Content on this page requires a newer version of Adobe Flash Player.

Get Adobe Flash player

Bookmark and Share

Emotional Distress: Counseling or Medication

Emotional distress comes in many forms and shapes. There are no x-rays or blood tests to explain what is going on or what is wrong, just your verbal description. The two most common mental health problems are anxiety and depression. However, there are many other diagnostic conditions such as problems with anger, concentration, mood and/or thinking.

Anxiety and depression come in varying degrees with different causes. They may arise from situational problems.  These may include difficulties in a relationship such as marriage, problems with money, and performance problems in school or work that may produce anxiety, depression or both. Family difficulties are also often a source of distress. It is hard to believe 50% of marriages end in divorce, but only 40% of people get divorced. How is that difference possible? Some people get divorced, two, three or more times, so the statistics on divorce go up but the people are the same.

Some people have anxiety or depression or both and yet nothing in their life experience appears to be the cause. For some, emotional problems are genetic in origin and there is a history of the difficulty in the family. The depression or anxiety seems to hit like lightening, seemingly out of no where. In other cases a trauma is the cause of problems precipitating either or both anxiety and depression. Trauma may come from witnessing a tragedy, violence, or being hit on the head in a car crash. X-Rays, EEG, cat-scan may reveal nothing, yet emotional problems emerge.

So what do you do?  Most people initially go to their primary care doctor. Some primary care doctors will take time to talk to their patients and family. Pediatricians are often better than doctors of internal medicine at talking with their patients and parents. Whether you are depressed or anxious, the most common medicine prescribed will be an antidepressant. Most antidepressants are prescribed by primary care physicians, not psychiatrists. Unfortunately, over-burdened primary care physicians often do not follow up but leave it to their patient to set up another appointment if something is not working. Further, most patients I have seen are not aware of side effects that they may be having from their medication.

The most common prescribed antidepressant last month was Lexapro simply because it was the newest. Next month it may not be. Lexapro has three virtues. It helps both anxiety and depression. It works within five days, not the eight weeks it takes many of the older antidepressants, and one tablet a day works as well as two or three. It has only two frequent draw backs: weight gain and in both men and women, interference with sexual performance and interest.

Many physicians are reluctant to prescribe anti-anxiety pills. They worry it is addicting and I have seen patients addicted to Xanax. Unfortunately, Xanax lasts only three hours. As it leaves your system you may have a resurgence of anxiety as a result of withdrawal and take another one immediately. If you are afraid of flying that is no problem. You take one pill, perhaps Xanax, ½ hour before flight time. The plane takes off you are fine. The pill wears off but you know you are landing in one hour and there is no further anxiety. Another common anxiety medication is Klonopin. It starts in thirty minutes and lasts eight hours. It wears off slowly and you don’t have rebound anxiety and so don’t need another one immediately.  Knowing you have the pill is itself reassuring so you may not even bother to take it. Every antidepressant has to be taken every day and the doctor will tell you to stay on it for a year. I have seen patients on Paxil or Zoloft who have been on the medication for four years, gained forty pounds, but thought it was just a part of the depression. Prozac, Paxil, Zoloft have remission rates of 35%. But 70% of people have some degree of relief though not a total loss of symptoms. So it is easy to misinterpret what is going on.

You may choose to see a psychiatrist to help you with your emotional concerns. Most psychiatrists will see you for 45 minutes the first time and tell you to come back in two weeks. They will then see you for twenty minutes to follow up. The third time they may see you for 15 minutes. Follow-up visits allow the doctor to assess symptoms and side effects and titrate your medicine.  Picking an antidepressant is not obvious. They vary person to person both in effectiveness and side effects and only trial and error provides a clue.  Fifty percent of people who start an anti-depressant will switch to another.

You may have gone to see a mental health professional. Psychologists will have Dr. in front of their name. Social workers, nurses or professional counselors will be called Mr. or Ms. Some mental health professionals may discuss medication with you and others may think it is not their responsibility. You may have started with a counselor and the presenting problem lessened quickly. The average length of psychotherapy, to use a more technical term, is six sessions. Many individuals are helped to better cope through a long-term involvement. Many people see a therapist as well as take medication and all evidence is that for depression the combination of the two is more effective than either one alone.For some people an antidepressant or tranquillizer is sufficient. They may have not had that much to say and they thought the therapist was boring. In other cases they might have liked the therapist and felt it just wasn’t necessary to return. For some the experience with psychotherapy is profound.

