Wednesday, February 08, 2006

Nia's med helps her psychosis...but causes obesity.

Imagine being forced to make this terrible choice. Alexander Linklater, in the Prospect:
...one morning, Nia was transformed. She left her bedroom, came to meals, had normal conversations with staff. Her face filled out with ordinary human expressions. A day later she was even laughing. A young woman, an intelligent teenager, had reappeared; the psychosis seemed to have left her. To see a patient respond to a drug in this way made the young psychiatrist feel like a real doctor. Almost ashamed of himself for feeling this, he noticed that he felt grateful towards Nia—for getting better.

What the staff didn’t pick up immediately was Nia’s hunger. The nurses were so encouraged by her regular appearance in the dining room that they didn’t question the heap of beans and potatoes. But soon it became apparent that insanity had been replaced by appetite. Within three weeks she put on three stone. Now, for the first time, Nia’s features were being corrupted. She started to take on the shape of many of the chronically mentally ill. Her jawline collapsed below puffed-out cheeks. Her stomach sagged above her jeans. Even the consultant found the contrast alarming...
An alternate med is tried, with poor results.
The young psychiatrist’s early optimism collapsed under the grinding reality of Nia’s dilemma. The first drug had worked. But the change in her appearance seemed intolerable—and potentially devastating for the self-esteem of a 17-year-old girl. The second drug hadn’t made her fat, but nor had it treated her illness. The consultant felt there was no option but to put her back on the Olanzapine. Again, it worked. The terrors of persecution vanished, the voices quietened down. Even her parents said that this was the old Nia. They cried over her.

The desire to experiment further with her medication left the consultant and the young psychiatrist. It was likely that the weight gain associated with Olanzapine would be very difficult to treat and that Nia would be fat, if not obese. But more disconcerting to the young psychiatrist was Nia’s apparent indifference to her predicament. While those around her worried about the beauty she had lost, she seemed unconcerned. Was she really as well as her family suggested? Had she really rejoined the image-conscious world of her peers?
Thanks to Mindhacks for pointing to this excellent article.

18 Comments:

Anonymous IndianCowboy said...

Perhaps she was unconcerned with her weight gain because of the 'robot effect'. I'm not even sure if that's a proper term or not, but many drugs work by interrupting or changing the relationship between presynaptic and postsynaptic neurons. In essence you lose the A fires then B fires relationship of the brain.

While she probably understood she was becoming obese and less aesthetically pleasing, the conscious understanding simply may not have been able to traverse the synaptic gap to affective pathways due to the medication.

grossly over-simplified of course, but just thought I'd throw it out there.

5:06 AM  
Blogger Fallen Angels said...

Anti-psychotics made me fat too...and I developed diabetes. The weight I figured I could try very hard to counter-act...the diabetes, another story. I do think the atypical anti-psychotics do more than increase your appetite though...I really wasn;'t eating very much more than I had before, but I gained 30 lbs in 4 months. Fortunately, I don't need them anymore...and the weight is *very slowly* coming off.

Sera

P.S. Wanted to add...I had no "robet effect", I felt like I was myself again. I think the "robot effect" is from being on several different meds in high doses ie: over medicated. When used properly, that doesn't happen.

5:49 AM  
Blogger Paris said...

I strongly disagree about the excellence of that article. While medication-related weight gain (and the diabetes that so often follows) is a serious issue, the authors' preoccupation with wanting to keep their patient attractive according to their standards instead of helping her be well according to her standards was appalling. They seem to be very concerned that no longer being the prettiest girl in the room was an equally damaging experience as schizophrenic psychosis. The fact that she didn't mind might not be because of her synapsis mis-firing, but could it possibly be that her loving parents raised her to believe that she was more than her looks?

There is a good article to be written about this issue, but it sure isn't in Prospect this month.

12:37 PM  
Blogger KelliAmanda said...

Speaking as someone who suffers from a less devastating but still serious mental illness, I can't see how this is even a question. It matters not what your body looks like, or even if it functions at all, if your mind isn't functioning correctly. I can see her docs trying another medication to see if they could achieve benefit without the drawback of extreme weight gain, but to question whether Nia was better off having control of her mind again versus being thin? Seriously.

1:34 PM  
Anonymous IndianCowboy said...

as a future health professional I'd be very concerned about a 3 stone weight gain over a short period. 3 stone=42 lbs in 3 weeks. That's 2 pounds per day. 2 pounds.

