Ever noticed how scientific opinions swing from one extreme to the other?

Take the importance of mothers in the development of children. In the early days of psychiatry almost every mental illness, from depression to schizophrenia to autism was blamed on bad mothering. Then in the 1960’s and 70’s the discovery of medications that helped these illnesses allowed psychiatry to reframe them as biological conditions, no different from cancer or heart disease. Parents were fully absolved for the mental illnesses of their children, except to the degree that they passed along bad genes that caused chemical imbalances in the brain.

Myths inevitably survive long after they’ve been scientifically disproven. Such is the case with the fantasy that mental illnesses can be written off solely to genes and chemicals. Over the last decade a string of scientific discoveries has shown that the biology driving mental illness has at least as much to do with the environment as with chemicals or genetic inheritance. And it increasingly appears that the single most powerful environmental factor is the love - or its lack - that children receive from their parents. So in a very real way we parents are back on the hook for the lifelong emotional well-being of our kids.

I say this based on a thousand studies. But to make the point here, let me describe a recent study in the Proceedings of the National Academy of Sciences that more definitively than any before it shows how parental care literally changes not just kids’ hearts and minds, but their brains as well.

Here’s how the study was done. Researchers at Washington University in St. Louis recruited 92 children between the ages of 3 and 6. Rather than asking parents about how they treated their children, the researchers brought the kids and parents into a lab and videotaped them as the parents, almost always mothers, tried to help their children cope with a mildly stressful task that was designed to approximate the stress of daily parenting.

Ratings of parental ability to nurture their children were done by study personnel who watched the videos while knowing nothing about either children or parents. Several years later, on average, the children had the size of a brain area called the hippocampus measured using magnetic resonance imaging (MRI). After taking into account a whole range of factors that can affect hippocampal size, the researchers found that children with especially nurturing, caring mothers, based on their behavior during the laboratory stressor, had significantly larger hippocampi (plural of hippocampus - you’ve got one on each side of the brain) than kids with mothers who were average or poor nurturers.

Why is this finding important? Because more than any place else in the brain, when it comes to the hippocampus, size matters. Other things being equal, having small hippocampi increases your risk for all sorts of troubles, from depression and post traumatic stress disorder to Alzheimer’s disease.  If you’ve got depression, having small hippocampi predicts that you won’t respond as well to antidepressants as well as depressed people with larger hippocampi.

Just as having small hippocampi increases the risk for all sorts of mental disorders, all the things in our lives that put us under undue stress and strain also shrink the hippocampus. This is as true for cigarette smoking as it is for being exposed as a child to abuse or parental neglect.

In addition to protecting us against brain illnesses, we all need big hippocampi because this brain area, while not much bigger than your little finger, plays a disproportionately  large role in how you will be able to handle the stresses and strains of your life, and how you will remember your life when it’s all said and done. This is so because the hippocampus is crucial for our ability to form and store personal memories. It is also of central importance for restraining the body’s stress and inflammatory responses, both of which can induce significant damage to bodily organs and the brain if not properly reined in.

The finding that especially nurturing mothers can literally grow their children’s hippocampi doesn’t exist in isolation. It is consistent with hundreds of animal studies showing that maternal nurturing has a range of biological effects relevant to physical and emotional health. An especially striking example of this is a study done several years ago in rodents showing that maternal nurturance (measured as amount of licking that rat pups received from their mothers) literally changed how the rat pups’ DNA was expressed in the hippocampus. As a result of these changes, pups who received extra licking had changes in their stress systems that have been repeatedly associated with well-being in humans.

So we underestimate our power as parents at our children’s peril. But I would be remiss if I left you with the impression that mother love is all-powerful or that genes and chemicals don’t matter at all. The association of parental nurturing with subsequent hippocampal size in children was only observed in non-depressed children. In children with signs of significant early depression, maternal nurturing in the laboratory had no association with subsequent hippocampal volume. Why this was the case is anybody’s guess, but it might suggest that at least some cases of major depression are indeed mostly genetic or “hardwired” from an early age, and so are fairly resistant to positive things from the environment.

