Episode 5 - Mood Disorders Part 1

shall we? So we're going to start talking about mood disorders today. I'm hoping we can get quite a way through it. We probably won't finish up with mood disorders, but we'll get as far as we can. So first of all, mood disorders are going to come in two broad flavors. Unipolar, what we call major depression and bipolar disorders. So the key thing here is that both of these disorders have depression as one of the symptoms. In bipolar disorder, as you know, we're just essentially adding in the manic phases to the depression. What will happen? What we'll see is that there are two types of bipolar disorder. One where depression is the primary symptom and the other where mania is the primary symptom. And in those cases, the opposite symptom is less intense. About 15% of men, 15% of men will experience a depressive disorder at some point in their life and about 24% of women. So quite high prevalence. One of the reasons why I sort of start out with this disorder is the one you're most likely to see on a day-to-day basis. When I was talking about college response, which is the screening program that's run by screening for mental health, that's one of those programs that we could do for the service learning project. They screened 600 colleges at 600 colleges last year. 37,000 students were screened in person. 48,000 were screened online and that showed a quite high prevalence. Now obviously this is skewed by the fact that it's those people that are either doing the screening in person or going online to do it. Plus some of the people that go online are probably just trying to mess with it. But still, it's a serious problem on college campuses, especially. So what do we tend to see in terms of symptomology of depression? You know, what are the things you associate with depression? Suicide? Good. Disinterest in previously enjoyable activities or lack of enjoyment of those activities. Isolation and withdrawal, yeah, yeah, yeah, from people. There can be disturbances in sleep either way, either hyper-somnia or hyposomnia, either sleeping too much or sleeping too little, yeah. Good. Okay. So there is an association between substance use and depression. It's unclear what that association is, but there's definitely an association. Although I'll say that there's an association with substance use and lots of the psychological disorders. One of the primary ones that you'll see is feelings of worthlessness. But now, all these things that you've identified so far for the most part have been what we call the retarded symptoms. The withdrawal, the sadness, sleeping too much, things like that. But as I said, it's important to recognize that depression can also be seen in terms of what are known as agitated symptoms, pacing. And that's really this kind of experience where someone is ruminating. They'll be ruminating in their mind. They'll be anxious. Their mind will be going in a mile a minute. They'll be pacing. You know, it all almost look like Mania, but it's depression. Pulling on things, you know, pulling on your hair or picking at your skin is one of the agitated symptoms. And oftentimes people will just sort of suddenly shout. It's not the same as like Tourette syndrome or a verbal tick, but they'll suddenly, you know, though their anxiety will cause them to suddenly say something like I didn't do that. Right? You know, this rumination that's going on in their head causes them to have to verbally express that frustration. Yeah. Yeah, sense of being overwhelmed with daily activities. Sure. Sure. Sure. Absolutely. Yeah. Yeah. Well, yeah, we use that terminology when we talk about schizophrenia and I kind of mixed it up, but these would be considered the negative symptoms. And these would be considered the positive symptoms. You know, positive being there's something there or negative being there's something taken away. Yeah. Yeah. So we typically see depressed mood, what we call dysphoria. You really identified most of those things already. And we talked about anodonia, loss of interest in previously enjoyable things. There's something that was identified by Aaron Beck who's one of the main figures in studying depression. Beck developed what's called the Beck depression inventory, which is one of the questionnaire formats that's used in diagnosis. And he called this the depressive triad. The idea that it is a problem of self and a problem of environment and a problem of future that we have this sense that there's something wrong with us as an individual. We have this sense that there's something wrong with our interaction with the environment and a sense that there's something wrong with our sense of the future, our hopefulness for the future. And he says when those three things, you know, you can have a couple of these things and not go into a depression. But he says when you have all those three things, it really, really drags people down. So that's sort of the kind of cognitive idea about your thoughts about the self, your thoughts about the environment, thoughts about the future are all very distorted. You don't really see yourself as yourself really is. You see yourself as a depressed self or as a worthless self. You don't see the environment as a real environment really is. You see the environment as threatening or the environment as undesirable. And you don't see the future as the future really is. You see the future is bleak or hopeless. Typically, we also see just a real slowing down of cognitive processes during depression. People just think a lot slower and you'll see this reflected in the unquiet mind memoir that we're reading. You'll see how her depression really slows down or thinking. And