Does therapy help? It depends who you ask. There are many different theoretical orientations to psychotherapy. Some tell you that you should have “evidence-based-therapy”. They maintain cognitive-behavioral therapy, a type of evidence-based therapy, has been shown to be the best. Cognitive therapy was radical in that it disposed of psychoanalytic therapy which involved exploring your childhood. Cognitive therapists maintain that you need to identify the ideas that are generating the distress and change your thinking. I am sure that works as well as anything else. Whatever the orientation, if your therapist has common sense and is responsive and warm, then you will feel helped. That is the only real evidence present in research as to what works. Talk helps when you are in distress and some conversations will be more constructive than others; especially the chance to discuss current problems, feelings and life experiences with a competent mental health professional.  There are individuals who despite taking multiple psychiatric medications participate in long term psychotherapy yet struggle with intermittent emotional difficulty. Without medication and psychotherapy their lives would be more profoundly compromised. The science is not yet complete and we do not all have the same emotional barometers in a challenging world.

Dr. Jeremy Kisch is a licensed clinical psychologist and has diplomate status with the Amerian Board of Professional Psychology.

No Comments.Leave a comment»

Be the first to comment

RSS feed for comments on this post. TrackBack URL

Leave a comment

Previous Articles

An experienced couples therapist once told me that “good communication and persistence would cure most problems.” (more…)

Some people suffer from symptoms of depression during the winter months, with symptoms subsiding during the spring and summer months.  This may be a sign of Seasonal Affective Disorder (SAD). (more…)

Offering to help someone who is in need of assistance just seems like the right thing to do. We’ve all had the opportunity to lend a helping hand, or go out of our way for a friend, relative or even a total stranger. The scene, more than twenty-five years ago, of that fireman diving into the freezing waters of the Potomac River to save victims of a passenger jet that crashed while taking off from National Airport during an ice storm lingers in my mind. We praise the heroic actions of first responders who risk everything to save total strangers. So, when someone who is familiar to you asks for help would you rush to assist them and do whatever is required? We’ve heard it said: ‘A friend is a friend – no matter what!” What if that “friend” is engaged in a behavior that violates the law or, your moral judgment. What if their behavior is, in some way, pathological? In those cases, helping that individual might wind up jeopardizing you. Your intentions were honorable but you wound up in trouble or having a major problem!

The complexities of our interactions became the focus of a theoretic formulation known as Transactional Analysis. TA is a method of analyzing and understanding communications and interactions ( transactions) between individuals. The goal of TA is to eliminate dysfunctional behaviors and develop effective coping strategies in our relationships. Clients learn to identify disruptive interactions and replace them with direct, Adult – Adult, communications.

Eric Berne developed the concepts of TA after extensive study and training in traditional therapy and the practice of psychiatry and psychology. He suggested that we develop “life scripts” early in our development that influence how each individual chooses to live and behave. The role of therapeutic intervention would be to “re-write” destructive and self-limiting script messages.

As a result of problematic script messages and learned styles of interacting, Berne noted that we develop dysfunctional patterns – called Games – in which we intend to gain positive “strokes” but actually reinforce negative feelings. Further, Games can be a way of interacting while avoiding intimacy (intimacy here defined as revealing the “real self” to others). Take, for example, the game of “Psychiatry.” You meet someone at a party. He is quite engaging and asks many questions about you. He seems interested in you and appears to be a good listener. However, when the conversation ends, you realize that he has revealed nohting of himself – thus avoiding intimacy. A second example is a game called “General Motors.” Same party: a bunch of guys stand around talking about the virtues and limits of Camaros and Corvettes. In the end, after a discussion of camshafts, transmissions and engine displacement, they part knowing nothing about each other. They interacted, but easily and skillfully avoided any personal knowledge of one another.

You may have heard the saying: “No good turn goes unpunished.” If we offer to help someone who has not requested it, we force them into the role of a “Victim.” They can easily turn and become hostile toward us, shifting from “Victim” to “Persecutor.” Claude Steiner points out that we are encouraged to be selfless, generous and cooperative with people, even if they are deceitful, selfish, stingy and uncooperative with us. Engaging in this type of interaction is guaranteed to take us from the position of “Rescuer” to the “Victim” position while the so-called “Victim” becomes the “Persecutor.”

In the game of “Rescue,” the Rescuer (that’s you) views that problematic, needy person as the “Victim” and thinks: I’ll save you!” As the paradigm progresses, the “Rescuer” becomes the “Victim” and the “Victim” becomes the “Persecutor.” Let’s look at a real life example.
rescue triangle

Archie (not his real name), a recovering alcoholic, was planning to go out on New Years’ Eve. He had tickets to a fancy gala and had rented a tuxedo. His date lived some distance away and he had planned to leave his house no later than six o’clock. Early in the afternoon, he received a call from Edith(not her real name) whom he had met at a meeting of Alcoholics Anonymous. She was “in a jam” and asked if she could borrow his car for a brief errand. Archie quickly agreed (boosting his own ego and self esteem) and told her to return the vehicle by 4 o’clock . “No problem,” she replied, as Archie watched his watched his washed and freshly waxed car roll out of the driveway. Of course, 4 o’clock came and went with no sign of Edith. By 5 o’clock Archie, agitated and concerned, started calling some of Edith’s favorite haunts (bars). He located her at a neighborhood pub and asked her to bring the car back immediately – she (now drunk) hung up on him. Furious, he called the police and reported the car stolen. He told them where the vehicle could be found and the police went to the bar to confront Edith. When they arrived, Edith told them that Archie had assaulted her and she had “fled for her life!” She filed assault charges against Archie and the police arrested him! Archie spent the evening at the police station, in his tuxedo. By the time he had arranged bail and was released, it was too late to go out- Happy New Year, Archie! The “Rescuer” had become the “Victim” and the “Victim” had become the “Persecutor.”