Given the complexity of the human brain, should we be surprised that every possible outcome of genes, chemicals and environment is actualized in someone somewhere? Meantime, one generation full of deeply loving parents would change the brain of the next generation, and with that, the world.

Between kids banging their heads in sports and soldiers banging their heads in battle, traumatic brain injury (TBI) gets a lot of press these days.

Sadly, TBI is very common, occurring in 1.7 million people annually in the United States, according to the Centers for Disease Control and Prevention. The condition ranges in severity from mild concussions with no long-term consequences to severe brain damage leading to coma and/or death.

Now Hollywood is entering the national discussion about TBI with “The Vow," a movie inspired by real events that tells how a tragic case of TBI nearly destroyed the love between a married couple.

In the film, a recently married young couple is in a catastrophic car accident that leaves the wife with serious brain damage. She has completely forgotten the past five years of her life.

Because she met her husband more recently than that, he is now a complete stranger to her. He remains devoted, but she is confused: How could she have agreed to share her life, and her bed, with someone she has no memory of ever meeting? Still, the husband is determined to get his wife back, and they try to date again in hopes of reigniting the fire of love.

Classic example of Hollywood’s preposterous take on life, right? Never could have happened... except that it sort of did. In fact, many basic facts of the movie are based on the true story of Kim and Krickitt Carpenter. And this highlights a key point about medicine.

If I’ve learned anything in my several decades as a doctor it is that the human brain and body are stranger than fiction. If you can imagine it, it’s probably happened, and a lot of things you’d never imagine have happened, too.

In fact, memory loss is quite common following a traumatic brain injury. It typically takes one of two forms.

Anterograde memory loss is the more common of the two. This type of memory loss is characterized by an inability to form new memories for a period of time after the injury.

Retrograde memory loss is less common. When this occurs, a patient becomes unable to access memories for things that have occurred prior to the head trauma. Usually this period of “lost time” is brief. But in unusual cases people can lose a year or more of memories, which accounts for the Carpenters' story.

Where "The Vow" wanders from reality is in downplaying the fact that any episode of TBI bad enough to cause severe amnesia is likely to do a lot of other bad things to a person, too. As a People.com article from 15 years ago makes clear, re-stoking the Carpenters' lost romance had at least as much to do with coping with changes in Krickett's personality as it did with her lost memories.

Like most people with significant brain trauma, she wasn’t the same person after the accident that she was before, and the changes weren’t all for the good.

The most famous case in history of TBI changing a person’s character occurred in 1848 when an extremely organized, loyal, perfectionist and hard working railroad crew foreman named Phinneas Gage had much of the front part of his brain blown off by an iron tamping bar that shot straight through his head in an unfortunate accident. Remarkably Gage never lost consciousness despite people being able to see daylight through his head as they carried him to a nearby hotel.

Gage made a remarkable recovery, but over time his acquaintances begin to notice strange things. Gage became lazy, slothful, irritable, impulsive and sloppy. He drank and spent his money on prostitutes. He lost his job and wandered down into the lower reaches of society, surviving on the good will of those who knew his plight.

So in this regard, "The Vow" doesn't do justice to the terrible truth of TBI - that it frequently robs people of who they were, not just in memories, but in thoughts, feelings and behavior.

And yet, sometimes memory loss itself can raise issues of profound philosophical importance. Years ago I had a patient with a most remarkable story, full of theological implications. Let’s call him Carlos.

He came from a small town in Arizona in the years when gangs were first making their entry onto the American scene. As a teen he fell in with one of these early gangs, became violent and engaged in petty crimes. Then, at age 18, he had a powerful religious conversion and became a born-again Christian. He replaced his switch-blade with a Bible and his life of crime with enrollment in the local junior college.

One hot summer’s day, while at a picnic with his church group, he dove off a bridge into shallow water and crashed his head into the mud at the bottom of the river. Friends fished him out and rushed him to the nearest hospital where he remained unconscious for the better part of a day.

