Getting SAD in the winter – Why do we have emotions?

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It creeps up on you in the mornings.

First, it’s the cold.

Then the dark.

And finally, the snow.

Winter is here.

For many of us, winter represents a slowing down of things. The days are shorter, suddenly you’re less inclined to go to the gym after work. Vacations have settled for the most part, and energies are redirected towards class or work or whatever it is you do.

It can also kind of suck.

Why is it that our moods are affected by this change of season? What is it about humans that makes us so sensitive to these changes? Does this have an evolutionary benefit? What if we get too sad?

To think about why the human mood (in general) changes during the season, we must first think about what mood is. Where did mood come from? One of the earliest forms of “mood,” is hunger. When in a hungry mood, even the most primitive animals will change their behaviour, and begin food-seeking behaviours. Their cytoplasmic cilia might undulate towards a chemical stimulus. They may swim to a shallower depth towards the scent of a school of fish. If you are a hunter, and encounter a bear in the woods, hope that it’s not hungry. It may not eat you. If it’s looking for a meal? Good luck! The point is the moods, in animals, represent a set of behaviours suited to a particular circumstance.

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Does this apply to humans? Of course. We gorge the cupboards when we’re hungry. On a macro level, countries and nations suffering from famine and starvation have orders-of-magnitude more unrest and civil war than their well-fed counterparts.

While hunger is a relatively easy “mood” to understand the benefits of, the behaviours and utility provided by more traditional moods like happiness, sadness, and anger, are more subtle, yet equally significant.

Anger can be considered synonymous with threat. People who are angry often feel threatened, and many of the behaviours associated with anger are involved with defense and mitigating a threat. Yelling, like the growling bear, is making yourself “big,” to intimidate an enemy. Elevated heart rate (tachycardia) occurs when you’re angry, in case the most extreme manifestation of anger, violence, is necessary. Sadness can be a little less clear. After all, what could be the evolutionary benefit of something often so painful?

Sadness is afforded power by virtue of the pain it causes. If we are sad about something, our brains want us to avoid that same circumstance from happening again. Losing a job, a messy break up, losing a loved one, these are all circumstances that our brain is telling us we should avoid again, and our behaviours begin to modify in hopes to avoid triggering the sadness again. If you’ve lost your job because you continually showed up late to work, the sadness afforded by the job loss may motivate you to be on time for the train more often in the future. While wallowing over a messy break up, you may find yourself reflecting on the relationship in search of “what went wrong,” and using this information to improve your relationships in the future.

The pain caused by the loss of a loved one is a little more nuanced. What change could sadness drive? There are a few answers. Historically, most deaths were preventable, and the result of a sabretooth tiger attack, or tribal warfare. Sorrow caused by deaths in these circumstances were clearly cause people to be more weary of protecting against tigers, and may either question the benefit of their war or double down and fight even harder. Today, many deaths have a component of lifestyle contributions, and grief after a loved ones death from lung cancer, who smoked, may cause us to question our own habits. The point is, even grief, sadness, and sorrow drive change, and have clear utility on an evolutionary, population level.

So what happens when you get too much of this? Well, depression, for one. A disruption of the normal mood cycle, by any number of factors, can contribute to the development of depression. In the case of anger and happiness, they can contribute to the development of mania. And the fact is, all of us are vulnerable to alterations in our moods when the environment changes, even if it doesn’t represent a frank depressive or manic episode. One of these factors is the season, as we discussed above. For most of us, it’s just the way things are. For some of us, it’s the winter blues. In extreme cases, it’s seasonal affective disorder (SAD).

What is SAD? How is it caused? What about the seasons impacts our moods? Can we use this information to inform SAD treatment? Tune in to part 2 to see!

Dr. Travis Barron is a resident physician in Toronto, Ontario.

Are you manic right now?

I recently had a patient who was diagnosed with pneumonia. We had been treating with antibiotics, as well as some temporary puffers, for symptom relief. Unfortunately the puffers did not suffice, and the antibiotics had not acted quickly enough. One evening, after he finished dinner, this gentleman began experiencing shortness of breath. He was concerned, and called an ambulance, who took him to the hospital.

On arrival to the emergency room he was offloaded from the ambulance and given some oxygen, which helped him immensely. His breathing actually settled relatively quickly and he was able to breath without the oxygen mask. The emergency room physician (ERP) took this opportunity to get a more wholesome history from him.

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“Do you smoke?”

“Not for the last few years.”

“Do you take any medications?”

“Just the puffers and antibiotic my doctor had prescribed.”

“Very good. Do you have any medical illnesses?”