Like you I agree that mental health is far more important than physical health. But at the same time, what good is a mind when the body around it detiorates.

But even from a mental perspective, yes this is cause for concern. Most of our behaviors are adaptive at some level, it's only when they get out of control that they create problems (sadness and fear are good responses to certain things; depression and anxiety are not).

I would be exceedingly concerned if a patient in my charge puts on 42 pounds and is completely oblivious to it. This means at some level they are not completely connecting with the external environment.

I agree with you that their language focuses a bit too much on beauty and not enough on either a. health or b. acknowledgement of the physical world.

I'm questioning whether she really did have control over her mind again.

2:30 PM  
Blogger Joel said...

I'm a little leary about contributing to this thread because I have been assaulted by "fat rights" antagonists who never seem to read that I am concerned about people who are underweight as well as overweight.

Once I said that being fat is not healthy. You should have seen the replies! One woman even threatened to gorge herself just to get fatter because of what I said! Others called me a traitor for wanting to lose the weight I'd put on because of my meds.

Hey, my blood sugar is up and my back aches because of the paunch I have.

The tragedy of the whole movement is that it encourages self-abusive behavior. I think only a minority of overweight people are of this stripe, however. (You tell me if it is pathological.)

More of them suffer from a sociological epidemic: people who were raised on farms, now find themselves working other jobs ~but they are still eating the same fatty foods they needed to get them through the hard work of the day~. Also there's the corn syrup that has seeped into many foods. "It's natural so it's good for you" doesn't work here. (Anyone remember that amarita mushrooms taste great but kill you?)

I know a few obese people who want to lose weight. When the FR people hear them, they get all over them, tell them to change their feelings. It's the same insensitivity I hear in my illness -- from both outsiders and insiders who refuse to self-medicate.

No thank you. I don't want to stay sick.

4:00 PM  
Blogger Joel said...

One more thing to remember: far more people die of obesity than die of anorexia. We need to set our priorities straight.

4:01 PM  
Blogger Joel said...

Last thought: both the fat rights advocates and anorexics are into it for the "beauty". So who is to say that they are free of image consciousness.

What matters is your health.

4:03 PM  
Blogger shrinkette said...

My own perspective: it is horrifying when a patient takes a medication and gains 42 lbs in 3 weeks. The angry commenters above should ask themselves if they would be willing to put on 42 pounds in less than a month! The rest of the body can't adapt that quickly. Soon the patient's knees and hips are giving out, basic activities become much more difficult, and the stage is set for more devastating health problems. To me, it's ominous that the patient isn't disturbed by the weight gain; it means she's probably going to continue to gain. Diabetes, heart attacks, liver problems, and sleep apnea come next. May future antipsychotics be free of such side effects.

11:23 PM  
Blogger Joel said...

Even though I am one of the "angry ones above" I'm with you, shrinkette. Let's not toy around with theories about "image" here: is it healthy to put on 42 pounds? Studies say no.

11:34 PM  
Blogger TP said...

I think the article gives the impression that the beauty/looks of the patient are considered to be more valuable than her health. Even reference to the weight gain is not framed in terms of the adverse affects this will have on her body, ie diabetes as you suggest, but rather that her beauty is under threat and this is more important than her health.

2:16 AM  
Blogger Fallen Angels said...

I hope I didn't come across as angry. I *am* angry about the diabetes though. That is truly an unreasonable risk. My weight gain was slower and far less dramatic, but I didn't intend to make light of it. The fact is that adding large weight gain to depression with (in my case) mild psychosis, fuels the depression which in turn fuels the psychosis and weight gain. Not a cycle I wish to repeat. I count myself very fortunate that a)my pdoc was watching things closely and b)my psychosis was transitory. As for the patient not being concerned...could it really be that she isn't willing to talk about the concern? This is one of the reasons therapy as a teenager didn't help me, I wouldn't talk, not about anything important anyway. There was a lot more to it than that of course, but that calls for a post on my own blog.

Sera

4:43 AM  
Blogger shrinkette said...

TP, you are right. The theme of the article is the patient's physical beauty, and the med's effects on her appearance.
This article does describe the world I live in. From the first sentence onward, it acknowledges stigma and prejudices regarding appearances (and the mentally ill). A known adverse effect of a med was poorly managed, and the effects on the patient's life can be devastating - emotionally, physically, and socially. If Nia feels hurt by this side effect, she may stop taking the med, with catastrophic consequences. Every single day, in my practice, we are struggling with this dilemma - "trading one stigma for another."