When he came around he appeared remarkably normal, except for one striking fact. Like the heroine in "The Vow," or Krickitt Carpenter in real life, he had a powerful case of retrograde amnesia stretching back over a year and a half that left him with a very patchy sense of what had happened to him during this period.

What he especially couldn’t remember was his powerful conversion experience. He was confused by how he knew so much about the Bible, and despite persistent efforts by his former parishioners, he never again “caught fire for the Lord”, as he put it. But neither did he return to his life of crime. He continued in junior college and grew up to be an electrician, a married man and eventually a city council member in his small community. Yet his wife never had any luck getting him to go back to church, other than Christmas and Easter.

What this story highlights is that more than any other injuries, those to the brain raise questions most of us would rather ignore. Did my patient lose his salvation? Did the accident change his soul? How can there be a soul if it can be so radically changed by a bump on the head?

No one has answers to these questions. But if there is any slight recompense to the frequently catastrophic consequences of a TBI, it is that the condition reminds us how precious our properly functioning brains really are.

The American Psychiatric Association is in the midst of redesigning a document often called the Bible of Psychiatry. It's known more officially as the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short.

For practical purposes, including insurance reimbursement, the DSM determines what does and does not qualify as a psychiatric illness in the United States.  Because of this, changes to the document can lead to profound effects on patients’ lives.  Changing criteria can dictate who and who cannot be considered to have a mental illness worthy of treatment... and insurance coverage.

Nowhere have proposed changes to the upcoming edition of the DSM generated more angst, or media coverage, than in the area of autistic disorders.

Anyone who has a family member with severe autism, or has known someone with the condition, might be surprised by this.  Of all brain conditions for which we don’t know the cause, none are more obvious than autism in terms of symptoms or impairment.

Autism strikes right where it hurts most, and that is the ability to understand the emotions and behaviors of other people.  In addition to severe impairments in social understanding and behavior, people with autism also typically engage in pointless repetitive behaviors and have obsessive, narrow interests, often centering around technology.

Occasionally autistic people demonstrate skills, as seen in the movie "Rainman."  One famous autistic patient can tell you the day of the week of any day in history.  I had a patient years ago who had exactly memorized all bus routes schedules for the greater Los Angeles area using a method he inexplicably called the “liver system."  He could - and did whenever prompted - recite exact times and stops over hundreds of routes for hours on end.

So the question remains: how could changes in diagnostic criteria change who does and doesn’t have such an obvious disease?

To answer this question, let’s do a thought experiment.  Imagine you are at the doctor’s office receiving news of your latest medical testing.  Would you rather be told that you had a large breast lump that was benign or a very small one that was cancer?  Or consider this: You go to the ER with chest pain.  Would you be very comforted if the doctor told you that you’d only had a small heart attack?

What these examples make clear is that some medical conditions are best thought of as either being present or absent.  Either you have a disease or you don’t. Now consider this:

We all know that high blood pressure is a silent killer, and that many lives have been saved by the development of safe and effective treatments. Setting aside what the number exactly mean, most of us probably also know that the upper range of normal for blood pressure is 140/90.  Suppose your doctor takes your blood pressure and it is 141/91. Knowing that this is high, she asks you to relax and then takes it again five minutes later.  This time it is 139/89. Would any of us say that you had a disease based on the first reading, but fortunately were perfectly normal based on the second?

All psychiatric diseases are like blood pressure.  They are on a continuum without gaps.  If one administered questions to identify any condition and rate its severity in a large enough group of people, one would find someone occupying every value from zero to the maximum score.

The problem in psychiatry is that our entire diagnostic system is based on the idea that mental illnesses are like cancer and not like blood pressure.  The DSM provides minimum criteria for each disorder, which means that no matter how close you are to having any given condition, if you fall below the line you technically don’t have it.

I suspect you can see the problem immediately.  If nature does not provide clear guidelines for where normal stops and mental illness begins, how does the line get drawn?  The quick answer is that it gets drawn in much the same way the voter redistricting lines get drawn: based on some data, a lot of fighting, and finally some not entirely satisfactory compromise.

