Jan 06

What’s the difference between clinical depression and just having ‘sad mood’ (sadness) or ‘feeling blue’? This often-asked question is often asked and sometimes, it may indeed be hard to tell whether there are already signs of depression if someone has been feeling depressed for some time.

To try clarify this question to some extent, feel free to undergo the online test on my website, or watch the nice TED video clip below about the topic. If you feel like it, just add your experiences or observations in the comments below – maybe they can be of help for others asking themselves similar questions.

Dec 31

To a high extent, the work of a psychotherapist consists of the treatment of the various forms of depression, so I’ve always tried to improve my understanding of this particular form of mental disorder – and of its most extreme form, the idea to commit suicide. So I’ve continuously gathered data on suicide – here you will find a compendium of the information I found, a sort of overview of the currently known facts and figures on this subject.

Frequency

It is estimated one million people a year die by suicide, which equals about one every 40 seconds – but that number may actually be even significantly higher, since the official numbers released by many countries are too low. Suicide thus contributes at least 1.5 percent of the global deaths and is the tenth leading cause of death. In 2006, 140,000 people had taken their lives, that equals 11.1 per 100,000 people. People under 25 years of age are most vulnerable (there was no significan change compared with previous years), and the elderly (where a significant decline in suicides was found).

Trends in some OECD countries, graph: OECD

Regional differences: within Europe, the rates in the northern countries are generally slightly higher than in the southern ones. An effect of latitude on the suicide rate was found in Japan, suggesting an influence of the daily duration of sunshine. Nevertheless, other countries can have significantly different rates of suicide compared to Japan at the same latitudes, like Great Britain or Hungary for example. Suicide is a significant problem in the former Soviet states, and more than 30 percent of suicides worldwide occur in China, where 3.6 percent of all deaths are attributed to suicide.
Regarding the impact of light/solar radiation by correlating the suicide rate with the number of hours of sunshine a day, a seasonal clustering of cases of suicides could be proved in 2011 in a study by the Medical University of Vienna that was published in the journal “Comprehensive Psychiatry”.

Particularl attention deserves South Korea where in recent years, the suicide rates have increased drastically, namely by 172% to 21.5 per 100,000. The number of suicides by men has almost tripled from 12 per 100,000 (1990) to 32 per 100,000. With 13 of 100,000, the suicide rate among women is also the highest. The OECD attributes the rise in suicides on the economic decline, dwindling social integration and the disintegration of traditional family bonds. But it may be doubted whether this is really something that extraordinary compared to Mexico (+43%), Japan (+32%) and Portugal (+9%), which also reported an increase in the suicide rate. In Hungary, the suicide rate has declined by 41 percent, but the country, with 21 suicides per 100,000, is still second only to South Korea. Finland’s numbers are also above average with a high suicide rate of 18, followed by France (14.2), Switzerland (14), Poland (13.2) and Austria (12.6, 27/100,000 in men, in women 10/100,000). Germany, where the number of suicides compared to 1990 decreased by 37 percent, with 9.1 in the lower third. Apart from Great Britain (6.1) and Mexico (3.1) the situation appears on the Mediterranean people to do well. In Spain (6.3) and Italy (4.8), far fewer people kill themselves than in other OECD countries. And the Greeks are drawn the least to commit suicide: here, just 2.8 per 100,000 kill themselves

Conflicting data on the so-called happiness research was revealed by a remarkable study analyzing the correlations between life satisfaction and suicidal tendencies. In a comparison with the average satisfaction of people according to the “World Values ‚Äč‚ÄčSurvey” and the suicide rates according to the WHO, the suicide rate is not only very high in the Scandinavian countries in spite of their high satisfaction but also in Iceland, Ireland, Switzerland, Canada or the U.S. The conclusion of the study was that the relation between high life satisfaction and high suicide rates was independent of harsh winters, religious and cultural differences in different countries (more)

One possible explanation for this ostensible contradiction could be that in an environment where many other people are ‘happy’, own discontent, own suffering is felt more strongly. If there is also despair of beign able to achieve a change, certain personality types may see suicide as a way out.

A few more details about Austria: in Salzburg, the Crisis Intervention Center (‘Kriseninterventions-Zentrum’; of others, I don’t have any data) recorded a significant increase in patients in their teens in 2010. In Austria, about twice as many people die by their own hand than after traffic accidents every year. In 2002, 1.551 chose to commit suicide, including 50 children and adolescents aged ten to 20 years. Self-injuries in children are also on the rise. At the whole of Austria, the suicide rate of the early 1960’s has risen sharply until the mid-1980’s – to 24 suicides per 100,000 of the population. Since then, the rate decreased and it is now (as already mentioned above), at 13 per 100,000 per year. This equals about 1,300 suicides per year.