The patient paused for a moment to think. He had been through this rodeo before, for other medical problems. He was wondering whether or not to mention to the doctor a previous diagnosis of bipolar disorder.

In the past, he had told physicians and paramedics about this diagnosis to underwhelming results. Instantly, the affect of the providers would change. Suddenly, his credibility was drawn into question. Where before he was allowed to speak and describe his story without interruptions, he was now met with requests to, “slow down.” The questions like, “are you feeling like yourself right now?” seemed to bother him the most.

This ERP on this particular day however seemed professional enough, and the patient wanted to be as transparent and honest as possible, so that his medical care could be the most informed it could be.

“I’ve been diagnosed with bipolar disorder, though I’m not on any medications, and I don’t know that I agree with the diagnosis.”

The silence was deafening, although it only lasted a second. The physician quickly regained her composure and started down another line of questioning.

“Have you used any drugs recently?”

“No.”

“Do you smoke?”

“I already told you I didn’t.”

“Are you manic right now?”

He tried his best not to role his eyes.

“I feel perfectly fine, I’m sleeping eight hours a night.”

“Are you having thoughts of violence or suicide?”

He looked at her sternly and decided not to answer this question – he was here, after all, for pneumonia. No razor blades had been held at any wrist.

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The conversation continued and eventually the physician left to order some investigations. Various nurses were in and out of his hospital room, all of whom seemed to suddenly have a lot less to say.

The patients condition improved, and he was eventually discharged on a low dose steroid for a few days to aid in his recovery.

“I don’t think I’ll take this tonight but I’ll take it in the morning.”

It was the ERP’s turn to role her eyes. The patient felt obligated to explain himself.

“If I do have bipolar disorder, the absolute last thing I want to do is take a steroid tonight, be awake the whole night, and have an episode.”

“Alright, see ya,” the doctor said as she left the room.

Now I had heard this story from the patient second hand of course, and I’m sure the dialogue wasn’t exactly as I have described above. But there are some things that are certainly true. This man was extremely aware of the prejudice he received, by virtue of the (unconfirmed) diagnosis he carries, and suffered because of it. He felt insulted, degraded, and less than human.

Great way to make people want to seek treatment for mental illness, eh?

There were a few things that bothered me about the story, the least of which was this physician’s skill in assessing mental illness. For the record, you could ask a naked man screaming about Jesus on top of a Walmart, who hasn’t slept in eight days, “are you manic right now?” and I would be shocked if they said yes. To those of us in the field, we recognize the mental status exam and the whole picture as key instruments leading to diagnosis. Personally, I don’t see the utility in asking seemingly well and euthymic (normal emotion) people what they think of their mental status, irrespective of their diagnoses, when they are seeking help for an unrelated medical problem.

Bipolar people get pneumonia too, y’know.

The physician’s apparent novice skill in this field isn’t why I chose to write this post – it’s the prejudice that came attached. Because this man had a diagnosis of mental illness in the past, and one of the “scarier” ones, his credibility was immediately drawn into question. Are you sure you didn’t accidentally take a bunch of cocaine before you arrived here? Are you positive you don’t want to blow your brains out after you leave here?

That’s not to say that this information doesn’t matter, because it does. On a professional level, whenever I assess someone with mental illness that may put them at risk, I’m always on the look out for any red flags or warning signs.

I’m also sure to treat the patients like humans.

Medicolegally, I understand the need. “Oh Doctor, you didn’t ask about suicide when you assessed Mr. so and so five months ago? And why is that? He did have bipolar disorder, after all.” And Im not saying theese questions shouldn’t be asked. How you go about it however, is another story.

Do any of you have real life examples or prejudice inflicted upon you, or a friend as a result of mental illness? Without going into too much personal detail, share below!

Dr. Travis Barron is a resident physician in Toronto, Canada.

The psych wards are full and why that matters

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“I can tell that things have been difficult.”

“That’s life, isn’t it? One thing after another.”

“Are you having thoughts of wanting to be dead?”

“All the time.”

“Are you having thoughts of attempting suicide?”

***

I recently met a patient in my family medicine clinic, a 28 year old gentleman who had immigrated to Canada as a young child. This man had experienced numerous struggles in his life, from escaping relative slavery in central Africa, to coming to Canada, achieving a professional education, and eventually got a job as an X-ray technician. That was, until recently.

For the last two years, the gentleman, “A”, had been struggling with depression and alcohol use, following the death of his mother. “A”‘s drinking quickly escalated over time, which worsened his depression, which caused him to drink more, and so on. “A” had disclosed these problems to his previous family doctor, who stressed the importance of alcohol cessation, and prescribed a medication.

