Tryptophan depletion and its implicatio – PubMed Mobile

http://www.ncbi.nlm.nih.gov/m/pubmed/11331552/?i=6&from=/9333716/related

In experiments, rapid depletion of tryptophan in the body worsened  unipolar depression in people who were already depressed.  Even more impressively, people who were in remission from their depression, when deprived of tryptophan, relapsed!

Tryptophan is an amino acid that is present in protein-containing foods.  It is a precursor of serotonin, which is the target  molecule for the class of antidepressants known as selective seratonin reuptake inhibitors (SSRIs).  They work by inhibiting the body’s method of recycling serotonin, which is secreted by brain cells as a chemical messenger.  That causes the net amount of seratonin to go up, since it’s not being reabsorbed.  Increasing the level of seratonin in the brain often improves depression.

My question is:  since  SSRIs are known to worsen bipolar depression, could tryptophan depletion improve it?

Treatment-Resistant Bipolar Disorder – Psychiatric Times

Treatment-Resistant Bipolar Disorder – Psychiatric Times.

A very complete and comprehensive review of treatments for treatment-resistant BP.  Unfortunately, rTMS (repetitive Transcranial Magnetic Stimulation), which is shown to be safe and effective for both unipolar depression and bipolar disorder, is not mentioned here, although of course ECT takes a prominent front seat.

The Psychiatrist and the Lightbulb

The husband and wife sat stiffly, as far apart on the stiff divan as the laws of physics would allow. The intervening silence froze the air.

“Well?” the cordial voice of the psychiatrist punched through the waiting silence, and it shattered and fell tinkling to the office floor. The man glared at him malevolently. The woman raised her eyebrows and nodded to the psychiatrist knowingly, while making a barely perceptible motion with her chin in her husband’s direction.

“I SAW that, Gladys!” the man accused angrily, rising slightly from the couch and shifting to face his wife. Gladys sat up primly, pursed her lips and folded her hands, gazing straight ahead beneath hooded eyes, her blue permanent curls trembling slightly.

“Now,” said the psychiatrist soothingly, “why don’t we start at the beginning?” And as there was no offer of a beginning, he took the more direct approach and asked the man:

“What brings us in here, today?”

“What brings US in here today,” snarled the husband, “is my WIFE! If you want to know why we’re here, ask HER, since she knows so much.” And he shut his mouth with a snap that could be heard all across the office.

Even I heard it, and I was just a second year medical student. This was my first time observing a psychiatric office visit, and it was turning out to be much more interesting than I had expected.

The psychiatrist sighed and tried again.

“Well, Mrs. Jones, why did you accompany your husband here today?”

“Thank you, Dr. Smedley. As you know, I had to lie to get him here, and he’s awful mad about that.” Mr. Jones snorted like a bull. “You can say THAT again. That’s the last time I fall for THAT line of__”

“Mr. Jones,” purred Dr. Smedley, “Your wife is only concerned for your well being.” Mr. Jones fell into a seething silence and glared at the doctor from behind thick black-rimmed glasses that made his eyes look twice as big as they actually were.

“Now, Mrs. Jones, if you would like to tell us all here what you told me on the telephone, I think that might be a good way to begin.”

“Well,” began Mrs. Jones uncertainly, darting anxious glances in the direction of her husband, who seemed to be occupying himself by entraining a psychic death-ray in her general direction, “It all began a few months ago when Gerald here started talking to the light bulbs.”

“I wasn’t talking to the lightbulbs, you little idiot, I was talking to the ALIENS who use the lightbulbs as an instrument of communication!” Gerald exploded, spraying saliva all over everything in his immediate vicinity. I had instinctively jumped back, but Dr. Smedley was wiping his eyeglasses with his pocket handkerchief.

Mrs. Jones simply nodded, shrugged her shoulders a bit and raised her palm as if to say, you see? This is what I’m talking about. Dr. Smedley frowned, scribbling furiously on his steno pad.

“Mr. Jones, may I call you Gerald? Thank you. Gerald, how long have you had this delusion that aliens are communicating with you through the light bulbs?”

“Delusion? DELUSION? What kind of an idiot do you think I am? Better yet, what kind of an idiot are YOU? HAH! YOU’RE the kind that they would NEVER speak to, so of course you don’t know. Of course you think it’s a delusion, because you’re a petty, ignorant little pissant that aliens wouldn’t waste their precious time on. And their time IS precious, too.”

Gerald climbed up and stood on the arm of the divan, directly beneath the ceiling light fixture, and cocked his head to bring his ear closer to the bulb. He closed his eyes and listened, nodding his head vigorously from time to time. His wife wept silently at the other end of the divan.

Here I got a little excited, hoping that he would go on and tell us more about the lives of aliens and their experience of time, but my hopes were dashed.

“Gerald. Please sit down. Now, I am about to demonstrate something about the nature of light bulbs, and I hope that after I show you this, you will be able to understand that light bulbs do nothing more than convert electricity into light. They are not capable of transmitting sound or any other kind of means of communication.” Dr. Smedley opened his desk drawer and produced a light bulb and a hammer.

Gerald’s eyes grew large with fear. “No. Doc, please. Please don’t do it. Those are very important. They contain essential classified secret emissions.” Dr. Smedley wrapped the bulb carefully in a tea towel. “No, Doc, you don’t understand. Once you bust those things, it’s all over. All is lost. You can’t go back—” CRUNCH! With a satisfied smile, Dr. Smedley carefully unwrapped the tea towel to reveal the shards of the light bulb, its now naked element quivering in shame.

