Lucy is a single woman who is a professor of anthropology at a local university. She is in her late 30s and she was referred to me for a consultation because of a complicated set of potentially interrelated problems with cognitive impairment, sleep disruption, anxiety, depression, a seizure disorder, and migraine headaches.
She’s an interesting person and I really wanted to help her figure things out, but I have to confess that I got very confused trying to figure out all of the ways that her symptoms might be related. It took me three sessions to just sort out the possibilities.
After five sessions I found that I was still having trouble making sense of things, which wasn’t terrifically surprising because she had been to see four other psychiatrists in the last 10 years, all of whom had failed to come up with a clear understanding of her problems.
Today I sat down with her and went over her mood chart for the previous 2 ½ months and suddenly saw clearly what was going on.
Before jumping into that, let me briefly talk about how complicated the potential relationships amongst these problems might be. Cognitive impairment and memory problems can be caused by sleep disruption, anxiety, depression, a seizure disorder, the medications used to treat seizures, and the medications used to treat anxiety and depression. Sleep disruption can be caused by anxiety, depression, the medications used to treat anxiety or depression, restless leg syndrome, or the medications used to treat seizures. Depression can be caused by sleep disruption, a seizure disorder, and the medications used to treat seizures.
You can see why I was confused.
And the best strategy for treating all of this depends on what the primary cause or causes are. Do you increase antidepressant medications because the depression is what’s making this worse, or decrease them because maybe it’s due to side effects? There are 100 such dichotomous questions, and one could argue for practically any strategy… And indeed previous psychiatrists have tried many mutually contradictory approaches…
To help me sort out some of my confusion, I used one of my favorite tools, a mind mapping tool from Mindmeister, to try to lay out some of these relationships and to assess the evidence for one or the other.
You can see the diagram that I created on the right.
Although this clarified what the possibilities were it really did not answer the question of what was going on.
Flash forward to my review of the mood chart. Basically she kept track of all of these symptoms with the daily rating.
As with everybody who tries this, she was initially skeptical for a number of good reasons including the fact that it’s very difficult to rate something like anxiety which varies from hour to hour on a mood chart with only one rating per day. I encouraged her to continue. and reassured her that almost always the information, however unreliable it might seem, when people fill out this kind of chart it almost always turns out to be useful.
The first thing I saw looking at her mood chart (I’ve color-coded the data to make it a little easier to read) was that her anxiety seemed to be tightly correlated with depression and depression also seem to be strongly related to difficulty concentrating and memory impairment. You can see this information in the image to the left.
Notice that she has tracked hours of sleep, whether or not she took a nap, her sleepiness, whether or not she had restless legs symptoms, the degree of memory impairment, whether or not she had migraines, the degree of difficulty concentrating, her anxiety and her depression symptoms.
As you look down the chart you will see that she becomes more and more depressed and, along with that, her anxiety goes up and this is associated with memory impairment, poor concentration and sleepiness.
However, that was only looking at the data from the last four weeks.
When I went further back in time I saw a very different pattern, one which corresponds to the confusion I was experiencing when she first came in to see me, and was not feeling very depressed.
During that initial period, anxiety and sleep disruption seemed to be most strongly correlated and there was a weak correlation between either of those and memory impairment and difficulty concentrating.
So the two months of mood charting pointed to two different patterns.
When she’s not depressed, insomnia and anxiety are correlated, but then when she becomes depressed depression overpowers every other relationship and almost all of her symptoms are mostly determined by how bad her mood is.
You can see this diagrammed in the second mindmap below.
From this we were able to pull together a treatment plan that has the best chance of success and perhaps resolve the mystery that she’s been wrestling with for more than a decade.
We needed to have two approaches to treat her difficulty.
The first one was focused on addressing depression, because if she was depressed that was the most urgent problem.
The second one focused on treating anxiety and insomnia once she was no longer depressed.
But the point of this post is that, with diligence we were able to figure out a treatment plan for a problem that Lucy had been wrestling with for years.
Mood charting works!