As these things can sometimes go, “A” was not able to abstain from alcohol, and unsurprisingly (given the ongoing, heavy substance use), they found the medications ineffective for depression and stopped taking them.

“A” eventually ended up back in his previous physician’s office for a separate issue, and the physician decided to check on his mood. It quickly became apparent “A” had continued to drink, and was severely depressed. He was now off of work and almost entirely socially isolated. “A”‘s physician spoke to him about suicide, and it became apparent that “A” had recently attempted suicide via overdose. He was, “disappointed,” the attempt was not successful.

Because of this, “A”‘s doctor had recommended they go to an emergency department to be seen urgently by a physician. “A” had some friends that had previously been through the emergency psychiatry experience, and told his physician there was, “no way,” they would go through that.

The physician, in keeping with her professional and moral duties, issued a form 1; what is a form 1? In Ontario, a form 1 is a form issued by a physician when they have concerns regarding your safety, due to mental health. The form allows you to be apprehended and brought into a psychiatric hospital for assessment.

“A” was picked up by police and they drove him to the hospital. In hospital, they were admitted to the emergency department, and given a glorified, locked, jail cell to stay in. His clothes were taken and they were under constant observation by a security guard outside of the hospital room (cell) door.

After 48 hours, “A” was discharged, and had been lost to follow up for over the last year, until I had met them, again for a separate issue.

***

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“Are you having thoughts of attempting suicide?”

Silence.

“I need you to be honest with me here, I’m very concerned.”

“I’m fine.”

***

“A” was not fine. In fact, it soon came out that, yet again, “A” had covertly attempted suicide. He was actively planning another attempt, and had begun to set his affairs in order, as though he would soon be dead.

I issued a form 1.

Why does it matter that the psych wards are full?

“A” was very unwell, and to this day I don’t know how he is doing. After I submitted the form 1, they refused to return to my office. Let me begin by saying, this is the least favourite part about my job. On a personal philosophy level, I do not believe that physicians, or anyone, has the rite to tell people how to feel and what to believe. I also know when to recognize severe, serious depression, that may be treatable, which puts ones life at risk. This was the case with “A”, and I can sleep easy tonight knowing that I did not abuse my government-given powers to take away someone’s liberty.

But this didn’t need to happen.

Far in the past, or in some parts of the United States (if you have money), there is a mythical beast called the elective psychiatric admission. This is exactly what it sounds like – elective, meaning not mandatory. Examples of elective psychiatric admissions include people with a moderate depression, people with severe anxiety, or someone in the need of a mood stabilizer or antipsychotic titration. Useful stuff, no? The philosophy behind elective psychiatric admissions is that we tackle a problem before it gets to serious. You want to treat someone when they are climbing the stairs, not jumping off the balcony.

Unfortunately, I am sad to say that in my short psychiatric career, I could count the number of elective psychiatric admissions I’ve facilitated on one hand. Two fingers, to be exact. And that’s not to say I haven’t met people who may benefit from such an admission – I meet people like that at least once a week. But the reality is, because psychiatric hospitals are overcrowded, there is only room for emergency admissions. These are your form 1’s, the acutely suicidal, the emaciated psychosis.

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Of course those people (emergent patients) need hospital, and indeed they need hospital more than an elective patient, by it’s very nature. But that doesn’t mean elective patients don’t need admission, as well. Inevitably, people who may benefit from an elective psychiatric admission are discharged home. Many of those people appropriately improve on an outpatient regimen, but not everyone – some people get worse. Way worse. So much worse, in fact, that they shortly come in need of an emergent psychiatric admission.

You can see how the cycle continues. As long as we deny inpatient treatment to people who are at anything but absolute crisis mode, people will become sicker, and further overcrowd the hospitals. Think of the bipolar man in need of a lithium titration who instead stops his medication and has a severe manic episode. He thinks he can fly, jumps off a building, and breaks both legs.

What about the effect on emergency rooms?

If there is any area of medicine and mental health who sees first-hand the effects of overcrowded, full psychiatric hospitals, it is emergency departments. As emergent psychiatric patients are felt to need admission, a back log is created when the psych wards are full. This results in psychiatric patients being housed, long term in the emergency department, hopefully awaiting some attrition from the wards.

I don’t know that you have ever been in an emergency department, but they aren’t pleasant. The psych beds in the emergency, even less so. They usually float somewhere between jail cell and operating room sterility. Not only is this an abuse of vulnerable people in need of help, but this causes further problems. Physicians are able to dedicate less and less time to each patient, as the mental health population of the emergency grows, which is a recipe for disaster. There are reasons there are nursing ratios on psych wards, because vulnerable people with mental health problems need support. This isn’t the case in emergency departments, and people often go neglected and ignored. Most importantly, it often escalates them with respect to agitation, and suddenly you’re in the position of having to inject someone against their will to keep the overcrowded jail emergency from exploding.