So back to autism.  Like all other mental disorders, it runs along a spectrum from people who most of us would have called nerdy when I was a kid to people who spend their lives unable to speak, rocking back and forth for hours on end.  We all agree that the silent, rocking folk are ill and need care.  But where does extreme nerdiness and social awkwardness give way to Asperger’s syndrome?  When is someone autistic enough to deserve the label?

This is the rub.  As with all spectrum conditions, there are far more people with mild autism than with its more severe forms.  Again think of blood pressure.  Lots of us run 150/92 - not many of us run at 200/110 (and those of us who do often don’t live to tell about it).

What the new DSM proposes to do is make it harder to meet criteria for autism, so that probably the majority of people who fall on the mild end of what people often call simply “the spectrum” will now be declared non-autistic.

Proponents of this move argue that much of the autism epidemic that has been observed in the last several decades may result at least in part from the fact that less and less severely affected people are being diagnosed.  Making the criteria stricter will reverse this trend.  It will also reduce the risk of stigmatizing people who in former times might have been viewed as eccentric, but non-diseased.

Opponents of the changes argue that many young people have been helped by receiving the diagnosis and that this help will vanish if they are no longer considered to have a “real” and “billable” condition.

What is the answer to this dilemma? Like all real problems in the world it falls along a spectrum.

The opinions expressed in this post are solely those of Charles Raison.

Asked by Trena, Cerritos, California

My baby boy died January 12, and my life has been a nightmare ever since. I have tried therapy, and I have been prescribed different antidepressants and nothing seems to help. I'm told I have post-traumatic stress disorder due to the nature of his death. Is there any natural alternative? Are there any other options out there, be it holistic or medicinal? How long does the grief last? I want to feel better for the sake of my other kids, but I just feel worse.

Expert answer

Dear Trena,

My heart breaks for you and your situation. Having young children, it takes no imagination on my part to imagine the horror and heartbreak of losing such beautiful little beings.

So the first thing you should know is that your reaction, while problematic, is most likely not abnormal. I admire you wanting to find ways to put your suffering behind you enough to help your other children.

We know from many studies that the type of trauma that you are experiencing as the result of the death of a child can negatively affect the mental health of the dead child's siblings. So you are right to be concerned.

And I want to suggest to you that you utilize your caring for your living children as a reason to seek healing and as a path for recovering.

Before we talk about specific therapeutic options, I want to suggest that choosing to focus as much as you can on your children, on who they are and on what they need from you, may provide a path out of your heartbreak. Their lives may remind you of your lost child, which may increase your pain initially.

So it is important that you don't beat yourself up if you find it difficult, or impossible, to focus fully on your other children. Just try your hardest, cut yourself a break if you're not perfect and try again.

There are natural products that have been shown to help with depression and anxiety, although you should know that they have not been as well-studied as standard antidepressants and anti-anxiety agents.

In collaboration with your clinician, you might consider omega-3 fatty acids, SAMe (S-Adenosylmethionine, pronounced "Sammy"), St. John's wort or valerian.

Again, chemicals - whether pharmaceutical or nutraceutical - might be of some value, but I think your long-term best interests lie with behavioral interventions.

We've discussed therapy. In terms of less traditional options, there are many. What you are looking for is something that will help you make sense of your loss in a way that will allow you to continue to suffer but to return to full joyful engagement with the life that stretches before you.

I don't know you well enough to have a sense of what to suggest in this regard. Many people benefit from a spiritual practice - be it church attendance, yoga or meditation.

For the sake of yourself and your children, you should also make a commitment to adopting the healthiest lifestyle you can in terms of diet and obtaining regular aerobic exercise.

Question asked by D. Epps from Georgia:

Is there a wrong way to detox off Xanax?

Expert answer:

Sadly, there are probably more wrong ways to detox off Xanax than right ones. Lots of people have a very hard time getting off Xanax if they’ve been on it for awhile no matter what approach they take. This is one of the reasons Xanax has fallen from favor in the last decade.