it tends to be not so much of a problem on short-term tasks that people can complete right away. But when things drag out for a long time, again, that sense of worthlessness is going to start to pervade that and it's going to be difficult to sort of plan for things in the future because the future just seems so bleak sometimes. We don't often associate anxiety with depression, but again, even with the retarded form of depression, as well as the agitated form, people will experience this anxiety, partly because they remember how they used to be and not like they used to be. And that's going to raise a lot of anxiety for people. And as you said, suicide is an unfortunate consequence of depression sometimes. times and suicidal ideation, thoughts of, if I'm so worthless, why am I even bothering taking up space on this planet? I'm using up resources that other more useful people could use, so I should just die. Now, suicidal ideation is a long way from planning or actually attempting suicide, but it's the first stage. That's one of the things that we don't talk about that much in this class, that I think it's important to stress. These diseases, these disorders are chronic disorders that go on and on and on for people and oftentimes fatal disorders. It's hard to really grasp the seriousness of these disorders sometimes unless you think of them like cancer and think of it as like cancer before we had very good treatments for cancer. We're treatments for cancer getting better and better, but there was a time when if you had cancer, it was really bleak. In the same way, our treatments are getting better for mental illness, but there are some mental illnesses where the treatments are difficult. The chronic nature of these diseases and the sometimes fatal nature is something I like to talk about. Those are the symptoms in terms of cognition and affect. Behaviorally, we tend to see behavior changes in movement and speech typically, and it's either going to be retarded, slowed down or agitated, speed it up, and it can go either way. It's going to be a difficult diagnosis just observing those behavioral traits. You're going to have to go into cognition and affect to try to figure out if it's depression. Somatic symptoms. We talked about this. Disturbed sleep, either hypersomnia or hyposomnia, so people will either sleep too much or they'll have insomnia. Wake up too early, can't get back to sleep. One piece of data from sleep disorders is that more serious kind of clinical depression tends to be associated more with waking up too early rather than not being able to go to sleep, for example. Again, it's an association, it's not causal relationship, but those disturbances tend to be associated with more serious depression. We talked about leading, and we didn't talk about loss of libido, oftentimes associated with depression, just lack of interest in sex, and general sort of somatic kinds of problems, oftentimes just being tired all the time, lethargy, pains, joint pain, aches in the body. Again, these are oftentimes the more prevalent symptoms in some cultures, for example, in East Asian cultures. You'll typically see these somatic symptoms and not the affective symptoms that we typically associate with depression. That's a good question. Do they not experience them or is it something in the culture that makes it undesirable to report them? I don't know. Yeah, that's a good question. I am not aware of that, but I could imagine. It's not one of the side effects of the antidepressants. That's anecdotal evidence. I haven't seen any research evidence looking at it. Anytime you're adding stress, you're compromising the immune system. These are stressful disorders to have. I can see how stressed, but I don't think it's depression, specifically, but more of the stress associated with depression that would cause some immune dysfunction. There are some subtypes of depression. The one you've probably heard of is sad, seasonal affective disorder. Living in Oregon is a tough thing to do in the winter. What it typically tends to be related to is just basically when the sun goes down earlier in the winter, and it doesn't come up till later, those long nights in the winter tend to be associated with higher rates of depression. That is confirmed by the idea that the seasonality is reversed in the southern hemisphere. We see it more in November, December, January, February, in the northern hemisphere, and more in June, July, August, in the southern hemisphere, right? They're winter, essentially. About 1 percent of people, the general population, will have seasonal affective disorder. It tends to be more intense as you get further away from the equator. The Scandinavian, Slavic, Norwegian areas tend to have high rates of seasonal affective disorder. Most part of depression is considered one of the subtypes of depression. Again, the prevalence is about 1 percent among women who have had children. Do you have any more data on that than I do? Your figures in terms of what? What's who? Who's who's our? Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. [ Inaudible ] Yeah. Okay. Okay. Right. Yeah. Yeah. Yeah. Yeah. Yeah. I'd like to see that clinical data if you can get it together. Yeah. The -- and I don't know how -- probably in that chapter of the DSM it has the diagnostic features of the subtype. Probably, yeah, most likely, yeah. Let's take a look at a video clip of a fellow who I think he has a major depressive disorder. And we'll -- we can chat about it after. I'd like to be depressed. What does it feel like internally in those times when you are very depressed? You're absolutely alone. you feel you are alone. You feel absolute worthlessness. You feel it is no hope in the future. As you believe everything is dissolving, you feel your marriage may be dissolving. Relationships with children may be dissolving. All this kind of thing. And you feel that you can never get back to being a member of a community. When were you first officially diagnosed as having major depression? Not until age 48. Can you tell me about that? I want to lead up to it a little bit. Whatever is comfortable for you? In college I could be on the dean's list or would they bounce me that semester from the school? That was again I think depression. When I graduated I was teaching and I began to feel I was the world's worst teacher. I felt worthless. I felt I didn't deserve anything. I didn't deserve life. If you can't teach you become an administrator. So I had a master's degree in education, administration, and became a principal. After a short period of time thought that I was the world's worst principal. In the meantime I was married, we had two children. Probably my wife said that I just wasn't functioning. One of the things that that illustrates real well is that very extreme. The world's worst teacher, the world's worst administrator, that very dichotomous thinking that is characteristic of the depressive disorders. When we think about disorders, one of the things that we have to think about and talk about is where do they come from? What's causing them? When we think about those theories we're going to explore mostly all three of these biological theories about where these disorders come from. The psychological aspects of these disorders, that is people's effective coping mechanisms and their ability to deal with them effectively. And then the social aspects. So the interpersonal, intergroup, relational kinds of aspects of these disorders that may lead up to these disorders may cause them. And then of course we always have to talk about the biopsychosocial model and how these things all function together. I'm going to pause this for just a second. Let's talk about biology. First of all genetics. When we do genetic studies for psychological disorders, what we look at is what's called the concordance rates for twins. So how likely is it that a pair of twins will have this disorder? And so we look at monosigotic twins, monosigotic meaning same DNA, one egg, one sperm, same DNA. Diesigotic meaning what? Two eggs, two sperm, different genes, same intrauterine environment. So fraternal, you call these commonly fraternal twins and these are commonly called identical twins. So among monosigotic twins we see a concordance rate of depending on the study you look at somewhere between 40 and 55 percent, 54 percent. But in diesigotic twins, that concordance rate goes way down and it approaches the general population. So there's pretty strong evidence that there is some genetic predisposition involved in depression and mood disorders. We do see an even stronger link though with genetics in bipolar disorder. So we're seeing that kind of play out in the unquiet mind book that we're reading. There are some differences in brain function, particularly in the prefrontal cortex tends to show reduced activity, the amygdala tends to show reduced activity. These can actually show either reduced activity or too much activity, but the more common is to show lower activities. We also have some indications that there may be some neurotransmitter dysfunctions involved in depression. And so particularly they're looking at researchers are looking at the monoamine class of neurotransmitters. So serotonin, nor epinephrine and dopamine. Dopamine is the neurotransmitter that you should associate with pleasure. You stimulate the dopamine producing areas in the brain. You get a feeling of euphoria. We think that that's related to substance use disorders too. Serotonin is a neurotransmitter that is very calming, has a very calming effect, and the notion is that there's two little serotonin available for individuals who have depression. So when we treat them with the reason that we think that's the case, we treat them with drugs that helps increase the level of serotonin that's available and they get better. So there's probably a link there. You've probably heard of one of the treatments for depression. SSRI drugs. You heard that. Selective serotonin reuptake inhibitor. And essentially what that does is it leaves more serotonin in the synapse of between two neurons so that there's more available to be used. It inhibits the reuptake process. This is getting back into introsight and what you learned about neurobiology. I'll go into this in a little more detail. And another class is called the MAOIs. Monoamine oxidase inhibitors. And what these do is instead of inhibiting the reuptake of serotonin back into the axon terminal between the neurons. This is inhibiting the action of this monoamine oxidase which is an enzyme that breaks down the neurotransmitters in the synapse. So it keeps those neurotransmitters from getting broken down and so that they can be used on the receptor sites again. So these are biological explanations for how serotonin might be involved and how we can intervene and help people maintain higher levels of serotonin. And people generally tend to show good responses to the SSRI class. The MAOIs aren't used much anymore because they have a lot of interactive effects with over-the-counter drugs, other prescription drugs, and foods. So you may see if you pick up medicine over the counter and you look on the back under the warnings, apparently frequently you'll see do not use if you're taking an MAOI. So these aren't used so much anymore. Those were an earlier class of antidepressants. The SSRIs