Similar experiences to this are why “A” was so reluctant to go to a hospital and seek help. And because of that, he’s lost to the system. I hope he isn’t dead. I’ve done everything I could to reach out, and now, only time will tell how that story ends.

What I do know, is that psych wards are full, and it matters.

Editor’s note: This post is awfully critical of a lot. If there is one thing I am not critical of, it is the excellent work of my emergency medicine colleagues, who often find themselves overstretched as they save lives, due to poor government planning.

I am extremely critical of the dehumanizing psychiatric rooms so common in our emergency departments, and stand by my description of them as jail cells.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Of depression

Sitting in the doctor’s office, I hear the words. They leave her mouth like an anvil and slam upon the floor, the noise made by each previous contact making the next syllable more impossible to hear.

“You have depression.”

I leave my body and float out of the chair. I’m outside the hospital, gazing down on all that was. I’m flying further, and further, overcoming the very curvature of the world, and then I see it. My future, everything that will become of me, and all that was, laid before my very eyes.

My first sense is loss. Loss of mystery, of individuality, and most importantly, of choice.

My head is spinning. I’m falling, crashing through the sky. I miss the chair and my body and drown below into the depths of hell. I’m confronted by all that has ever scared me, a violent torture to my all-seeing soul.

I’m fired, divorced, my family has shunned me. Strangers spit on me, I’m left to rot. Slowly I decay into nothingness until the coolest realization, as I’m forced to linger while all I once loved is forgotten to me.

My heart skips a beat and I’m back in the chair. The doctor is still talking, I realize to myself. I haven’t heard a damn thing she’s said to me in the last five minutes. I hope it wasn’t important.

“The important thing is that there is hope, treatment, and I am going to help you.”

I stumble home from the office, dreading the moment I finally stop. When my footsteps no longer crowd my ears, I’m left with my thoughts. Depression. What does this mean?

It takes a while, but my life takes a surprising fork as I journey on the path to recovery. I actually get better. I’m working again, and somehow, my relationships are more fulfilling. It’s a Saturday, and I want to go to the park. Why? Just because. It’s a refreshing release, to finally do something because.

On Monday, I’m back in her office. She’s asking me questions and I can’t stop thinking about this chair.

“How are you feeling?”

I speak for a while and we exchange pleasantries. She’s happy to hear I’m doing well. In a way, it feels surreal. The doctor catches my smile and asks me what’s up, and I give a small chuckle.

“Last time I was here, I thought I was drowning.”

Editor’s note: The above is a fictional piece I wrote, as inspired by a recent conversation I had with a patient regarding the meaning of a diagnosis. They had felt a diagnosis made a lot of assumptions about them, and what their future looked like. They were glad to be proven wrong.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The pills aren’t working

“I’m never trying this again, it was awful. I thought you said this thing was supposed to make me feel better?”

“I’m sorry that happened to you. As we discussed, some side effects like nausea and headache are quite common when you start–“

“Start?! I took this thing for four whole days, doctor. I need a different pill. Will my depression and anxiety every go away?”

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Medication selection can be a painful time for patients. As with our diagnoses, often times there is trial and error in selecting the right medication that works for you. When it gets to the fourth, fifth, and sixth medications in some cases, it can be demoralizing, not only to the struggling person, but to their doctor. The fact is the science isn’t the most clear to the researchers in the laboratory, let alone a doctor in the office, and for that reason arriving at a suitable psychiatric treatment regimen can take some time.

Don’t despair – the medications work! Not only often, but usually. I see and help people recover every single day in my office, and it can be refreshing. However, that’s not always the case. Sometimes, struggling lasts a little longer than we would like it to. Sometimes, people lose faith in the system and look elsewhere for help. These cases can be tough; but there’s an upside! In my opinion, the majority of these treatment failures are actually preventable. So what am I talking about?

There are many reasons a particular medication regimen does not work. First and foremost, the most common reason I see, as described in the example above, is a misunderstanding of the expectations of an antidepressant or anti-anxiety medication.

Anti-depressants take time to work.

The textbooks would tell you that you need six weeks at a suitable dose to have a full effect. What does this mean? Here’s an example;

Week 1 – Sertraline (Zoloft) 25mg, oral, daily
Week 2 – Sertraline 50mg, oral, daily
Week 3 – Sertraline 75mg oral, daily
Week 4 – Sertraline 100mg, oral, daily
…
…
Week 9 – Sertraline 100mg, oral, daily
FULL EFFECT
Week 10 and onwards – Sertraline 100mg, oral, daily

The dose this person required was 100mg, and not until 100mg was achieved for six weeks do we see full effect.