However, there are growing doubts within the Austrian scientific community as to the accuracy of these statistics, and I want to outline them a bit further to help you, the reader, understnad the underlying problems of suicide studies: fewer and fewer autopsies are performed as in Austria, which decreases the possibility to distinguish suicides from natural deaths. Thus, in countries with the highest autopsy rates as in the Baltic states or Hungary, the suicide rates are generally higher than in countries with low autopsy rates. Similarly, in countries where autopsy rates are declining, at the same time there are also increasingly fewer registered suicides (Source: Archives of General Psychiatry 2011 (Link). So with statistics like these, there is always reason to question whether such statistics can be trusted at all.

More gender-related details: is in the developed countries, the gender ratio of suicides is roughly 2-4 (men) : 1 (women) and seems to be increasing. Asian countries show a smaller ratio, but it seems to be increasing as well. Only China has more women than men dying from suicide.

Risk factors for suicide

Among the many factors that may raise the risk of suicide, the most important known ones currently seem to be:

  • male gender (OECD: 17.6 per 100,000 males, 5.2 for women)
  • a history of self harm
  • psychiatric disorders and / or
  • Alkohol-/Medikamentenmissbrauch
  • upbringing and education
  • suicide depictions in the media
  • smoking

Genetics and Neurobiology

Autopsies of suicide victims showed changes in central neurotransmission functions, such as the serotonin system (mood-regulating hormones). Low cholesterol concentrations are associated with higher suicide risk, but the risk is greater if the lower cholesterol level was reached with diets rather than by using statins. The authors suppose that this may stem from the fact that dieting people have a higher risk of mental problems, but so far, there was no corroborating evidence for this theory. Furthermore, family histories of suicide at least double the risk for girls and women. Although the evidence is scanty here as well, a number of researchers suggest that high levels of aggressive behaviors and impulsiveness may also be associated with an increased risk of suicide. Especially in young boys, suicide rates increase over the years of their growing up, while a higher suicide risk because of hereditary components was primarily detected on the maternal side.

Professional guilds

Suicide rates are higher among non-workers (unemployed, retired etc.) than among employed persons/professionals. Higher rates are also partly linked to mental illness, which in turn has a connection with unemployment.

Among the professionals, however, some groups show an increased risk: medical practitioners have a high risk in most countries, and doctors (and related jobs in the health professions) generally have the highest risk. Nurses also have a high risk. Particularly in these groups, the easy access to venoms seems to be an important factor influencing the high rates. Anesthesiologists are particularly vulnerable among physicians because narcotic drugs are used in many suicides. Several other high-risk professions are dentists, pharmacists, veterinarians and farmers.

Age Groups, Ethnicity, ..and Seasons

In most countries, suicide rates are highest amongst elder people, however, in the past 50 years, the rates among the younger population has increased as well, especially in men. Suicides are committed most frequently in spring, especially among men as well. People born during spring or early summer have an increased risk of suicide, especially women. Americans of European descent have higher suicide rates than Americans of Latin American or African origin, with this difference increasingly leveling out amongst young African Americans due to the increased suicide rate among young African Americans slowly. Indigenous groups such as Aborigines in Australia and Native Americans also have higher suicide rates, possibly due to cultural, social exclusion and greater alcohol abuse.

Suicide Methods

Quite generally, men prefer more violent means of suicide (for example, by strangulation or shooting themselves), and women ‘softer’ forms (self-poisoning), which is probably the explanation for the sharp difference in successful suicides between men and women (see above) and the suicide attempts that both sexes undergo in about equal rates. Different cultures show different preferences in methods, in South Asia for example, women typically burn themselves. Access to specific methods could be the factor that finally leads to putting suicidal thoughts into action. In the U.S., firearms are used for by far the most suicides, with the risk of using them for this purpose being the highest where guns are found in households. In the rural areas of many developing countries, the ingestion of pesticides is the most common method, which reflects the toxicity, easy availability and the lack of storage. At up to 30 percent of suicides worldwide, pesticides are involved.

Comorbidities und Connections with Mental Disorders

Mental health problems are a major factor in suicides. It is believed that of about 90 percent of people who kill themselves, they suffered from a kind of psychiatric disorder. Depression increases the risk to the 15- to 20-fold, and about 4% of patients suffering from depression die by suicide – but only about 20-30% of depression are recognized (!). But even for those, in most cases many years are passing to the correct diagnosis, and then, still, less than 50% of the diagnosed patients ever starts looking for a psychotherapy and/or receives pure pharmacological support. This means that most people suffer on a chronical basis, but don’t search – or can’t find – adequate help.

Clinical signs of suicide where depression was involved, are patients with previous self-harm, hopelessness and suicidal tendencies. About 10-15% of patients with bipolar disorder die by suicide, but the risk is highest at the beginning of the disease. About 5% of schizophrenia patients also die by suicide. Alcohol abuse, anorexia, attention deficit-hyperactivity disorder (ADHD) and body dysmorphic disorder (KDS) all increase the risk of suicide. Especially the last example explains in part why the risk increases in women after breast-enlarging surgeries.