are the more recent class of antidepressants. Okay. So psychological explanations. Here we go with Erin Beck. Beck says how you think is a very important component in how you feel. Thinking that is cognition is directly related to affect. And what he says is we learn these patterns of thinking and childhood that result in negative affect. For one thing, negative self-schemas, the idea that we generally tend to think of ourselves as not adequate or inadequate or not good people, not good children. This sort of constant rumination about negative thoughts rather than positive thinking. And then just basically when you think about the environment, when you think about the world, you are distorting the perception. The reality is different. The objective reality to other objective observers is different than your distorted perception of the world. And so what, as I said, what he'll say is there's this cognitive triad where these negative views of the self and of the environment and of the future all combine to really create this really intense sad experience, just very deep sadness, worthlessness, hopelessness. So, you know, there is something about looking on the bright side of life, you know. But that's not necessarily a way out of depression. But those people who may have that more optimistic view, especially early in life, maybe less likely to develop depression later in life, so. You know how to improve your mood? Yeah, fascinating research, basically activating the muscles that are involved with smiling causes and measurable changes in mood, yeah, so there you go. Maybe. So what do other, besides back, what do other people say? Well, first of all, there's a Seligman's explanation about learned helplessness. Marty Seligman is a psychologist, I think he's at Yale now. And what he discovered was when you put an organism, in this case, he is classic experiment used dogs, when you put them in a situation where they can't escape from some unpleasant stimulus, they will eventually just lie down and like not bother trying to escape anymore. And then what becomes even more bizarre is if you give them the ability to escape, they won't even use it, all right. So, it's this idea that you just learn that you're helpless to avoid being, in this case, shocked, they were using shock with dogs, another, not necessarily, it depends on how valuable the outcome of the research is and you know how damaging it is, yeah. Pretty well regarded, yeah, quite highly regarded, yeah. It's demonstrated and replicated in numerous different environments, numerous different organisms. Oh yeah, Yale, I think, yeah, Martin Seligman. Not really, she's generally considered to be, I have what's something called the Stockholm syndrome, but yeah, where you begin to identify with your captors, but that syndrome has not very good empirical support. Another explanation from the psychological perspective is that we all have different styles of attribution, what's attribution mean, yeah, that's why I asked, okay, okay. So a framework perhaps for understanding and describing causal relationships. And it is highly subjective and so what, one of the psychological theories is that we have different kinds of attribution styles on different kinds of dimensions, so some of us attribute our successes and our failures to more internal qualities, our ability, our strength, or our inability or our weakness, others attribute their successes and failures more to external attributes. Well, I just got lucky or, you know, that test was just too hard, right. Stability and instability is another domain where they're looking at attribution styles, some people tend to attribute their behavior to more stable factors, others attribute their behavior to more unstable factors, and global and specific attributions are another factor. So some people will make global attributions about themselves and others will make more specific domain dependent attributions, right. So some people might globally perceive themselves as more externally influenced. Their focus of control is more external, and they don't have control over their events and the environment, you know, their life is kind of subject to the whim of the environment. And that, you know, is going to lead to certain kinds of thinking and certain kinds of attitudes. And then also interpersonal factors, time and time again, this is going to come up, social support, clinical research on clinical disorders, time and time again shows the value of social support and positive outcomes from mental illness. And you'll see that theme actually come up in an unquiet mind too. So what we see in people with depression is they tend to have smaller social support networks and those social support networks tend to be less supportive of recovery and perhaps even encouraging of disability or illness. We tend to see less supportive families and people with depression and, you know, it's a bummer to be around someone who's depressed, right. So again, these aren't causal factors, there's probably an association, there's probably a complex interaction of these factors. We do tend to see these things more associated with depression. That's what I mean, it's interactive, yeah. And I think that's actually true, it's a huge thing that is found through these data and that's why I think it's intended to support a different social support, because it's not important in the life, in the mental disorder, but I think it's actually difficult to see it to be at the end of the social family. Yeah, either by their own design or by just the progress of the illness, yeah. It depends where you are, yeah, there are support groups in mostly in major cities, but