What if 100mg isn’t enough? Well, a further increase may be required. The maximum recommended dose of sertraline is 200mg. You and your doctor may ultimately try a 100mg dose for a few weeks, decide it is sub therapeutic, and titrate further. Yes, this means we can be talking week 15, 16 in some case. But remember – this is for full effect. In reality, a skilled clinician and a patient can often tell after the first four weeks of a treatment whether there may be a significant benefit from a particular medication. That’s what the doctor’s are for!

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Side effects are expected and will happen.

And they aren’t permanent. Like anything, your body takes time to adjust to anti-depressants and anti-anxiety medications. In fact, the presence of side effects shows that the medications are getting to the brain and having some kind of effect! It’s important to appreciate that this is a normal part of the journey, not only with starting, but with significant dose increases.

Side effects suck and the last thing your doctor wants to do is make you feel worse – like all things in mental health, trust me, it’s an investment! Side effects like nausea and headache and anxiety tend to go away after the first half week-full week of therapy (yes, anti-depressants and anti-anxiety medications can cause transient anxiety – it’s your brain adjusting to the changes). Doctor’s are also all about safety, and don’t worry, the side effects are reversible with dose decrease.

What is considered a true treatment failure?

Part of my job when you come see me for a mental health problem is to take a detailed medication history; people have often tried multiple medications over time, and if something hasn’t worked in the past, it’s unlikely to help in the future. But what constitutes “doesn’t work?”

Not the above example. For a course of an SSRI to be considered a treatment failure, you need to have completed at least six weeks on an appropriate dose of that medication. A rough estimate of an “appropriate dose” is half the maximum dose.

***

The moral of the story? The medications work, they take time, and they can be a nuisance. Careful time, understanding, and collaboration with your physician is the best way to work through a mental health disturbance. With patience, I promise we’ll help you.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Numeracy and Symmetry

From Part 1:

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Part 2

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Numeracy and Symmetry

Have you ever seen a kid walking in the mall (sorry Gen Z), jumping from small blue tile to small blue tile?

“Avoid the lava!”

“Watch out for the monsters!”

This is a completely normal behaviour, and many children, including myself, dabble a little in the lava-tile game.

But imagine if to you, it meant a little more. Imagine that your found yourself unable to walk on white tiles, because of a crippling sense of anxiety that if you did, something bad would happen. You would probably know this doesn’t make much sense, which only adds to the madness.

It wouldn’t be easy going to the mall.

This type of behaviour, in it’s extreme form, falls under the umbrella of a symmetry/numeracy based obsession. In this type of OCD, the obsessional thought is usually something along the lines of, “if this isn’t this way, than something bad will happen.” There may or may not be a specific type of “bad”-consequence perceived. Some examples;

***

An eight year old boy goes through the home and makes sure every single TV and computer has the volume set on an even number. His father has the TV on 15 one day, and the child gets very upset and throws a temper tantrum when his father doesn’t let him change it. The next day, his mother asks him what happened. The boy responds, “if the numbers are odd numbers, I’ll die.”

A twenty four year old woman is late for work every day. She’s eventually fired from her job, and ends up in a doctor’s office while she is off of work. “I think I need help doctor.” “OK. You’re in the right place. What do you think is going on?” “Every time I look in a mirror, I can’t leave until I catch my nose at the perfect angle, perfectly symmetric. I don’t know why, I just can’t. Some days it takes up eight or more hours.”

A fifteen year old is teased at school for his quirky behaviour. He doesn’t tell his parents why, and they only know that he is being bullied. One day, when dad is picking the boy up from school, dad notices the boy jumping from dark tile to dark tile on the sidewalk. “What was that about?” dad asks when the boy gets in the car. The boy blushes and says, “can we just go?”

***

These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it, and the remainder of the, “four kinds,” series.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Doubt

From Part 1:

Doubt

Sometimes, OCD can be obvious. Other times, it is more nuanced. This is the case with obsessional doubt, one of the most common, but under-recognized, subtypes of OCD.

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So what makes doubt obsessional? To understand that, we need to remember what makes an obsession an obsession. An obsessional thought is unwanted, and comes about seemingly out of our control. This is called an intrusive thought. Obsessional thoughts occur over and over again, and won’t go away. Importantly, obsessional thoughts consume a significant amount of time, and result in a functional impact. Remember, if it’s not causing you problems, it’s not a disease!