Physical health also plays a role, but with some strange results. Surprisingly, people with higher body mass index (BMI) have a significantly greater risk of depression, however, their risk of suicide is lower (15% decrease in suicide risk per 5 kg per square meter of body surface area increase in BMI). The reasons for this are unknown. Cancers, particularly of the head and neck, HIV / AIDS, multiple sclerosis, epilepsy and several other diseases also increase the risk of suicide.

Other factors that increase the risk of suicide include physical abuse and sexual abuse over the childhood, or events that affect the entire population (such as natural disasters or the deaths of celebrities). After the death of Diana, the Princess of Wales, in 1997, the suicide rate rose by 17%, most clearly in her age group. War involvements reduce suicide rates, possibly due to the social cohesion that is generated in the communities. People who have suffered a loss by suicide, are themselves at increased risk, and suicide clusters may occur in communities or through Internet contacts. The authors add: ‘A significant proportion of the evidence shows that certain types of media that report on or present suicidal behavior, may influence suicidal behavior and self-harm in the general population.’

A ‘hot potato’ in the psychiatric community are recent studies showing that even antidepressants can induce suicidal thoughts not only in adolescents, but also in adults. I already posted a few articles related to these studies in this blog.

(Sources for the aforementioned numbers: Health at a Glance 2009: OECD Indicators; MedAustria)

Suicide und Self-Injury

In addition to rising suicide rates, there is also an increase in self-harm among young people, as pedagogues report in many Western countries. The reasons for this may be traumatic experiences in early childhood. The brain has a high plasticity and very vulnerable to external factors during this stage of development. Serious diseases, sexual abuse, neglect and lack of communication in bringing up – often caused by hours in front of the television or computer games – are also considered to be significant risk factors for later suicide attempts. They may also cause children and adolescents to harm themselves physically. Burned skin from cigarettes or scratches from knifes or razor blades must be understood as a cry for help.

While in 1950, only 40% of people who attempted suicides were under 45 according to the WHO, we were already at 55% in 2004. A reason for depression occurring at earlier stages of life might be the earlier onset of puberty and the decaying of family structures. If there is healthy communication within the family, and if common concerns and problems can be expressed and discussed, it is much easier for young people to overcome a crisis.

(Source: Der Standard, 06/2004)

How can suicided be prevented?

Suicide preventionThe claim to be able to prevent suicides would be a difficult one to fulfill because of the large number of factors that are involved until it actually comes to a suicide attempt. Strategies could be aimed at high-risk groups or trying to reduce the risks for the population as a whole. Firstly, any person with depression should be checked for suicide risk by professionals specifically asking about suicidal thoughts and plans. This shows the importance of specific training and sensitivity of physicians who are often enough the only ‘professionals’ many depressive persons might have contact to at the first place. Studies from the Nordic countries show a decline in suicide rates by 20 to 30% after general practitioners were trained to recognize depression properly and to help patients to get appropriate therapy (psychotherapy and supportive pharmaceutical measures).

In cases of high or imminent suicide risk, immediate action is necessary, including vigilance and monitoring of those affected, possibly through hospitalization. In addition, potential tools that may be used for suicide attempts have to be removed and an aggressive treatment of the associated psychiatric disorder be initiated.

A restriction of access to potentially lethal substances or tools can indeed help to prevent suicides. The introduction of security cameras on bridges and increased control of firearms, as well as the safer storage of pesticides and poisons (especially in rural areas of developing countries) has been proven to significantly reduce the risks. Education programs to improve the mental well-being as well as stricter control of the media reporting of suicides could also have preventive effects. On the objection that persons who wish to commit suicide would find ways and means to realize their goal in any case it may come as a surprise that for example when switching from toxic coal gas to non-toxic North Sea gas in the UK, the suicide numbers declined dramatically, while, for example in Japan right after the release of two films that were romantically idealizing the issue of suicide, the corresponding numbers increased significantly. Helsinki had the world’s highest suicide rate in the 90s and was able to cut it to 18 per 100,000 through prevention programs.

Because on the internet – in addition to advice and instructions for suicide in ‘suicide forums’ – a new trend had been detected in Japan to arrange collective suicides online, the government of South Korea (which had recently suffered the world’s largest increase of suicides, see above) will block related Internet sites, and there are also plans to make it more difficult to find information about suicide on Internet portals by blocking specific keywords such as suicide, ‘how can I die’, ‘collective suicide’, ‘suicide techniques’ and others. In addition the government plans to create a legal basis for the police to request the personal information of Internet users from their service providers who promote suicide or offer advice to persons willing to undergo suicide.

The challenges to prevent suicides in developing countries requires special attention, as most of the suicide-related research is done in developed countries, while the highest suicide rates are in fact found in developing countries. On nation-wide measures it is also worth mentioning that after a recent meta-analysis of randomized studies ([1], [2]) had suggested that the risk of death and suicide in people with mood disorders receiving lithium has been reduced by 60 percent, researchers have brought up the idea of adding small doses of Lithium to tap water.