Xanax was the hottest thing going in the late '80s and early '90s. It was considered the most potent and useful of the class of medications called benzodiazepines. Benzodiazepines, which include such well-known drugs as Valium, Klonopin and Ativan, promote relaxation and sleep by making it harder for brain cells to fire.

These medications can be spectacularly helpful when used appropriately. But their use comes at a price. When taken on a daily basis for more than a few weeks, the brain develops a dependency on them for normal functioning.

Xanax has a very short half-life, which is a fancy way of saying that it goes into and out of the body very quickly. This property appears to make Xanax even more likely to cause emotional and physical dependency than other benzodiazepines. The short half-life means people will often start withdrawing from Xanax between scheduled doses, which tends to powerfully reinforce their psychological dependency of the medication.

This property has, over time, made Xanax among the least popular of benzodiazepines among psychiatrists.

If you take Xanax long enough, you will become physiologically dependent on it. This does not mean that you are an addict or that you are abusing it. It only means that if you stop the medication suddenly you are at risk for a very dangerous withdrawal syndrome that can include delirium and seizures and can be lethal.

So the wrongest way to detox off Xanax is to just suddenly stop taking it. This can literally be a fatal mistake.

Another very common “wrong way” of trying to detox from Xanax is to attempt to get off the medication too quickly, which can cause such discomfort that people become afraid to continue the detox process.

It can take months to successfully come off Xanax, and often the last little bit is the hardest to get off.

So patience is of great importance for successfully weaning oneself from Xanax. Under the guidance of a physician, the detox can often be made easier by switching from Xanax to an equivalent dosage of a benzodiazepine with a long half-life such as Klonopin or Librium, and then gradually tapering off that agent.

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Sometimes this works. But in my experience, this switch is so uncomfortable for some people that they can’t tolerate it.

Benzodiazepines get a bad rap because they do have abuse potential and they do cause dependency. But they can be wonder drugs for some people. Many year’s worth of long-term data suggest that they do not cause significant harm, even when taken for long periods.

I like benzodiazepines, but I would never start anyone on Xanax for the reasons I’ve outlined above. On the other hand, more than once I’ve seen people - especially older folks - who have literally ended up in the psychiatric hospital trying to get off Xanax. Most of the time they had been doing just fine for years and it was some new doctor who decided they had to get off the Xanax “no matter what.”

This seems crazy to me. Not being on Xanax is better than being on it. But living a reasonable life on Xanax is considerably better than making yourself sick trying to get off it.

A final important point. No matter what you do, make sure you work closely with a clinician with expertise in detoxing off benzodiazapines.

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Question asked by Risha from Sacramento:

My son suffers with anger and low self-esteem but is outrageously cocky toward me. He is almost 18, we don't get along lately, and I feel like he is jealous of my happiness. I feel like it is my fault, as I raised him as a single mom and spoiled him a lot, and now it feels like it has all backfired on me. I am crushed, but I am also starting to have my own resentment toward him.

He suffers from ADHD and most likely a mood disorder, but he refuses to make time to see the doctor. When I schedule appointments, he often wants to reschedule, which leads to having to start the whole process over. I don't want to give up, but with no support, I just don't know what to do. I am 35, I had him young, and I want to have a life, too; and I just don't see how that can happen when he refuses to help himself. It's like he wants me to do everything for him. Please advise.

Expert answer:

I've been thinking awhile about your question. Often there is a straightforward answer to people's dilemmas, but yours is not one of those. Even if I really understood your son's issues and the problems in your relationship with him, there would probably still not be any obvious, easy way to resolve things.

Having said this, let me tell you about a technique that can make solving these types of complicated problems simpler. Rather than focusing on all the issues you are facing and trying to make them right, try focusing on the outcome you want to achieve. In your case, I suspect you want your son to treat you better and take responsibility for improving his own mental health and functioning.

With this desired outcome firmly in your mind, a first step is to watch closely to see which of your actions move him a little toward this goal and which move him away from it. My guess is that much of what you are doing now is helping to promote his bad behavior and irresponsibility. Try to see this clearly without letting it bother you too much.