Taken all together, obsessional doubt occurs when someone repeatedly doubts they have remembered something. Obsessional doubt is also often coupled with compulsions, to relieve the anxiety associated with the doubt. Compulsions in doubt-based OCD tend to complement the doubt, and therefore the compulsions tend to be reassurance-based. Now I know this sounds underwhelming, but trust me, it can be debilitating. The following are some examples of people I have met (with their stories altered, of course) with obsessional doubt.

***

Richard was a 27 year old man living in Toronto. He was getting ready to go out on a date one evening and found himself very anxious. He was getting ready to head out, and had the sense he had forgotten to turn off the stove. He checked the stove and realized it was off. He did this two hundred and twenty two times, for good luck. Before he knew it, he had missed his date.

Dema was a 29 year old female admitted to an inpatient psychiatric ward for severe OCD. During rounds one morning, the word “complete,” was mentioned. Dema fixated on the word and became unable to answer any other questions. She repeatedly asked I repeat the word, “complete,” so that she could ensure she had heard me pronounce it correctly.

Mohammad was a 17 year old young man. He presented to my office one day complaining of difficulties studying. He found himself unable to move beyond the first few pages of his notes, as he felt he had to perfectly memorize everything if he were to succeed. He reflected on a similar incident a year prior, where he developed a fear he would forget his memories with a family member. He would repeatedly look at pictures of the memories he had, to ensure they were real memories. This would take hours a day.

***

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it, and the remainder of the, “four kinds,” series.

Dr. Travis Barron is a resident physician in Toronto, Canada.

What makes something addictive? Are ADHD drugs addictive? What about sugar?

“I’m going to head to Tim Horton’s for a coffee.”

“Sure, no problem.”

You walk to Tim’s and you begin to realize you’re hungry. It’s 11:45 AM and lunch is only fifteen minutes away. You’ve brought your lunch to work today as well so you should be good.

Just a coffee, you say to yourself.

“Hi, welcome to Tim Horton’s! May I take your order?”

“Hi, yes I’ll have a large coffee with milk, a vanilla dip doughnut, and a pack of those doughnut sticks you have.”

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What is it that makes fried, sugared dough addictive? Or deep-fried potatoes? Or sour patch kids? Or anything, for that matter?

In our brains, there exists something called the nucleus accumbens. This part of the brain is known as the reward centre. What does this mean? Every time you do something that feels good, this centre “pings,” and makes you feel good. Why does this part of the brain exist? Well, it’s actually essential to our survival! Things like eating, drinking water, and having sex, are vital biological functions for our species. Without them, we would not survive. Very few of us, however, are thinking about, “I need to survive and propagate my genes,” as we eat and have sex. No, most of us do these things because they feel good. That’s where the nucleus accumbens comes in. It pings and rewards us with a shot of dopamine, the brain’s “happiness chemical,” when you do something that’s good, biologically. It’s a built-in incentive system to ensure we are doing, and feel good about doing, those functions essential for species survival.

This system, however, is imperfect, and it is prone to being hijacked. The nucleus accumbens is where many substances of abuse act, including cocaine, crystal meth, and any number of drugs. This is why many people with drug addiction become very skinny, and can waste away. The drugs hijack the system, and reward you more than food. Drugs steadily train the brain that the best rewards come from the drugs, and not food or water or sex. A great example of how strong the craving for drugs can be is a study that examined rats, who had electrodes placed in their brain at the site of the nucleus accumbens. The rats were given the ability to hit a button in their cages, which would activate the electrode, stimulate the nucleus, and cause a reward. The rats eventually choose to die while hitting the button, and totally neglect vital functions such as eating and drinking.

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But what is it that makes a substance addictive? Sugary foods can be addictive and cause cravings, for example, while carrots almost certainly do not. Cocaine and crystal meth are extraordinarily addictive drugs, while ritaline and vyvanse, medications for ADHD which act similarly, are not. What is responsible for this difference?

We think we know!

The nucleus accumbens appears to be sensitive the the size of a potential reward. Finding a penny on the ground, for example, makes us feel a lot less better than finding a one hundred dollar bill. Biologically, this discrimination has allowed the brain to prioritize eating high caloric foods, over low caloric foods, although both may taste good. (This function would have evolved prior to the food-availability we experience today in the Western world – the drive to eat higher calorie foods is a clear disadvantage to many of us nowadays.) The same principle applies today, which is why sugary, fatty foods are so addictive. The sugar and the fat, the nutrients essential to life which are activating the nucleus accumbens in the first place, are higher in doughnuts than they are broccoli, and therefore we crave doughnuts. This is actually a great example of how the advantage of a particular behaviour, and whether it is a mental illness, depends entirely on context. A drive to eat high caloric foods would have previously been evolutionary essential – now it causes heart disease.

