Ambien

Hamlet by William Shakespeare

“To sleep, perchance to dream…,” Hamlet wondered  in his famous To Be or Not to Be soliloquy.

If he lived in modern times, Hamlet would probably pop an ambien and call it a night if he desired to sleep. This popular sleeping aid is gaining quite a bit of attention in the mainstream celebrity world- it’s use amongst celebs is almost as ubiquitous as their active Twitter accounts.

Jay-Z along with Alicia Keys raps about it in Empire State of Mind in reference to partying in NYC- “the city never sleeps, better slip you an ambien”; John Mayer tweets about his personal use and sings about it in Heartbreak Warfare; Jimmy Fallon jokes about it on his late-night talk show; and Tiger Woods probably takes it on nights before playing in the majors. Why not? He takes it for crazy ambien sex with one of his many former mistresses. You probably remember that infamous night he crashed his SUV which led to the unraveling of his secret lifestyle- yep, he was driving under the influence of ambien.

Ambien is a sedative or hypnotic prescription medication that knocks you out like a left hook from Manny Pacquiao.  It was first approved by the FDA in 1992 for the short-term treatment of insomnia. But it didn’t gain widespread use until the generics (zolpidem) came out in 2007. Although not approved for treatment of chronic insomnia, it is not uncommon for doctors to prescribe it for long-term use.

Common side-effects of ambien are drowsiness, impaired motor function, and a drugged feeling.  But more interestingly, side-effects may also include hallucinations, amnesia, euphoria, increased appetite and libido, and extroversion in social settings. And these effects may perhaps be the reason behind  the trend in ambien misuse for recreational purposes.  There are also many documented reports of ambien-related bizarre behavior, ie.  people cleaning out their fridge from sleep-eating politicians involuntarily joining the DUI club from sleep-driving, and wives engaging in unusual sexual behavior of which they have no recollection.

Before the days, or nights, of ambien, the common sleeping pills were the benzos (xanax, valium, ativan) and the barbiturates. These medications are far more dangerous than ambien. They are addictive and lethal in overdoses.  Guess which prescription meds were found in Marilyn Monroe, Jimi Hendrix, and Heath Ledger when they prematurely died?

Ambien is potentially lethal in an overdose since it’s a sedative, especially if combined with alcohol. The cause of death is cessation of breathing. Fortunately, there aren’t too many documented cases, if any,  of death primarily by ambien overdose. In my own clinical experience, I haven’t seen any yet.

Hamlet was contemplating suicide in his soliloquy- “for in that sleep of death what dreams may come.”  If he were to take a large dose of ambien, he would be at some risk of a fatal overdose. But he’s more likely to hallucinate and engage in an ongoing conversation with the skull until he falls soundly asleep, and not remember a thing the following morning.

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Darkness


Shutter Island (2010)

Shutter Island, the recently released psychological thriller, fortified by the Scorsese-DiCaprio combo, brings to light the dark history of psychiatry (I will not reveal any spoilers, so no need to fret if you plan on seeing this movie). I definitely recommend this film- it’s gripping, eerie and suspenseful, and not gratuitously scary. I watched the movie with several of my psychiatry co-residents, and most of us were quite impressed.

The story is set in the 1950’s, which happens to be a revolutionary period in psychiatry. Two key medications were discovered around that time to treat severe mental illnesses once thought to be unmanageable. Lithium, a mood stabilizer, was used in 1948 to successfully treat bipolar disorder and Thorazine was found to be the first effective antipsychotic medication to treat schizophrenia in 1952.

The use of medications to treat mental illnesses, or psychopharmacology, was instrumental to paving the way to deinstitutionalizing psychiatric patients- that is, transitioning patients from living permanently in locked institutions to living functionally in the community. Prior to the practice of psychopharmacology, many of the therapeutic methods of psychiatric treatment in the early part of the twentieth century were not only experimental, but harsh, cruel, and extreme.  The one that undoubtedly ranks at the top is the lobotomy.

Lobotomy is a surgical procedure performed to damage the frontal lobe of the brain, which sits directly behind the forehead. This region of the brain is essentially what differentiates us from other animals. It functions to help us make complex decisions, express our unique personalities, and engage in acceptable social behaviors. Without a functional frontal lobe, we would be no better than a donkey (and I’m not referring to the one in Shrek– that donkey has personality, albeit inappropriate). The most infamous type of lobotomy was the transorbital lobotomy, developed by Dr. Walter Freeman in 1946.  He made it a 10 minute “office procedure” using mainly an ice pick and a hammer, approaching the brain through the roof of the eye socket (you’ve got to click on the link to see for yourself).

The premise behind the lobotomy was that psychiatric illnesses were a result of malfunctioned nerves connecting the frontal lobe to other brain regions. In turn, severing the faulty nerves will allow for new healthy ones to regenerate, thus relieving the psychiatric symptoms.  This hypothesis proved costly to be invalid and wrong, at the expense of many patients.  Sadly, despite being a controversial procedure even since its introduction in 1936, it was commonly used and widely accepted by the medical profession in the 40’s and 50’s. By 1951, almost 20,000 lobotomies were performed altogether in the US.

Fortunately, with the advent of the antipsychotic medications in the 1950’s, lobotomy died off almost as abruptly as it rose up (although psychosurgery is still currently indicated and effective for severe OCD). The beginning era of psychopharm helped move psychiatry into its current and brighter age.

As if in the darkness of the time period in psychiatry’s history during which Shutter Island takes place, DiCaprio uses matches to light his way on the creepy island.  The film’s storyline is just as disturbing and dark as its historical and scenic backdrop, if not more.