Family members and the social environment in general also have an essential role. Relatives may be the first ones who can notice that someone might isolate himself or is depressed. It is of utmost importance to recognize these signs (see article about presuicidal syndrome) and to talk to the affected person about it. Nevertheless, the options and means of family members and friends are often limited – it is therefore important to involve external help (a psychotherapist, counselor, psychiatrist or at least a family doctor) if one feels overwhelmed or feels no longer able to reach the person.

Treatment of Depression

That psychological treatment can prevent a suicide in many cases is a well known fact that has been proven in numerous studies. The World Health Report 2001 already reported, quoting several studies, that some mental disorders may be chronic and of long duration, but that with proper treatment, those suffering from mental disorders can now lead a productive life and participate in their communities. Up to 60% of people suffering from severe depression can get well with the right combination of psychotherapy and antidepressants. I’ve written a detailed article on this topic in the publications section of my German-language website, which specifically describes and comments the latest standards for the treatment of depression.

(Further sources: APA, AZ, Der Standard 03.06.04, The Lancet Vol. 373, Issue 9672, p.1372-1381, 18 April 2009, Telepolis [1], see also links to sources right within the article.
This blog entry was first published in 12/2009; continuously updated as soon as I get aware of new facts. Last updated: 12/2012).

more blog articles about suicide

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Dec 29

Today, I stumbled upon an impressive and moving interview with the survivor of a suicide attempt that was published in a newspaper article in September 2000. In a state of presuicidal constriction / presuicidal syndrome, Kevin Hines jumped of the Golden Gate Bridge and survived this jump only by extremely fortunate circumstances .

Photo © Seattle Times

Bild © Seattle Times

Today he can talk about it and works in a helping profession (nurse). In his spare time, he tries to inform and educate others about the importance of an accurate and professional medical and psychotherapeutic treatment of mental illness. ‘I’d feel lucky if with my horrific experience, I can just keep only one person from taking his own life,’ he says in the NZZ interview with G. Sachse. Indeed, during the (time-limited) course of a presuicidal syndrome that may define one of the worst stages of depression but also of paranoid delusions, the way the affected person perceives, experiences and thinks about what is going on may be much different than under normal circumstances, and it may also be linked differently than usual with one’s emotions and behavior. At the end, the affected person may see no other way out than to take his/her own life. Only after the abating of the syndrome, other options can be perceived and imagined again – that is why in times of crisis it is so vital to seek professional help right away (eg by doing an emergency-call, calling in for a crisis appointment at a psychotherapist, vitising a psychiatric clinic etc.) just to overcome the most difficult time. At least, friends or other acquaintances should be called up – the idea is to “play for time”, to aim at getting over this barely endurable phase by all means, at least to get through until the next morning. If, unexpectedly, you as the suffering person would still not feel better at that time, you should contact a trusted physician. Consider, however, that for periods of serious depression, it is actually recommended to consult a qualified psychiatrist or psychotherapist, even if it has not yet already come to suicidal thoughts, or if these thoughts have already subsided – to avoid them from coming up again by treating the underlying depression.

In conversations with clients who have dealt with phases of suicidal constriction, they repeatedly confirmed how happy they were about having ‘survived’ the critical phase once they had stabilized again and how lucky they felt that they didn’t end their life before. Sometimes, they had experienced completely unexpected positive events in the time since their deepest phases of depression, but more generally, their life had taken a positive turn since they had continued with their psychotherapy, an upturn that was not forseeable.¬†“Give life a chance” – this common slogan (that is usually used in a different context) shouldn’t be forgotten especially in the phases of life where it apparently can’t get any lower.¬† As we know from economic sciences, it is systemically inherent that after a low point, it can only go upwards again. What could be worse in life than a stage in which there doesn’t seem to be any way out other than death? As paradoxical as it may sound, after successfully having weathered the worst hours of a particular night, life will most probably already feel at least an iota better the next morning. Talking to someone (especially one with a person who is professionally trained to assist in difficult phases of life), it is usually possible to develop completely new perspectives, perspectives that can give life a positive turn on a long-term scale.

To avoid being misunderstood: this is certainly not always an easy or quick process – but properly accompanied and instructed, the majority of people succeed at the end.

Further information:

Depression – Mythen und Fakten rund um eine ‘Zeitkrankheit’ (Artikel R.L.Fellner; german language)
Vier Sekunden bis zum Aufprall (NZZ Interview mit Kevin Hines 2009; german)
Lethal Beauty РA jumper [..] makes a new life  (San Francisco Chronicle 2005)
(Blog entry first published in German language (‘Gedanken eines Suizidversuch-√úberlebenden’) in 03/2009, published on English website: 12/2011)

Dec 27

Andropause is an onset of hormonal changes in men – mostly between the ages of 40 and 50 -, which is triggered by reduced testosterone levels.