You know it's a serious problem, or you wouldn't have written in to me. With a clear head, try to identify anything you are doing that results in better behavior on this part, and build upon this.

Very often, relationships will transform only when one member radically changes his or her behavior toward the other person. Your son may be irresponsible and angry in part because you have been doing everything for him. If this is true, you might find his behavior improves significantly if you make him responsible for his own life and leave him to suffer the consequences of his behavior and actions. This is what happens to young people when they join the military, and it is why the military is often so good for them.

I've seen many young adults similar to your description of your son whose behavior and emotions improved significantly when they had to begin making their own way in the world.

But a word of caution: Sometimes, young people with serious mental illness are not able to make this transition and get much worse if and when their parents demand that they "grow up." In these cases - all of which are heartbreaking - parents have to decide to either cut the child loose to face dire life circumstances or realize they will need to oversee and intervene in the young person's life indefinitely.

However, even in these situations, if a parent watches his or her behavior to identify what improves and what worsens the child's behavior, things can often improve.

Let me leave you with a final thought. Trying to change your son, at the age of 18, is a very difficult undertaking. A smarter way to help resolve the problem is to focus on yourself and your own issues. I never cease to be amazed how profoundly relationships can change when one person gets help for his or her own issues. You might consider seeing a therapist yourself to work on your own reactions and behavior within the relationship, rather than trying futilely to force your son into treatment.

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Question asked by Emma from New York:

I have had depression for almost seven years. I saw a psychiatrist and therapist for eight months, two years ago; it made me feel worse. I started to see another psychiatrist and therapist last November; it only mildly helped. I tried Prozac first, but when the dosage increased, I started to have hallucinations and delusions. I was then prescribed Celexa (disrupted my sleep greatly) and then Cymbalta, which showed no change. I also was given several sleep medications. Medications just do not seem to work; they all have side effects. I just moved and have not found more doctors here. My depression and sleep problems seem to get worse with every day. What should my next step be?

Expert answer:

Dear Emma,

It would be a better world if I could assure the people who read these answers that your situation was unusual. In fact, your story is fairly classic and sadly common.

Many people with depression develop chronic symptoms that are resistant to their best attempts at treatment. Sometimes an answer can be found and relief obtained; other times nothing seems to help and the suffering continues.

There are many possible reasons why psychiatric symptoms don't go away in response to either medications or psychotherapy. I don't know enough about your experience with therapy to hazard a guess about what went wrong in particular.

But looked at more generally, there are three reasons why psychotherapy might fail: the wrong therapist, the wrong therapy, or resistance to psychotherapy.

Before deciding psychotherapy is not for you (i.e. that you are resistant to it), let me encourage you to think about how you felt about the therapist and/or the type of therapy you received.

If your therapist was someone you didn't emotionally connect with or if the treatment didn't seem to really engage you, let me suggest you try again with someone and something new.

With medications there are two primary possibilities for your history of nonresponse. Either you are resistant to antidepressants, or antidepressants are not the right medications for what you've got. The side effects you describe make me wonder if you might not have an undiagnosed bipolar disorder.

Sometimes people with bipolar disorder are helped by antidepressants, but often they respond better to other classes of medication, such as lithium, valproic acid or one of the new atypical antipsychotics. It might be worth talking with a mental health clinician about whether you might have a bipolar condition.

As I've written more than once in these answers, many of us psychiatrists are "two-trick ponies," meaning that when we've provided psychotherapy or some type of pharmacological intervention, we've done what we can do.

Scientific findings increasingly suggest that other interventions may also offer real promise, such as exercise, meditation/yoga and healthy eating. Let me encourage you to educate yourself about these potential sources of benefit.

In addition, it is very important that you sit down with yourself and honestly examine whether you are doing things that we know make depression worse, such as drinking too much alcohol, or taking drugs, or continually putting yourself in stressful, depression-causing life situations.

If you identify any of these factors as being live issues for you, let me encourage you to adopt a take-charge attitude in trying to rid them from your life.

