A Difficult Patient Asks Who Am I? Part 5

By | July 27, 2011

The center for pain and emotion in the limbic system are extensively cross wired.

Joan next asked why I was prescribing antidepressants when she was in pain and did not feel depressed. Parenthetically, I am not sure this is an accurate appraisal on Joan’s part and while I have not seen very many vegetative symptoms of depression in her, she has many of the features of an agitated depression. Furthermore, many patients suffering from agitated depressions are extremely resistant to the diagnosis and treatment. In any case I told her that pain centers and the centers for happiness and depression are extensively cross wired in the limbic system of the brain. That is why drugs that modulate one system often affect the other as well.

I told her none of the medications that I was suggesting produced an artificial state of euphoria or really change the primary signaling patterns within the brain. The primary effect of these medications is to change the rate at which normally released neurotransmitters were cleared from the synaptic clefts and repackaged. Thus they have more of an effect on the integrative responses to repeated or multifocal stimulation of the involved centers than the response to the initial stimuli.

Furthermore the effect of these drugs occurs in three distinct phases, an acute phase lasting hours to days during which time the primary effect of the drug on transmitter reuptake and repackaging take place, a subacute phase starting at about 2 weeks and lasting for about 6 months during which new synapses are being formed and chronic phase where major remodeling of neural circuits takes place. What is most important about the last two phases is that they represent the effects of learned behavior, which is facilitated, but not cause by the drug. This introduces the question of psychotropic drugs vs. psychotropic behavior and learning.

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