Testosterone is the primary male sex hormone and is produced in the testes. It affects all body cells and is responsible not only for sexual development, but also for the specific skin, bone and muscle structure of men. It is equally important for the production of red blood cells, which supply the body with oxygen. And after all, testosterone also plays a significant role in providing sexual pleasure and emotional balance. At around one’s middle years, however, the production of this hormone gradually drops, and so do the testosterone levels in the blood. This reduction causes problems for many affected men: in German language, the saying “die Fitness ist kraftlos und die Lenden sind saftlos” (freely translated as ‘no gas in the muscles, no fluids in the loins”) expresses the feeling when the so-called andropause kicks in: depression, irritability, loss of concentration and vitality.

Possible symptoms of the andropause include:

  • Mood disorders such as anxiety, irritability, aggression
  • Tendency to depression
  • Increased weight and body fat, increasing abdominal girth
  • Increasingly poor short-term memory
  • Decreased concentration and attention span
  • Sleep problems and / or stronger daytime fatigue than before
  • Reduced desire for intimacy and lower sex drive..
  • ..or rational desire for sex, but still, sexual apathy
  • Erectile Dysfunction
  • Less frequent and intense ejaculation
  • Osteoporosis
  • low self-esteem
  • Hot flashes and night sweats

There are, however, considerable differences of opinion among experts as to which of these symptoms actually indicate a so-called ‘male menopause’ or andropause and were initially caused by testosterone deficiency, because for each of the symptoms in the list, there could be other root causes, even if a reduced testosterone level would actually be detected in a patient. Thus, in a way, the so-called ‘testosterone replacement therapy’ is often not much more than a ‘shot in the dark’.

Testosterone replacement therapy – yes or no?

Some doctors and hospitals today offer testosterone replacement therapy without much hesitation to men, often with the particular aim of helping them to regain their desire for a satisfying love life. Even with impending cardiovascular diseases, this hormone is sometimes used for prevention, because studies have shown that testosterone has a protective effect on arteries and veins, so there are good, potential reasons to say ‘yes’ to this kind of therapy (usually in the form of tablets, gels, patches or nose sprays). However, it is important to know that a hormone replacement therapy does not help at all if one simultaneously depletes his bodies’ health and resources. It is remarkable and perhaps not entirely coincidental that many men who are looking to start a hormone replacement therapy are also often frivolous users of¬† ‘fitness booster medication’ (self-medicated).

Ideally, taking on an artificial testosterone substitution should increase muscle mass, bone density, libido and performance. Under certain conditions, the ‘extra dose’ testosterone may also accelerate the development of an existing prostate cancer. A preventive control (PSA control) is therefore highly advisable.

But there are also proven health tips for men, which in contrast to the artificial feeding of testosterone reliably pose no health risks and are also very well suited to raise the testosterone levels:

  • Development of more self-discipline for a healthy lifestyle – something that many men never achieved in their lives
  • Balanced nutrition (vitamins: more fruit and vegetables; low-fat: greasy, oily foods and refined carbohydrates lead to weight gain, but: obesity appears to influence the production of testosterone!)
  • The waist circumference should be less than 100 cm (see BMI test on this website)
  • Enough sleep – at least 6-8 hours per day
  • Care for a balanced mental state – if something brings you out of your balance on a reglar basis, seek necessary support through psychotherapy or coaching: optimism and a balanced state of mind help to reduce stress. On the other hand, if men are overloaded (perhaps even chronic), endocrine glands will produce significantly less amounts male sex hormones.
  • Smoke and drink less
  • Natural resources: oats and ginseng have a testosterone-like effect, and an extra portion of zinc also helps the testosterone levels: lobsters, oysters and shrimp, soybeans, wheat bran and pumpkin seeds. Casanova was known to eat 40 oysters a day!
  • Exercising also stimulates the production of testosterone: best results are achieved with intense strength training with sets of 10-15 reps, peppered with breaks of 60-90 seconds (intervals of 15-30 sec will stimulate the production of growth hormone).
  • Good sex: sexual excitement and ‘games of desire’ help to raise our hormone levels over a period of up to two days and thus counteract the natural way of deficiency. Even erotic fantasies will stimulate testosterone production in the short term, falling in love raises our testosterone for up to many months.

Men have the luxury of being able to affect their hormone levels through their lifestyle more than women, because their hormonal situation does not change so abruptly and radically with age.

In the “self test” on my website you will find a self-test for testosterone deficiency, which can allow an initial self-assessment. In case of doubt, a medical examination with blood test is recommended.

(Initially published in German language (‘Testosteron-Spiegel erh√∂hen’) in 10/2010. Image source: understandinglowt.com)

Dec 19

“Burnout in Thailand? Impossible!”

That’s probably what most of us would think. But symptoms of ‘burnout‘ are not always linked to high workload alone, they can also have other causes. I have identified 3 groups of people that are vulnerable to symptoms of burnout, even in a sunny, tropical country like ‘mai bpen rai’ (‘everything up to you’) Thailand, but of course also other tropical countries abroad:

First, there are the foreigners who try to make a living here and who are employed by foreign or local companies. Often, they have to face high amounts of work-related pressure and stress right from the beginning of their assignments, while having arrived completely unprepared for the cultural changes they would have to face. Many are surprised and overwhelmed by how hard it can be to ‘juggle’ giving up the old life, finding and adapting to a new home, new colleagues and their work ethics, and learning how to get around and at the same time, to meet all the expectations they put on themselves.