certainly. not in the rural areas. So biopsycho-social model, so social factors that are related with depression, certainly socioeconomic status, and we'll see this over and over again in mental illness. People with, in lower socioeconomic status groups, have higher rates of mental illness. What's up with the idea that women tend to have higher rates of these disorders? I gave you the statistics earlier, and so women are, you know, basically about twice as likely to have two to three times as likely to have these disorders. One idea is the high rates of sexual assault with women, the statistics are about one in four, by the time they reach 18 will have been sexually assaulted, men have about half that, you know, it's about double, and so one in seven for men. So there may be something related to sexual assault that may have a factor, and then physical assaults. So women obviously, women tend to be more likely to be the victims of domestic violence, whereas men oftentimes tend to be more involved in public fighting, for example. So, you know, that domestic violence is more sort of shaming. The public violence is more sort of from an aspect of sort of masculinity and protecting masculinity. And the idea that here that women in domestic violence situations, the person who's beating them is typically a trust in individual. So you've put your trust in someone, they've betrayed that trust, and that's extraordinarily disrupting psychologically. There's also some interesting hypotheses about the effects of industrialization. The idea that depression rates have increased historically, partly because we've moved more away from our own individual subsistence production, and more into this, you're becoming more of a cog in the machine, right, and you become less individualized, more de-individualized, and that can be disturbing. Industrialization also tends to lead to increases in the divide between the rich and the poor, and that can exacerbate depression. And then Western culture, there are also some hypotheses about the idea that it is not acceptable in this culture to be sad. This culture expects you to be happy, to be productive, to be up, to be doing things. And guess what, in bipolar disorder and those manic phases, you're looking good in those terms, right? But in the depression phases, you look like crap, right? So our Western cultural expectations may feed into these things too. We expect to be happy, we don't expect to be unhappy. Any ideas on this question? They're associational, yeah, there's no causal relationships here. And some of these are hypotheses rather than actual research. This doesn't get supported, this hasn't been studied that much. There's a lot more study here that shows some associations. Yeah. That's a good hypothesis, I'm going to be worth trying to look at, yeah. Extended families can be beneficial if they're supportive extended families. That's, you know, there's all kinds of variables in there, that's part of the problem. So, the reason for this separation, I don't know if you're talking about it in the 20s, is you think, make the child not abandoning and then have been resurrected by not following it, not keeping it up to the side, and so there are all these generations of people who, well, okay, don't consider it, you have to set aside or you're going to make an end for the person who won't be able to function on their own. Which is completely down, so it's quite involved with bringing down my researches out there, and so we've got all of these generations of all of the variation in, you know, the whole way we approach things, it could be impacting family nets that you, too, originally. Yeah, it's just so difficult to randomly assign children to being either in an attachment, a secure attachment, or an insecure attachment group. [laughter] Yeah. [inaudible] Yeah, yeah. [inaudible] Yeah, yeah, yeah. Yeah. [inaudible] Mm-hmm. [inaudible] Mm-hmm. [inaudible] Mm-hmm. Okay. Good. Good. Yeah, alternative hypotheses, yeah. [inaudible] [inaudible] So, yeah. [inaudible] Yeah. [inaudible] Yeah. [inaudible] Yeah. [inaudible] Yeah. [inaudible] Yeah. [inaudible] Mm-hmm. Mm-hmm. Mm-hmm. That's what I say. [inaudible] So, it's very difficult to generalize that view to every individual and every family, right, and every culture. So, it just, you know, deserves more research. Yeah. That makes more jobs for researchers. [laughter] Hold on, just a second. Are you, can you guys stick around for about seven minutes or so? Everybody okay with that? I've just got one more clip that I'd like to show you. This is a clip from a new, I think it was from like a news show or documentary in Australia. And it's about a woman with bipolar disorder. And she, it's about her descent into the disorder and then about her recovery from it. So, I think it's a worthwhile way to end the class today. And then when we pick up on next class, we'll talk more about treatments for the disorders. Okay? So, hopefully this will play okay. [ Music ] [ Inaudible Remark ] Mae'n gwneud gweithio'n gwneud. Mae'n gwneud gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio' 'Cato Callum' haddol, after its selling in her high school certificate the future of the blood and the risk of her life had been full of promise and reward. And six months into university things started to go terribly wrong. Okay, then home from the scheme or that in her first year of university she stayed in the house. And she was behaving very strangely. I just thought that she was becoming a big movie. She was also becoming a bit more affectionate from the way that she dressed and some of the things that she's there. I noticed towards the end of the stage, that things had to