“Do you see now, Gerald? This is nothing more than a piece of tungsten metal attached to a special piece of glass. No one could possibly use this as a communication device, even if there WERE aliens,” he said kindly.

“Gladys, get up. We’re going. This man is dangerously insane.” Gerald collected his wife and hustled her out the door. She kept her eyes down, this time, no longer seeking the eyes of Dr. Smedley. He had discredited himself a little, I think.

“Well now, what did you think of THAT for your first outpatient psychiatry case?” Dr. Smedley turned his high beams on me.

“Well,” I began carefully, “personally, I really wanted to hear more about the aliens in the lightbulbs. Like, what did they say to him, and how often did he talk to them, that sort of thing.”

“Ms. L_,” Dr. Smedley glared at me. “Aliens do NOT talk to people through light bulbs!”

I knew I was pushing it but I had to advance my case. “Dr. Smedley, isn’t it true that each person experiences reality in his own unique way?”

He nodded, “Of course.”

“In that case, is it not possible that this man’s reality happens to be that aliens communicate with him through the lightbulbs? I mean, whether or not this is the objective truth, it’s still his reality, right? So who are we to argue with him about what is real or not real for HIM?”

As I delivered my speech, I observed Dr. Smedley becoming redder and redder in the face, but somehow I could not stop myself. All of the outrage that had been building pressure during the absurd and degrading occurrences of the interview with the Joneses came pouring out all at once. I felt suddenly, triumphantly, at peace.

But oh, no! What’s this? Dr. Smedley climbing upon his desk–where just five minutes before Gerald had stood upon the divan—and Dr. Smedley is jabbing his forefinger at me, for emphasis, and shouting “WE—ARE—THE–AGENTS–OF–REALITY!” Over and over, again and again. WE. ARE. THE. AGENTS. OF. REALITY!

Aghast, I backed slowly out of the room and closed the door, never to return. Just like Gerald and Gladys Jones.

THE END

Postscript~with very little poetic license, this is a true chronicle of the first day of my psychiatry rotation in medical school, in 1983.  Proving, once again, that truth IS stranger than fiction.

 

ⓒ 2012 Laura P. Schulman, all rights reserved. All reproduction without express written permission of the author is prohibited.

 

Short Story: Carotid Surgery

WARNING:  IF YOU ARE SQUEAMISH OR FEEL THAT YOU MIGHT BE UNSTABLE TODAY, PLEASE DO NOT READ THIS NOW.

 

There’s a good reason women make the best surgeons, she thought. Quick, deft hands, single-pointed concentration, focus. She thought of the women jet engine mechanics she had met in the Air Force. Not that she had been in the Air Force; but in the course of her duties she had met them.

Now, however, she was intent on the task at hand. Drat this light, she thought. She really needed a more direct light source, but one has to work with what one has at hand.

Slowly, painstakingly, she drew the outlines with a surgical marker: carotid triangle; carotid vein; carotid artery. This, the artery, was what she wanted.

She steadied the syringe she had readied with an oh-so-fine needle: 27 gauge. 2% lidocaine with epinephrine. Enough analgesia for comfort, and enough epi to ensure a relatively bloodless field. She couldn’t help chuckling: bloodless indeed.

Squinting in the insufficient light, she injected the layers: first the skin, then the loose fascia of the neck. Lastly, the layer surrounding the vessels of the neck, careful to avoid direct injection into the wall of the vessel, which might cause a spasm.

Now it was time to cut. She picked up the number 11 scalpel and steadied her hand. Carefully, carefully opening the delicate skin of the neck, noting with satisfaction that the epinephrine had done its job. There was no need for the tiny hemostats she had ready, in case of superficial bleeders. The next layer, the loose fascia, pulsated bluish, overlying the great vessels of the neck. These she would blunt dissect with the larger curved hemostats, just teasing away the delicate layers of gauzy tissue to expose the artery. She injected a bit more of the anesthetic, just to be sure. No need to cause discomfort, which might result in involuntary movement.

At last the artery was exposed. She marveled at its pulsations, at the tiny arteries that nourished the big one, and the miniscule veins that issued from it, carrying its waste into the larger system of veins, to be cleansed by the liver and kidneys downstream.

Holding her breath, she slid the first hemostat jaws open, under the artery. Clamp. The vessel, trapped in the jaws of the clamp, stopped pulsing abruptly. There was no going back now. Now the second hemostat, exactly one and a half centimeters below the first: clamp. She raised the surgical scissors, poised for the definitive cut between the clamps.

Tilting her head to see better in the mirror, she cursed the dim light in that bathroom again. And then, the definitive cut! She removed the two clamps and was instantly drenched in red liquid.

A scream of agony splits the night as she sits bolt upright in the bed, heart pounding, drenched in sweat, clutching the sodden bedclothes as she struggles, locked in the arms of the Angel of Death like biblical Jacob.

Frantically clutching her throat, she rushes to the bathroom, the very same bathroom, and strains toward the mirror in the same dim light.

Nothing. Her throat, graceful and bluish white as ever, shone back at her from the reflection.

Sucking in a deep gulp of air, letting it out in a sigh that brought the dog running, she splashed water on her face and neck, toweling off the sweat.

“It’s OK, buddy,” she whispered to her whining canine companion, “just another nightmare.” The dog smiled anxiously, wagged his tail tentatively, and licked her calf. She reached down and patted his faithful head.

“Good thing I have you,” she murmured. Stripping off her sweat-soaked nightgown, she rinsed off in the shower before throwing on a fresh one. She sank into the recliner with a book: sleep would not visit her again, tonight.

2012 Laura P. Schulman, all rights reserved. Reproduction in any form prohibited without express written permission from the author.