Then, there are foreigners who try to start their own business in an Asian country like Thailand. These expat entrepreneurs are completely on their own, having thought that their experiences as tourists should have prepared them well enough. Soon, however, they face all kinds of obstacles in building up a successful business venture here as foreigners. Many things don’t work out as they would have back home with the same effort and money put into the project. Many little annoyances might gradually not only take the fun out of their dream of working in an Asian country, but lead to outright frustration and the feeling of never reaching a point where everything runs smoothly. And I haven’t even mentioned dealing with governmental institutions and paperwork.

Finally and probably surprisingly, even retiring in Thailand (but just as well in any other tropical country) can lead to ‘burnout’. I already mentioned the huge changes a migration to another country involves, and even if everything started happy and smoothly, after some time, the excitement might gradually fade away, perforated by disturbing or even annoying little experiences, social isolation or conflicts with other people. Also, many Westerners suffer from a lack of challenge and communication: they are bored out by the daily routine that kicks in after a while and feel stuck between meals, drinks and hanging around without any kind of challenge. Even finding someone to talk to at a certain nouveau level might prove difficult. But being ‘bored out’ has many physical similarities to burnout and might gradually make us just as sick and depressive. So it is important to take these signs seriously and fight them at an early stage before one gets overwhelmed by his or her own negativity.

In an followup entry of my blog, I will write a bit more about typical symptoms of burnout and boreout, and also outline strategies on how to deal with them.

(This short article is the blog-adapted version of an article dealing with psychological expat problems and general mental health issues that was published in various newspapers and magazines in Thailand, 2011; image credit: Shiho Fukada, NYT)

Dec 08

Women treated for severe psychiatric conditions including major depression shortly after giving birth were more likely to be diagnosed as bipolar later in life compared to those whose first psychiatric episode happened at any other time, in a new study from Denmark.

Researchers said they didn’t know if some postpartum depression or schizophrenia-like episodes were actually misdiagnosed bipolar disorder — or if more women with those initial diagnoses developed bipolar disorder over time.

“We’re looking at severe psychiatric episodes,” said study author Trine Munk-Olsen, from Aarhus University. She noted that while “postpartum blues” are relatively common, severe depression and other acute psychiatric episodes requiring inpatient or outpatient clinic care only occur in about one in 1,000 new moms.

“The severe episodes are rare, but they are serious episodes and of course they should be taken seriously. You want these women to get help, no doubt,” she told Reuters Health.

Bipolar disorder is characterized by alternating swings between severe depression and “mania,” when a person is overly excited, happy and energized. It can be treated with medications including mood stabilizers and talk therapy.

The condition most often manifests in early adulthood, and the National Institute of Mental Health estimates six percent of the U.S. population has the disorder at some point in life. Previous studies have suggested giving birth may act as a trigger for a first overt episode of bipolar disorder. But few women are actually diagnosed as bipolar in the weeks after having a baby.

The researchers theorized that a severe psychiatric episode shortly after giving birth could be a signal of underlying bipolar disorder. So they tracked women in Denmark for 15 years after their first psychiatric episode to see whether the timing of that episode — shortly after childbirth or not — predicted who would later get a bipolar diagnosis. Using Danish registries, they found 120,000 women treated in an inpatient hospital or outpatient clinic for their first bout of severe depression or another psychiatric condition starting around 1970. Of those, 2,900 had those episodes within a year after giving birth to their first child. That didn’t include women with an initial diagnosis of bipolar disorder, since the researchers were interested in women with other psychoses that later became bipolar.

Over the next decade and a half, close to 3,100 of all women initially given a different diagnosis were ultimately diagnosed with bipolar disorder. Of women who had their initial psychiatric episode in the first month after giving birth, 14 percent were eventually diagnosed as bipolar. That compared to between four and five percent of women who were first treated in the rest of the year after giving birth or at any other time.

“It is likely that some of the women were misdiagnosed — we cannot rule that out — but it is likely that some of the women develop bipolar over time,” Munk-Olsen said.

The results translate to a four-fold increase in the probability that a severe psychiatric episode in the month after giving birth, versus one that happens at some other time, will ultimately lead to a bipolar diagnosis. Among those with such early postpartum episodes, the patients admitted for inpatient psychiatric treatment were also twice as likely as those treated as outpatients to later be diagnosed as bipolar.

“Clinically these findings make absolute sense,” said Dr. Verinder Sharma, an obstetrician and gynecologist who studies bipolar disorder at the University of Western Ontario in London, Canada. “We have seen that childbirth is a potent and specific trigger of bipolar disorder.” Sharma, who wasn’t involved in the new study, told Reuters Health that hormone changes that occur during this time, as well as sleep loss, might trigger some women to develop bipolar symptoms, which could be misdiagnosed as depression or an anxiety disorder.