There are countless examples of this paradigm: the house guest who never left; the loan that was never repaid. However, the key to avoiding the game of Rescue is to carefully analyze whether the alleged “Victim” is really a victim; or have they created their own problem. After all, we are each responsible for our own behaviors. What is the “payoff” for you as the “Rescuer?” If you can understand your own motivation and can take an objective look at the so-called victim, you may discover your own co-dependency or realize that you are “enabling” the pathology of the other person.

Depression strikes anywhere

Depression strikes anywhere

At some point, someone in the wine industry found some physicians and suggested that they come up with a plan to convince all of us that drinking wine was a great idea. Since that time, we have been told, repeatedly, that drinking some red wine – everyday- is really good for us.

The health enhancing basis of this medically proven assertion is that red wine contains anti-oxidants and we need these compounds in order to maintain our health. It is a fact, we need anti-oxidants to maintain our immune systems and promote good health.

A brief scan of the health food literature clearly indicates that antioxidants play a significant role in maintaining physiological balance in our bodies.  As oxygen interacts with the cells in our bodies, one to two percent of our cells will be damaged and turn into free radicals.

The term free radical refers to the fact that molecules from damaged cells are missing one molecular component and search for that missing molecular side chain in other cells. These free radicals attack other cells (attempting to add their missing parts) and can injure these cells, thus leading to disease.

Usually, antioxidants maintain control over the free radicals in our bodies. However, if the system is over loaded with free radicals from cigarette smoke, pollution or excessive use of alcohol, a cascade of free radicals causes more cell damage and may be a causal factor in heart disease, Alzheimer’s disease, Parkinson’s disease and cancer.

Increasing our intake of Vitamin C and Vitamin E can neutralize and disrupt free radical reactions. Flavonoids and Polyphenols in fruits and vegetables are also valuable sources of antioxidants. In addition, research has demonstrated that our bodies require a complex mix of vitamins and minerals to neutralize these free radicals.

So, infusing our bodies with flavonoids from blueberries and strawberries as well as the chemicals in broccoli and green tea is clearly advisable. It is also suggested that we should stop smoking and reduce our intake of alcohol.

If it is true (and it is) that wine contains anti-oxidants, then what’s the problem with drinking wine everyday- as proposed and recommended by many physicians? When we ingest alcohol, it is metabolized in the liver by certain enzymes that break alcohol into substances that can be used by the body. As you consume more alcohol, you increase the enzyme allowing the body to metabolize more alcohol.

People who rarely drink alcohol notice that their tolerance is quite low. By contrast, individuals who drink significant amounts of alcohol, on a regular or daily basis, show an increased tolerance for it.   For example, I once saw a stylish forty-something woman who had been referred for sleep problems. She reported that she started to take “just a dram” of wine, in the evening, from time to time, to help her sleep.

This had started about two years before her visit. Now, she was consuming a large tumbler of wine each night and was still having problems. Her tolerance had significantly increased and her difficulty with sleep patterns had continued.

Does daily drinking always lead to problem drinking?
No, certainly not always. However, if the body is able to metabolize alcohol a bit more effectively, then there is the opportunity for daily drinking to lead to problem drinking. The use of alcohol, on a daily basis, gives the children at the table, the idea that the daily use of alcohol is O.K.  Giving kids a “taste” of the parent’s beverage gives the message that underage drinking is tolerated.

Years of clinical experience have indicated that alcohol acts as a “magnifier” for conflicts between family members.  If someone is using alcohol on a daily basis, and it is readily available within the home, there is a minimal boundary between use and inappropriate abuse. In addition, there is a clear relationship between the use of alcohol and aggressive behaviors. Further, significant chronic use of alcohol leads to other illnesses.

Liver disease, cardiac concerns and kidney disease may also be a result of significant intake of alcohol.   Also, when alcoholic brains are weighed at autopsy, they are “lighter;” – they weigh less than normal brains. That’s not a good thing.

So, when you do a risk/benefit analysis, it would seem that if you want to increase your intake of antioxidants, don’t justify that glass of wine by thinking that you are doing something that produces health benefits. If you want to increase your intake of antioxidants, eat blueberries!