look an even more different. I hadn't watched that much of it. So I went on stage and it was way better to be able to sleep. The mood swings became so arctic that way. So she was quickly friendly on that. And we made this group which was my son usual group, a university student. And to give a style anyway to a screening shot of him with language group. You were the time he had some of the worst scripts in the world. We had a university party in Canada having five which was really quite unusual for us. We were friends for 20 years now and we don't have so much to worry about. I was really scared because I just thought about we were my best friend. But it wasn't quite sure about what the future holds. I wanted to do a comment about that and I didn't gather outside the family home. It was a reasonable snack and it was three in the morning and she was obviously. You'd have to say almost inside and raving. I had to go over some pathogens from the Bible and it really felt like I was being interrupted. She left there and she didn't want to come in. It was screaming and telling me to get out. I was lying in bed, I was just wasn't sure what was happening. So it was more upset because of the environment they had become upset. And it was terrifying, had some of the terrifying freezing on the outside and like a roar of us. Through the course I foregoed. I have to do something. What did you do? Kate's father forced it into a car. He was taking a small, more short hospital in Sydney, but ended up like she jumped out and scared it. Later, the mother drove to the hospital, only to find that her daughter and husband had never arrived. She had been hanging across the scene outside for more traction, which is the area where we were coming from. Kate by now was completely psychotic and refusing to cooperate. After being threatened with a stretch record she gave in and was taken by ambulance to the Royal Mall of Shaw Hospital. The next day she was scheduled and voluntarily into a psychiatric hospital, which remained for nine weeks. I definitely didn't think I should have been there. I was definitely always thinking about some kind of escape, some kind of getting out of it. I think one of those things was that I had the special information and I was always attracted to the government and the system. She always used to say, "Where's the car? Where's the car? Where's the car? Where's the outside? Come on, let's go." I would seriously contemplate how I could get her past the guards and past the security. To get her to the car and go on the boat and do everything to be fine, I could learn to stop my fingers on one of these places as I can walk. Kate O'Connor was eventually diagnosed with bipolar disorder, or manic depression, as it used to be known. Heres was one of the most extreme forms of the condition, dominated by manic and delusional highs, then followed by crushing lows. Depression is one of the most debilitating aspects of the disorder. The news was shaturing for Sue O'Connor, whose own mother was by Colin. It's a disease that can be up to 70% of it, ever so it can often start with some kind of behavior. Sue felt guilty for passing on the gene to her own little daughter. I think I've dealt with that. I felt it was my fault I had passed this on. And as I had, I felt as though it was my mother that had passed on to who. Kate got those genes, she also got a bunch of really good genes. I was depressed and I was still in hospital and then I came out and I was like, "What was that all about?" I still, I think, definitely in retrospect, was not convinced deep down that I had a real condition. For nine years, after that first devastating illness, Kate was well and life continues as it had been. She started painting and finished university at qualifying in design and visual communications. She convinced us that she did not have bipolar disorder and would never have to return to hospital. Then one morning, she started to feel invincible. Her creativity knew no bounds. 48 hours later, she was on vision. I would never have said that I was God, but one is showing what's the Virgin Mary as such. I was just very closely linked to being on a mission to God, maybe one of you know, maybe I was John. I was also not found in a jungle baptist. Kate was shitting once again and it was something interesting. She had been there and thought it was all the conspiracy. She was going through times by calling over the fence. We heard that there was nothing that heard down at the dock in Burmae. So we spent like a whole day driving around. I think that Burmae had walked down to the shores because it was through Burmae or just there. And then had gone up in some of the bridges to take you out of the country. I mean, most of them just passed away. Because I do want to go home and get my passport. Finally, the country would tell you that Burmae was on the way. She jumped in the hammer and they swimming. So I had no idea what was going through. But she was calling with, so she got in the struggle. So, when he found her, she wouldn't say that she was a witch, but eventually, even he must have been able to get them, must have not been from her. By the time through a corner run, Kate was gone. I was later to shovels and to thorns as Kate knocked on a stranger's door. They took it off, so she complained of having a microchip implanted in her brain. We arrived in our cell and she was still thinking that she had the sheath in her brain, but somehow it would come from the brain onto a female. And I think she had a heart monitor on her finger. So when he spoke to her, she wouldn't speak to you, she'd speak through the finger. She'd go, "How are you?" and then she'd say, "What's