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Re: NO HOPE to everybody » Anna Laura

Posted by pfinstegg on December 12, 2002, at 9:40:43

In reply to Re: NO HOPE to everybody, posted by Anna Laura on December 12, 2002, at 6:24:05

Hi Anna Laura... I read about your SPECT scan, and was wondering what one might do about the hypoperfusion to the thalamus, etc. I haven't had a SPECT scan, which if I understand it correctly, is a measure of blood flow to various brain areas by means of radioactive glucose. I have had an MRI, which shows that the left hypothalamus and left pre=frontal areas are abnormally small- the MRI being a test that shows brain volumes, but not blood perfusion. I'm assuming that low brain volume and low brain blood flow co-exist, and are caused by the same basic abnormalities in brain chemistry.

So few people with MDD or BP have had these studies done, but I feel certain that when doctors start doing them more routinely as part of a diagnostic psychiatric workup, a huge percentage of people suffering from depression are going to be found to have these SPECT and MRI abnormalities.

I am reading a lot on Medline to try to find out what causes these brain changes. The big culprit seems to be prolonged stress, which can become self-perpetuating even when the original stressors are long in the past. Stress is now generally considered to be the trigger for depression (all types), with each person's genetic and environmental threshold being different. Once excessive stress is chronically present, the hypothalamic-pituitary-adrenal (HPA) axis goes into over-drive. The way to tell, physiologically, that this has happened, is when you have a normal T4, but a TSH at the upper limit of normal, or slightly above normal. Another test that becomes abnormal is the DST suppression test, or the slightly more sensitive version, the CRH-DST suppression test. What these tests show is that the hormones originating in the hypothalamus- TRF (thyroid-releasing-factor) and CRH (corticol-releasing-factor)- don't turn off normally even when there are adequate levels of thyroxine (T4) and cortisol in the bloodstream. This means that there begins to be a destructive "final common cascade" (to use the words I keep reading) of excessive amounts of TSH, ACTH, cortisol, and also mineralocorticoids (particularly glutamate), which act upon the receptors and transmitters of the hippocampus, amygdala, pre-frontal areas and basal ganglia in such a way that, although the cells in those areas are not thought to die off at an increased rate, new cells do not grow the way they do normally. The cells themselves are altered- they are much less active metabolically, with shrunken cell bodies and shortened dendrites- meaning less secretion and less uptake of all of the neurotransmitters- serotonin, dopamine and nor-epinephrine. It's supposed to be the shrunken, inactive state of these neurons which accounts for the findings of hypoperfusion and loss of brain volume. Because excess TSH, cortisol, and glutamate have these damaging effects on crucial parts the brain, the hippocampus especialy, it loses its down-regulating ability- it can no longer tell the hypothalamus to slow down its damaging hormone over-production, and a gradually worsening vicious cycle (HPA dysregulation) is established. Of course, you can have this just occasionally, just a litte, or a lot. It can progress, or stay quite stable.

I have been looking for articles on what interrupts this cycle. For some people, ADs of all the classes, but particularlu MAOis and tricyclics, do reverse the hypothalamic overactivity. For other people, ECT and TMS can do it. Psychotherapy itself can apparently also do it, but it has to be the kind that does not make stress worse- examples of the ones that work best include CBT and the relatively new two-person, or relational psychotherapy, which involves learning self-soothing techniques while improving one's object relatonships.

Well, this is as far as I've gotten! I have a medium degree of HPA dysregulation, and have chosen to try TMS, relational psychotherapy and the European tricyclic tianeptine. For add-ons, I take 2 gms. fish oil, plus two things which are supposed to lower cortisol: phosphadatylserine and alpha-lipoic acid. I'm presently doing all of this except for the TMS, which starts in January, but I notice some real improvements- considerably less apathy- and the suicidal thoughts are completely gone. I know I am really lucky to have been able to get all this treatment- and do hope that you will be able to obtain effective treatment, too. For me, the most helpful person was a neuro-endocrinologist- he sort of graciously pressured my internist and psychiatrist into taking a more serious and up-to-date approach, stressing the importance of maximal intervention NOW, before things progressed to a melancholic or psychotic form of depression, which he thought could happen.

I wish you the very best of luck. and hope to hear that you have also found a really effective treatment. It's seems to be difficult for doctors, unless they are very well-trained, to recognize how serious this illness is, because we can usually act perfectly normal in their presence!

Pfinstegg


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