However, he said, there are still many questions about the role that having a baby plays in a woman’s chance of becoming bipolar. “We don’t know whether these women have the illness because of childbirth, and if they didn’t have children they would have gone without any episode of bipolar whatsoever,” he said. The findings also can’t prove that postpartum depression, or giving birth itself, causes bipolar disorder, and the researchers didn’t measure whether less severe, more common postpartum blues are linked to bipolar symptoms.

Still, they wrote Monday in the Archives of General Psychiatry that severe psychiatric symptoms which first show up soon after a woman has a baby should be added to the list of features that could increase the risk of bipolar disorder.

Doctors, Munk-Olsen told Reuters Health, should “think about when women have their onset, and you might have an indication that there is an underlying bipolar disorder. We want these women to be diagnosed correctly, in order to help them in the best way.” In particular, Sharma added, doctors who are treating women with new psychiatric symptoms after childbirth should rule out bipolar disorder before they think about simply treating with antidepressants, which could make certain bipolar symptoms worse.

“It’s really important to think about the diagnosis of not just depression but of severe depression and definitely bipolar disorder in new moms who present with a sudden onset of mood symptoms,” agreed Dr. Dorothy Sit, who studies mood disorders in women, including postpartum psychoses, at the University of Pittsburgh and wasn’t involved in the new report.

(Sources: Reuters; Psychiatric Disorders With Postpartum Onset: Possible Early Manifestations of Bipolar Affective Disorders in: Arch Gen Psychiatry. Published online December 5, 2011. doi:10.1001/archgenpsychiatry.2011.157. Image credit: drop.ndtv.com)

Dec 08

Image: WikiCommons licenseAdolescents who were abused and neglected have less gray matter in some areas of the brain than young people who have not been maltreated, a new Yale School of Medicine study shows. The brain areas impacted by maltreatment may differ between boys and girls, may depend on whether the youths had been exposed to abuse or neglect, and may be linked to whether the neglect was physical or emotional.

The results, published in the Dec. 5 issue of the Archives of Pediatric Adolescent Medicine, show that 42 adolescent subjects who reported being either abused or neglected show a reduction in gray matter — the tissue containing brain cells — even though they had not been diagnosed with a psychiatric disorder.

“Here we have teenagers who may not have a diagnosable illness but still have physical evidence of maltreatment,” said Hilary Blumberg, associate professor in the Departments of Psychiatry and Diagnostic Radiology and in the Yale Child Study Center, who is senior author of the study. “This could help to explain their trouble with school performance or increase their vulnerability to depression and behavioral difficulties.”

The reduction of gray matter was seen in prefrontal areas, no matter whether the adolescent had been physically abused or emotionally neglected. However, in other areas of the brain the reductions depended upon the type of maltreatment the youth had experienced. For example, emotional neglect was associated with decreases in areas that regulate emotions.

The researchers also found gender differences in patterns of gray matter decreases. In boys, the reduction tended to be concentrated in areas of the brain associated with impulse control or substance abuse. In girls, the reduction seemed to be in areas of the brain linked to depression.

Blumberg stressed these deficits found in adolescents are likely not to be permanent.

“We have found that the brain, particularly in adolescents, shows a great deal of plasticity,” she said (neuroplasticity; comment by R.L.Fellner). “It is critical to find ways to prevent maltreatment and to help the youths who have been exposed.”

(Source: YaleNews; E. E. Edmiston, F. Wang, C. M. Mazure, J. Guiney, R. Sinha, L. C. Mayes, H. P. Blumberg. Corticostriatal-Limbic Gray Matter Morphology in Adolescents With Self-reported Exposure to Childhood Maltreatment. Archives of Pediatrics and Adolescent Medicine, 2011; 165 (12): 1069 DOI: 10.1001/archpediatrics.2011.565)

Oct 31

There is a weakness that is particularly frequent among people in service professions, causing burnout and depression rates in the service industry to be some of the highest.

The ‘Helper Syndrome‘ describes a strong drive to make other people feel better. In some cases it is done to ease or divert the helpers from their own pain. But by no means you have to be a ‘professional’ helper to behave this way, it can be a friend, neighbor, associate or yourself who is vulnerable to getting pulled into responsibilities and tasks that others wouldn’t even think about taking at the first place.

The Helper Syndrome can contribute to outright abusive forms of relationships: the ‘helper’ might increasingly experience signs of burnout or feel exploited, and their highest efforts might increasingly be taken as a matter of course with little gratitude for their support – no matter how much energy the helper invests, he might never get to a point where everyone is satisfied.

Another unhealthy aspect of the helper syndrome can be a lack of self-awareness and abuse of the responsibility a helper has towards the helped. This is because a helping relationship is typically unbalanced; people are not on equal footing. A good helper will be sensitive to the imbalance, while an abusive helper will ignore or even seek it. Instead of supporting the other in becoming stronger or looking for additional (often: professional) means of support, the helper tries to keep them dependent, and focuses on reaching their very own goals. To achieve their goals they might even abuse their power, or the trust of the recipient.