up?" I thought that was the right thing to do. She said to them, "I had a lot of people at the time, but I turned them down." And then she'd speak to you, "How are you?" Kate, a corner continued to find the diagnosis of bipolar disorder. And over the next two years had three more synchotic adversaries. One was on the Greek island, just found a ring. One thing that's coming up with an adversaries here, interimagine, expand as much as you want to. Just how to expand your entire island. That's sleeping. We're supposed to, um, they have bummerings to explode. After the last episode came with you in another crushing period of depression. By now, she had five pages like hottie over those. If any, to see you with her life, her career, and her relationship. Great. Just amazing, you know, um, to see if someone's going around for the day. One of the cops that is around her illness has been her best friend to Lizzie. Oh, did you hear that? Oh, no. She's not my friend anymore. She's my family. She. I need her as much as she needs me. I think so. I can't put into her as much as she needs to. She's been such an amazing friend for so many years now. I can't even imagine, you know, I'll see how it ends. And the friendship is a bit too much of a burden. No. No worries. I like it. I like it. I like my calendar. I think you're forward a little bit on the graph. Yep. Right? Yeah. Okay. I was going to do it. This was the other stuff. Yeah. In the last two years, cases turned in life around. She's had an exhibition of her paintings and started her own very successful design business. Can I hold this for the tattoo here, please? Yeah. And she has finally accepted her dying noses of bipolar disorder and changed her life to do all of it. She also regained access to sarcasm. I think that the two of us think of people that are probably sort of inmate here either and that they ignore it or say that they're just a situation for them and they end. Or to just take it incredibly seriously. And that's what these are like. They're like, "Hey, I think one's our final balance. She doesn't do either of those things. She's very respectful. We hope you're honest. I think she's very keen to measure as little impact as far as possible. And I've asked you for two. I think she made it a number of benefits. I learned through my journey that this particular condition is basically to have respect for the condition. And that is something that is always going to help me manage it basically by being aware of it and basically giving it respect, which sort of means being aware of my limitations. So honey, please. Can I call you now? Yes? Okay. Yep. Okay, so Connor decided a year ago to come off all the medications, including the anti-psychotics and moods daily lives. There are all medications that are hard work to take. Generally, they can cause separation, they can cause slow mentation. They can cause weight gain. Also, things are young. Active person doesn't want to have. And particularly in this, we're incredibly burdensome. I think there are certain circumstances in which it is reasonable for a patient, but I would sort of to have a trial of medication. Those circumstances would include being very well informed about the illness. Being motivated, having a good relationship with Dr. O'Keefer, and having very supportive family and friends. In case of the hassle, all those things. Try not to accommodate it. Don't worry, I'm going to get hurt. I'm going to get hurt. This approach is not one of the psychiatrist would agree to for many people. Case is a rare exception. Here is a real risk that you could have another psychotic episode. Most doctors do not agree with stopping medication and advise people to consult them first. But Kate does have a strategy in place. Her family and some friends have her permission. They see any warning signs to contact her doctor and she will be medicated. To me, it's a gamble either way, because I've been on medication when I'm back to hospital. There's always going to be a risk for me, I guess. It's something that I can never rule out of my future. It will never happen again. I would like to think that it's something that can be managed at a hospital in the future. In more than likely, there will be an absolute hope for you. I get a lot of inspiration from her. Of course, once she has to go through just one day of day life. That puts everyone else, we cannot go out and sleep as well as we want. You know, drink when we want to do this and do that. She has a really good balance now. What Kate has shown you over the years is that although it's hard to have them in time, and it's not the end of the world, it doesn't mean the end of your life that you know it. I hope one day she finds a lovely partner who will support her and that she can live her life as she would like. And I see great sons without having them. She has lots of long made love. So, you know, a real illustrates some really salient points that we made here. You know, the idea that there's probably a genetic relationship. The idea that it tends to be a chronic disorder that exists over time. And the importance of social support certainly, you know, in having that supportive context, you know, even allows her to discontinue medication for a while and have somebody that's going to watch out for her. Sorry, that took more time than I thought it would. So, I'll see you, I guess, on next Friday, again. One of those days. The 8th, the Friday, the 8th, you're scheduled to have a midterm exam. I won't be here, but I'll schedule someone else to administer it for me. Yeah, there will be about a week ahead of time. Yeah, I'll probably bring a copy into class too, yeah. Yeah, yeah.