8:01 AM  
Blogger Fallen Angels said...

I've been thinking about this post for a few hours today and something has stuck with me. This patient was in a hospital setting...how exactly did she get access to 7000 (!) calories per day, for 3 weeks? It takes 3500 calories to gain 1 lb...and she gained 2 lbs a day?

Sera

11:16 AM  
Blogger Joel said...

I agree, TP. It's the health issue that matters.

Let's not forget that anorexics often come under attack, too. They are often used as the excuse for not paying attention to one's weight for health reasons.

That's unfair and unrealistic.

Damn, I'm yapping a lot on this topic.

1:28 PM  
Blogger Joel said...

OK, instead of yapping more here, I posted something to my own blog:

http://paxnortona.notfrisco2.com/?p=3774

2:35 PM  
Anonymous Anonymous said...

I think Sera makes an excellent point about the hospital's responsibility in this. I'm amazed at the amount of junk food served in a psych hospital. I saw people munching through out the day on all kinds of junk: ice cream bars, ding dongs, popcorn, I couldn't believe it. There was no limit to it at all. People gorged themselves. I asked why they didn't have more healthy alternatives, and they told me it was a cost issue. Apparently a ding dong is cheaper than an apple.

4:32 PM  
Blogger katy said...

I was diagnosed with major depression at age 20, which looks like it was a misdiagnosis of bipolar type II, because I was later diagnosed with that at age 32.

When I was first put on amitriptyline (Elavil) to treat depression in the late 90s, it didn't even dawn on me at first just how much it was affecting my appetite. I was having the strongest cravings of my whole life. I've never been pregnant, but I swear they must have been comparable cravings. It was like, I need chocolate ice cream. NOW! or I'm going to DIE! I started craving sweets like mad and certain types of foods. I got up to 300lbs in 1.5-2 yrs? Thankfully I'm 5'8", but still. The Elavil was chosen not only because of the depression, but because I have bad migraines. The Elavil worked well to both treat the depression and to help prevent many of the migraines. It gave me tachycardia though which was unpleasant, and had me huffing and puffing and wheezing after simple activities such as making the bed. But I wouldn't hear of going off of it. I hated being fat. I thought I was fat before having gained the weight, but this medication had allowed me to go back to school and to work, and that was my main focus at the time.

Eventually though, I was at the highest dose I could go and had to switch meds. After going off it, the weight slowly started to come off and my appetite went back to normal. My migraines however were back full force. I was sent to a neurologist who put me on Topamax about 4 yrs ago I guess. That caused me to start losing weight very quickly and easily. I was literally forgetting to eat for days at a time and had to make a point to eat every day. This didn't help--I kept losing and losing. I went from 300lb to 125lb in less than 1.5yrs in the most unhealthy way possible (and it showed). Once I hit 125lbs I had to go off the Topamax because I could not stop losing weight. I looked anorexic and sickly.

Not long after that I was put on Olanzapine, which promptly made me gain about 30-40lbs. I asked my pdoc to take me off of it because I just didn't have the energy to go through any more of that, and she agreed. Since then I've gained 10-20lbs here and there on various medications. I'm not terribly happy with my weight but it's nowehere near that high I reached many years ago.

Currently I'm on another tricyclic at a low dose--nortriptyline this time. Didn't take long before I started having monster cravings out of nowhere. I discussed my concern about this with my pdoc, and she suggested adding Topamax to the mix. So far, that has worked well and has kept my appetite at a normal level. Have not lost a lot though but have a fighting chance now! The mood stabilizer I've just started is supposed to be weight-neutral. There really do need to be more weight-neutral psych meds. (antipsychotics especially).

Imagine being forced to make this terrible choice.

I guess the bottom line though is that when your life has become a black hole, you just don't care anymore about something as trivial as your dress size. You are just thankful that you are back in control of your thoughts and emotions.

Sometimes it also feels like a responsibility. Like you have a responsibility to yourself to try. To take that period of time that you are best functioning, and make the most of it that you can. Because it can be ripped away at any moment, and the next time there might not be the 'right' medication. So you go for it, and you decide not to regret it.

11:08 AM  

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