So whether the motives for such behavior are altruistic (‘I want to give something back‘, ‘I don’t want them to do the same mistakes I did‘, ‘I want to share‘, ‘I can do it!’) or driven by dubbing their own psychological issues, it is always a sign of emotional imbalance and exploitation, of oneself or others, if someone ignores their own limits and tries to ‘fix’ everything only by themselves.

Typical forms of ‘helper’ relationships are: long-term relationships of non-addicts with addicted, aggressive, selfish or controlling personalities or relationships defined by a strong imbalance (with one partner being the ‘teacher’, ‘the sugar-daddy’ or ‘the boss’). They are functional for both, but quite resistant (and vulnerable) to change, which prevents at least one of the partners from achieving greater self-esteem and realizing his or her full potentials. While professional helpers can use supervision to reflect their work, in our private lives we can just try to take care for ourselves to avoid getting entangled in dysfunctional helping ambitions.

(Picture credit: http://westallen.typepad.com; This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2011)

Aug 05

Beauty surgeons and the cosmetic industry love it (critics claim that they are even doing their best to support? it): the ‘Dorian Gray Syndrome‘ describes a phenomenon where people turn into heavy users of cosmetic products and medical procedures in an attempt to preserve their youth. Oscar Wilde’s famous novel ‘The Picture of Dorian Gray’ first introduced the psychological dilemma of affected persons to the wide public: conseqently the syndrome was named after the novel’s protagonist.

While this syndrome as a whole is not scientifically acknowledged, many patients suffering from it actually show diagnosable traits of body dysmorphic disorder (having excessive concerns about perceived defects in their physical features), narcissistic character elements (like a sense of superiority or being more occupied with themselves than with others), and signs of delayed maturation in certain aspects of their psychic development. In their preoccupation with their outer appearance and difficulty to accept their aging process, DGS patients are often users or abusers of hair growth and weight-loss products, mood enhancers, medication against erectile dysfunction, they are often owners of gym membership cards and very often patients for cosmetic surgery (laser resurfacing, botox injections, aesthetic surgery etc.).

In case you happen to know someone who you think might show signs of the Dorian Gray Syndrome: this person might also have depressive tendencies which, if untreated, might trigger autodestructive symptoms if he or she tries to suppress the negative self image by using drugs or repeatedly undergoing surgeries. But who would want to define when it would be ‘justified’ to look out for help? Some might not want to live a life burdened by compulsionary thoughts of this kind, but be able to fully enjoy their lives and take life as it is – like so many others do.

But then, what can be done about it? For some of the affected persons, a personality disorder turns out as the root cause for their body dysmorphic disorder, for others it is a lack of self-esteem. While in order to improve one’s psychological balance, a personality disorder can only be managed by various means (like by medication and counseling aiming at better self management), self-esteem can be improved quite well utilizing methods of psychotherapy. This doesn’t have to be a process that requires years of ‘talking cure’ – distinctive and long-lasting improvements can usually be achieved already after a few months of regular sessions. The goal of these sessions is to work out a more confident and accepting take on what our body involves.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2011)

Aug 05

“What can I do, it’s in my genes!” In recent years, this has become a standard explanation for many of the health problems we have to face in our lives. Indeed, there are few human diseases without scientific studies trying to pinpoint ‘genetical causes’ as the root. Consequently, there are efforts to find genetic roots of mental problems as well. But 150 years after Mendel (the ‘father of modern genetics’) had outlined his ‘Laws of Inheritance’, we have still to see significant therapies that could wipe out major human burdens like cancer, addictions, diabetes or violence by purely genetical means. This is not to say that genetic science doesn’t have potential; but all the other influential factors should not be forgotten.

One of the weirdest aspects of the notion that all things human are genetically predetermined is that it takes everyone completely out of the context of their environment. We might as well not put personal or societal energies into trying to improve ourselves or others, because it’s inevitable and unchangeable anyway… But in fact there is just a very small number of very rare diseases that are truly genetically determined. Most complex conditions like ADHD, schizophrenia, a tendency to violence or addiction might have a predisposition that has a genetic component, but a predisposition is not the same as a predetermination. Genes just seem to give us different ways of responding to our environment. Some of the childhood influences and the method of child rearing in turn also affect gene expression; they can actually turn on or off various genes to put us on a different developmental track which may suit the kind of world we’ve got to deal with.

For example, a study done in Montreal with suicide victims looked at autopsies of the brains of these people and it turned out that if a suicide victim had been abused as a child, the abuse actually caused a genetic change in the brain that was absent in the brains of people who had not been abused. That’s an epigenetic effect: an environmental impact that is capable to either activate or deactivate certain genes.

So, in adaptation to the famous quote of Shakespeare, “There are more things in heaven and earth than are dreamt of in our scientific world.” And there are more things we can do to change ourselves than we might imagine.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2011)

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