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Question asked by Stephanie via e-mail

I've been having a lot of panic attacks, almost every day; sometimes when I'm working, dealing with the kids or just nothing at all. I'll get shortness of breath, chest hurts on both sides or just one side, and a lot of my heart skipping a beat. And it scares me. I'm 29 years old and in good health. How can I control this?

Expert answer:

Dear Stephanie,

I don't need to tell you that panic attacks are among the most hideous experiences a human being can have. They are such strange occurrences. While being in no physical danger at all, you feel as if you are in mortal peril. In the midst of perfectly good health, you feel as if you are on the edge of sudden death. And telling yourself that there is no real danger is of almost no help whatsoever.

My strongest piece of advice is that you make an appointment to see your doctor immediately. Many primary care doctors feel comfortable treating panic disorder or will know a clinician who does.

Like everything else in psychiatry, treatment options come in two general flavors: medications and psychotherapy.

The best proven psychotherapy for panic attacks is similar in many ways to the type of therapy that I've described several times before for obsessive-compulsive disorder. It has two main components, neither of which is pleasant, but which are in the aggregate often highly effective. First, the therapist would work with you to gradually expose yourself to situations that cause panic. Then, once you are in these situations, he or she would teach you to tolerate the terrible panic feelings when they arose.

I suspect that just thinking about doing this might have you breaking out in a cold sweat, which is why it is so important to get professional help.

Among psychotropic medications, two classes are particularly effective for panic, and they are very different from each other. Benzodiazepines, like Valium, Ativan or Klonopin, have powerful anti-anxiety effects that happen very rapidly after they are ingested. If you have long panic attacks, or attacks that come in prolonged volleys, these medications work quickly enough that they can interrupt things in mid-attack.

Most antidepressants also treat panic attacks, but unlike benzodiazepines, they require several weeks of being taken daily before their effects are usually seen. For this reason, many clinicians will start patients on an antidepressant and a benzodiazepine. Once the antidepressant has been on board for several weeks, the benzodiazepine can often be discontinued.

Let me alert you to a few challenges in these treatments. Psychotherapy is great, but depending where you live and the state of your finances, it can be hard to find and expensive. Benzodiazepines work extremely well but have addictive potential when taken long term. If you elect treatment with an antidepressant, make sure that your clinician starts you on the lowest dose possible, because - paradoxically - antidepressants can cause panic attacks when they are first taken and can certainly worsen them in people already afflicted.

The good news is that all these treatment options are effective, so it is very likely you will be able to gain control of your symptoms, find relief and continue with your life.

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Question asked by Benjamin from St. Catharines, Ontario

I was wondering if my brother, who we have been told is bipolar, could develop schizophrenia? My uncle, my mom's brother, was schizophrenic and unfortunately fell victim to the mental illness. We are aware that there have been some mental health issues with males on my mother's side of the family, so could it be possible that he could be schizophrenic as well as bipolar?

Expert answer

Dear Benjamin,

Your question points to a major problem confronting the field of psychiatry, which is the imprecision of our diagnostic categories. The problem has a simple cause but no simple answer.

The cause comes from the fact that all our disease states are based on symptoms and how they are clustered together, rather than on any real biological mechanism.

In this way, our diagnoses are similar to the way most medical illnesses were defined before the 20th century. For example, in the old days people with fluid in the lungs and chest pain were said to have pleurisy - it was defined by its symptoms.

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Nowadays we recognize literally hundreds of different reasons for pleurisy symptoms, many of them with specific treatments that have no effect on other causes for pleurisy.

Diseases such as schizophrenia and bipolar disorder are like pleurisy and not like adenocarcinoma of the lung or pneumococcal pneumonia or an aortic dissection, all of which cause pleurisy, but all of which are disease conditions based on an understanding of physical mechanisms rather than symptoms.

Both schizophrenia and bipolar disorder are better thought of as syndromes rather than specific diseases. As such, someone has schizophrenia if he or she meets symptom criteria for schizophrenia spelled out in the diagnostic manual. The same thing holds for bipolar disorder.

It sounds simple enough, but things immediately get complicated. First, schizophrenia and bipolar disorder share important symptoms; for example, psychotic thought and behavior can be present in both conditions, making the syndromes hard to differentiate.

