenia at all – it could be many other things.”
“The goal of treatment is to restore a person’s function – the treatment should work; the treatment should make somebody better.”
“Any clinician who is worth having should be extremely interested in hearing side effects, and should work with you to prevent, reduce, or eliminate them.”
About the Host:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Contacts:
Website: www.ErikMessamore.com
Dr. Messamore @LinkedIn
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There are so many forms of therapy today that it can be hard to decide which is best for you. One of these types is “psychotherapy,” which sounds a lot scarier than it is. In this episode of “Ask a Psychiatrist” we learn about what psychotherapy is, how it can benefit your thought life, and why fears about undergoing psychotherapy still persist.
Dr. Erik Messamore explains the history of psychotherapy and how Freud’s findings dominated professional psychiatric thinking for decades. After about the 1960s or so, Dr. Messamore explains, psychology underwent enormous strides to get us to our modern psycho-pharmacological thinking. And it is better than it’s ever been.
Discussing both the therapy methods and our evolving understanding of psychoactive drugs, Dr. Messamore tears away the veil and shows why psychotherapy is nothing to be afraid of. Differing from “supportive listening,” true psychotherapy targets the causes of psychological symptoms and provides a framework for handling them in your day-to-day life. Whether or not medications are necessary is decided on a case-by-case basis, but the interesting thing is that the relationship between your thoughts and your brain chemistry is reciprocal. Mood-altering drugs can “correct” brain chemistry, but so can corrective thoughts. What each person needs for their own therapy will vary.
Overall, psychotherapy is not a form of healthcare that should be feared. Your doctor will help you feel safe, comfortable, and help you to understand every step of the therapeutic process. To fear this is to miss out on great work you can do in your own life.
Click here if you’d like to ask a question or suggest a topic to address in a future episode.
If you’ve found this information helpful, please share it with your network!
KEY TAKEAWAYS:
QUOTABLE:
“Freud’s view was that these top-level symptoms have, at their origin, a conflict between the id and super-ego.”
“Psychoanalysis is a valuable and rich form of therapy, but it’s certainly not for everyone.”
“The research points to psychotherapeutic approaches that focus on the here and now.”
“Saying antidepressants correct a chemical imbalance is extremely over-simplified and probably not applicable to every person experiencing a psychiatric symptom.”
“For a person with depression, and who feels like a failure, it’s much easier for them to believe that they may have just made some mistakes than to believe that everything is going to be alright.”
“The data shows that the people who practice these techniques become well. They get better at regulating their own emotions.”
“The right therapy should be deployed for the right condition.”
“The goal is to be comfortable, and it’s your therapist’s job to guarantee that.”
About the Host:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Contacts:
Website: www.ErikMessamore.com
Dr. Messamore @LinkedIn
Follow the Podcast:
Podcast Facebook page
The podcast currently has 13 episodes available.