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Borderline Personality

Ryder and Jolie in Girl Interrupted (1999)

Hollywood is rich in mainstream movies with characters with Borderline Personality Disorder (BPD)- Winona Ryder in Girl Interrupted, Penelope Cruz in Vicky Cristina Barcelona, and Uma Thurman in My Super Ex-Girlfriend to name a few.  Even celebrities themselves have been associated with the disorder- Angelina Jolie, Megan Fox, Lyndsey Lohan, Amy Winehouse, and Christina Ricci to name several. I wouldn’t be surprised if the list of celebrity borderlines ran longer than that of their fictional counterparts.

So what is Borderline Personality Disorder?

Borderline originally earned its name in psychiatry from being thought to be on the “border” between psychosis and neurosis. In lay terms- almost but not entirely crazy (now refer to the aforementioned celebs to see if you get an aha reaction). The disorder is characterized by pervasive instability in mood, self-image, behavior, and interpersonal relationships. This typically means people suffering from BPD have chronic feelings of emptiness and low self-esteem, suicidal thoughts and gestures (cutting), anger issues, and even bisexual tendencies. Marsha Linehan, an expert on BPD, describes borderlines as “the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.”

Relationships tend to be very intense and unstable. I don’t watch much reality TV, but I’d bet network executives cast borderlines primarily to inject drama into their shows to boost ratings. Borderlines are capable of switching from deep affection and adoration to hostile rage and contempt quicker than you can say Britney Spears.  Breakups are especially difficult. Due to fear of abandonment, borderlines may threaten to hurt themselves if their partner wants to move on or date others.

The cause of BPD is unknown, but almost certainly there is a history of childhood trauma. This includes parental abandonment and neglect, poor communication and disruption in the family, and physical and sexual abuse. Clinically, BPD is often misdiagnosed as Bipolar Affective Disorder (BAD) because of the overlap in mood instability symptoms. The main difference is that borderline symptoms are triggered by interpersonal difficulties while bipolar symptoms are autonomous and independent of relationship stressors. Medications are far less effective for treatment of BPD than BAD.

The treatment of choice for BPD is Dialectical Behavioral Therapy (DBT). It’s a form of talk therapy that helps borderlines learn to manage intense emotions to minimize self-destructive, maladaptive behaviors and thus function better in relationships. The goal is to promote acceptance, yet encourage change, which is inherently contradictory and confusing.

For simplicity’s sake, let me use Bruce Banner and his emotional self-destructive alter ego, the Hulk, as a case in point to illustrate the theory behind DBT. In order for Bruce to have a functional relationship with any woman, he cannot transform into the Hulk. But the Hulk is an inseparable part of Bruce, which he can never truly get rid of.  Similarly, borderlines can never get rid of their childhood trauma. DBT will help Bruce learn to accept that he is the Hulk, while concurrently teaching him to harness his emotions so he will not become the Hulk.

BPD can be quite a severe and debilitating disorder. Relationships are particularly intense and unstable. In the entertainment world where steady relationships are already few and far between, an aging celebrity borderline probably stands a better chance of sustaining a career without needing cosmetic touch-up surgery than maintaining a lasting marriage.

Good luck Brangelina.

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Shocking!

One Flew Over The Cuckoo’s Nest (1975)

I recently watched One Flew Over The Cuckoo’s Nest, a classic drama film from the 70s starring Jack Nicholson who plays a patient hospitalized at a locked psychiatric facility. The film is an adaptation of the novel written by Ken Kesey. Interestingly, Kesey gained inspiration for the story from talking to psychiatric patients while high on LSD at the Menlo Park Veterans Hospital in the early 1960s. Coincidentally, I have also worked with patients at the MPVA, sans LSD however. He scored his LSD free of charge from the government, when he volunteered as a Stanford student to be a subject in the covert CIA-financed study of the effects of psychoactive drugs on human behavior.

I don’t usually rent old movies, but I wanted to watch this film because of the infamous “electroshock” therapy scene. Euphemistically referred to as electroconvulsive therapy (ECT) in the medical profession, most people seem to always react with horror and repulse whenever ECT is mentioned. The reason, not surprisingly, is the atrocious image instilled in people’s minds from the movie. After viewing the clip myself of Jack being forcefully “shocked”, I can definitely understand why people are so horrified of ECT  (Check it out for yourself).

I don’t know for sure if ECT was administered in that inhumane fashion back in the spooky days of the asylums, but Jack was definitely wronged¹. Contrary to Jack’s experience, modern day ECT requires informed consent and is done in a controlled environment under general anesthesia and with a muscle relaxant. He shouldn’t have been conscious, convulsing, and writhing in pain. There was no need for the forced insertion of the mouthpiece or the multiple guys pinning him down. More importantly, he shouldn’t have received ECT in the first place- he was not depressed, manic, or psychotic. It was solely given as a form of punishment for his unruly behavior.

ECT is a very effective treatment for severe depression, especially for patients who have not responded to multiple trials of antidepressant medications. It should be legitimately considered by patients for antidepressant treatment, and not reflexively rejected because of the unfavorable depiction from the film.

Hollywood definitely likes to portray ECT as something scary and disturbing, as also featured in Requiem for a Dream.  The entertainment industry will probably never show ECT in its true form, because that would be just too boring and not shocking enough.

Addendum

1. In response to questions about the history of ECT- The procedure was invented in the 1930s. Anesthesia, and later muscular blockade, was not introduced until the 1940s, and took more than a decade to gain widespread use. Thus, many patients suffered from broken bones and ruptured tendons.  Informed consent was also not strictly practiced, if at all, during those days. I guess Jack did receive the standard ECT of the early era.

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