If a person is heavy on psychosis and relatively light on either depression or mania, he or she looks schizophrenic and is called such. If a person is heavier on depressions and manias and only has psychotic episodes when in a mood state, he or she looks more like someone with bipolar disorder and is called such.

To add to our diagnostic troubles, over time many people's symptom patterns swing from mostly psychotic to mostly mood-related and back again, making them sometimes seem schizophrenic and sometimes bipolar. And other people spend most of their lives in an intermediate state, with lots of psychosis and lots of depression or mania, but not enough to be fully bipolar. These people are called schizoaffective.

By definition, a person can't have bipolar disorder and schizophrenia at the same time. But a person can sure struggle for years with psychosis, odd behavior and mood swings and be hard to classify clearly into one diagnosis or the other, which sounds to be the case with your brother.

In the midst of these complications, there is some good news. More important than his exact diagnosis (which is after all only a description of his symptoms and how they cluster over time) is the fact that both schizophrenia and bipolar disorder respond to similar medications.

The important thing is not his diagnosis, but his need to get into - or remain in - consistent treatment, which offers the best hope of providing a hopeful long-term outcome.

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Question asked by Susan from Oklahoma

I have OCD. When I hear the sink faucet turn off, it makes a squeaking noise, and I feel tense and need to use antibacterial wipes on my hands. I also feel tense and need to use antibacterial wipes when I hear someone say the word "gas," when I see a red gas tank anywhere, when I see a gas nozzle at a gas station (or on TV), and the red color of a gas tank on anything plastic similar to a red gas tank. I also hate looking at sinks in the bathroom and kitchen because I feel tense and literally walk around the apartment covering my eyes so I do not see those objects when I am passing them. Why do I feel so intensely about these things? What can I do?

Expert answer:

Dear Susan,

I am sorry to hear about your very intense and disabling struggles with sinks and red tank-like objects.

Your issues might sound odd to folks who don't know much about OCD (obsessive-compulsive disorder), but for anyone who suffers with the condition, or has treated it, your problems are very typical.

This is good news indeed, because it means that your problems can very likely be improved significantly.

Although OCD is one of the most disabling of psychiatric conditions, it is also one of the most treatable. And although many patients are not able to rid themselves of symptoms entirely, almost always, the symptoms can be brought down to a manageable level, allowing people to resume their normal lives.

Given the intensity of your symptoms, I would recommend you see a mental health clinician, who will recommend a specific type of behavioral therapy, a serotonin antidepressant, or both.

I wish I had space in this blog to tell you any of the myriad cases I've seen of people whose lives have been turned around by these interventions.

But in the meantime, because you've asked me what you can do, let me make a few simple suggestions

All effective psychotherapies are based on the discovery that the intense discomfort caused by obsessions (in your case the fear of germs) fades if a person can resist doing the compulsion that the obsession sparks (in your case, using hand wipes or avoiding looking at sinks).

On the other hand, compulsions - while giving immediate relief - actually make the obsessions worse over time.

Here's an analogy: We've all had the experience of having a place that itches. When you itch, you scratch, but we all know that the scratching, while relieving the itch briefly, only makes it worse over time.

On the other hand, if you ignore the itch, it fades over time. Obsessions are like the itches, and compulsions are like the scratching.

So the way forward is not easy, but it is doable if you take it a step at a time. What you need to do is purposely expose yourself to the things that cause the mental torture and then tolerate them for as long as you can without doing any compulsions.

You could start with any of the obsessive triggers. I might start by saying the word "gas" over and over again for as long as you can stand without wiping your hands. Another simple - but far from easy! - approach might be to sit in front of a sink in your apartment, staring at it without looking away.

The longer you can do this, the more you'll notice that the anxiety is fading.

If you are saying to yourself that these activities are too difficult to even contemplate trying, then I doubly recommend that you seek professional help.

Believe me, I know from experiences with patients and family members how terrible this disease is. But remember: I also know well the sweet relief in people's eyes when they take action and begin to heal.

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