So what’s the deal with drugs?

Well, the same principle applies. The strength of a stimulus is directly proportional to how addictive the substance is. So what affects the strength? Food that are higher in sugar and fat cause a higher level of nucleus stimulation, therefore we crave food that are slowly killing us. This is also true for drugs of abuse; crystal meth is several orders of magnitude stronger than cocaine, and meth is a hell of a lot more addictive. But there’s more! The speed of the stimulus also matters!

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When a sugar/fat/drug reward is given to us suddenly, the nucleus reacts more strongly to it, and we get a higher reward. This also reinforces the strength of an addiction. This has implications for food, which is why a banana and a candy with the exact same amount of sugar make us feel differently. The candy which instantly digests and gives us a sudden jolt of sugar, is highly addictive. The banana, which takes time to digest and releases the same amount of sugar, just over time, is not addictive!

This principle also applies for drugs, and gets to the root of why ADHD medications are not addictive – usually. The medications used for ADHD tend to digest very slowly, and although they act on the brain in the exact same way as cocaine and crystal meth, are not addictive. This is because that, relative to drugs of abuse, the medications are released very slowly.

The exception can be if you use ADHD medications in ways they are not meant to be – such as snorting or injecting (neither of these are safe methods to use). By snorting/injecting, instead of digesting you get around the bodies need to digest, and you can get a sudden jolt of dopamine, which would potentially contribute to an addiction.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Contamination

Yesterday, in the language matters segment, we discussed what Obsessive-Compulsive Disorder is not. Why is this important? I find that a large driver of stigma against mental illness, is the emergence of medical and psychiatric language in common speech. When this language is used carelessly, a false image of a world where everyone has a mental illness can develop, and people become jaded to the topic. By discussing what mental illness is not, I’m hoping to dispel at least some of the myths and stigma surrounding the field.

OCD is real, and it’s debilitating – but it’s not all doom and gloom! OCD happens to be treatable, and the first step towards treatment is diagnosis. OCD happens to be one of the most underdiagnosed and missed psychiatric illnesses, so getting the diagnosis can be harder than you’d think.

Before we begin, I’ll reiterate a point from yesterday’s discussion – for it to be OCD, or any mental illness, there has to be a functional impact. In other words, if it doesn’t cause you a significant problem, it isn’t an illness! I’m not in the business of policing thoughts and behavior.

The four kinds of OCD

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Contamination

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Perhaps the most widely known manifestation of OCD is contamination fears. People with contamination-based OCD will have obsessional thoughts of contamination, meaning they are extremely preoccupied with the idea that germs, disease, or some contaminant substance, will spread through some form of contact. These fears can go both ways, meaning the individual may have fears they will become contaminated, as well as fears they will contaminate others. These thoughts can consume hours a day and make thinking about anything else near impossible. Importantly, these fears typically do not make sense to the person experiencing them. I person with an obsessional thought that they will develop cancer from touching doorknobs knows this doesn’t make a whole lot of sense. But alas, their brain obsesses over it. This kind of thought is called an egodystonic thought, meaning that the thought or belief is different from how you actually feel.

Contamination obsessions may manifest with compulsions. An important point here is that for a diagnosis of OCD, you do not need both obsessions or compulsions, just one or the other (both tend to be present but one or the other may go under-recognized). Examples of contamination compulsions may be wearing many layers of clothing and gloves, despite it being a warm day. People may have to wash their hands thirty times or more after touching food, just until it feels right.

Contamination-based OCD is not being a neat freak, though being too much of a neat freak can be a mental illness. What am I talking about? To be honest, it’s a difficult topic to relay in words, but essentially, it gets down to what is driving the neatness. If someone has true obsessions (best elicited by a physician in their office), they will probably be having a thought more akin to, “I’m going to get AIDS from these scattered papers,” than someone who is just very neat, who would be having a thought like, “I need the room to be clean otherwise I won’t be calm.” The very neat person is displaying cognitive rigidity, which can looks like OCD, but is distinctly different. Rigidity is more alike what we would call a personality trait.

Editor’s Note: Stay tuned for the remainder of, “The four kinds of OCD.”

Dr. Travis Barron is a resident physician in Toronto, Canada.

Language matters – What OCD isn’t

“The chicken smells delicious.”

“I know, I marinated it 24 hours.”

“That’s amazing. I think they’re ready to be flipped.”

“OK, let me do it. The lines need to be perfectly crisscrossed,” she laughed, “it’s my OCD.”

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Obsessive-Compulsive Disorder is a mental illness characterized by obsessions, a specific type of thought that occurs over and over, and compulsions, repeated rituals or activities that typically relieve anxiety associated with obsessions. Now, before you realize that you definitely have thoughts that won’t go away, and self-diagnose yourself with OCD, you probably don’t. In fact, only about two and a half percent of the population (2.5%, or 5/200) in North America will experience true OCD at any point in their lifetime.

So what’s going on? Before we talk about what OCD is, lets talk about what OCD isn’t.

OCD is not rumination

“Ugh, I can’t believe he said that to me!”

“I know, what a dick.”

“I’ve been thinking about it all day… all I can see is his face…”

We’ve all been in an argument. A heated one. Probably with a relative. If you’re unlucky, maybe even a mother-in-law. These things are upsetting, and they’re part of life. But they also suck. It can be difficult, and is certainly common, to find yourself ruminating about a fight, a conflict, or other sources of stress like a work problem or a death in the family.

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OCD is not rigidity

“Make sure you have the papers on her desk laid neatly.”

“What do you mean?”

“She’ll freak out, she likes everything neat, she’s so OCD.”

A feature of true OCD is how unmovable many of these behaviours seem to be at the surface. Someone with severe, untreated OCD may find themselves incapable of leaving the house without checking the stove one hundred and twenty nine times. They may find the alternative, leaving without doing this, intolerable. This is an example of a rigid behaviour.

There are other examples of rigidity, as described in the example above with the desk and the papers. If people have high standards, or are very anxious, they can often have similar intolerance towards certain aspects of their life being altered. For example, if you are a perfectionist, you may have intolerance towards a messy desk, and therefore be very rigid when it comes to desk tidiness. If you are very anxious, you may have to leave for work twenty minutes earlier than you have to, despite getting there thirty minutes early, every morning. You may find leaving later intolerable. This might even cause conflict with more laid-back loved ones.

OCD is kind of getting a song stuck in your head – forever.

If you’re lucky, it’s a song you like. All the same, it can be annoying to get a song stuck in your head. It’s also quite common.

Current psychiatric opinion supports that this phenomenon is similar, or maybe even the same, to many true obsessive thoughts. The main difference between getting a song stuck in your head and OCD? Impact and duration.

The single most important feature of OCD is that it causes a functional impairment. As a physician, I’m not in the business of judging you, your thoughts or your behaviours. When a behaviour begins to cause functional impact, and impair your quality of life, it becomes a disorder. True OCD also taks up a significant amount of time, which is in part how it causes a functional impact. Yes, “Hey Ya!” by Outkast is annoying, but getting it stuck in your head on July 1 is not the end of the world. True OCD, can be debilitating.

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So what is OCD?

A twenty three year old female law student. She’s spends six hours, every evening, after a long day at the university, studying. She does this for weeks and finally writes her exams. She fails miserably, and it’s devastating. She comes into your office complaining of depression and you start to talk about the exams. “I couldn’t study everything, I never had time.” “How is that possible, you studied so much!” “I couldn’t get past the first chapter. Every time I read a paragraph, I freaked out and was worried I forgot it, so I had to repeat it over and over and over until I had it perfectly memorized.”

A eight year old boy is seen standing in the corner of the house before he leaves for school. His mom notices he’s muttering under his breath for a few minutes and finally he leaves for school. That night, before bed, she asks him about the muttering. He finally opens up. “Every time before I leave for school I have to say, ‘Mommy loves me,’ one hundred times before I go or you’ll die.”

A thirty year old man lives at home with his parents. He’s brought in to the psychiatric emergency by his father one evening. His father discloses that his son has been unwell and has been unable to wash or clean himself. He has an intense fear that his left index finger will cause AIDS, and has been unable to touch anything, or anyone with it. Including himself. He’s required his family to bathe him.

These are all examples of real people I have met – with their stories heavily altered, though the principles remain – with true OCD, functional impact is real. To be fair, these cases were pretty straight forward, and not everyone is so lucky OCD can go undiagnosed and missed for decades, resulting in real people having real suffering for unnecessary reasons.

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What about the example above?

Well, it depends. This person probably does not have OCD. When I hear a comment like this, I immediately suspect “OCD” is being substituted for “rigid behaviours,” due to the behaviour being fairly unusual for typical OCD. There are forms of OCD which focus on symmetry (stay tuned!), though I suspect this is not the case here, because the person is laughing about it. Remember, it’s only OCD if it’s significantly inhibiting your function!

Editor’s Note: Stay tuned for What to do about OCD, and The four kinds of OCD.

Dr. Travis Barron is a resident physician in Toronto, Canada.