A couple of kids:
Suzy Q (1) was 9 years old with hyperactivity, impulsiveness, poor school performance, extreme resistance to school attendance, property destruction at home and at school, swearing, threats to destroy property, and threats to commit suicide. She made two suicide gestures, one at home and the other at school. She drank, but spit up, a tablespoon of methyl alcohol and reported it to the nurse at school the next day. She later wrapped a rope around her neck in gym with sufficient force to make her turn red. She drew no attention to herself but relied on other children to report her act to the teacher. She apparently was reacting to her failure to win a leader role in dodgeball.
A low dose of Prozac elicited several manic episodes including a false fire alarm and an attempt to drive some bulldozers; however, the suicidal talk and gestures stopped almost immediately. Once the despondency was challenged, she was maintained on 20 bid of Ritalin. Her sense of bravado, of being impervious to adult sanctions faded within a few days of her stopping Prozac. She once more "cared" what adults and other students would think about her.
Chuckie Geez was 8 yo and referred because his teacher strongly suspected ADHD. Classroom observation, however, indicated that the teacher probably had ADHD and Chuckie was a very anxious and exacting child who called out to correct her frequent gaffs. The teacher, nonetheless, convinced his parents to give him a trial on methylphenidate; tears, despondency, and social withdrawal immediately followed.
In addition to insisting his teacher get things right, Chuckie also had a conviction that no one liked him (possibly true), that he was the smallest and weakest in gym (true), and that his parents would be happier with him dead (not true). He also had recurring bad dreams, shared his parents bed every night, and had a strong preoccupation with Power Rangers. He already had "failed" two prior school placements because of his disorganized and disruptive classroom behavior.
Five mgms of Prozac eliminated the bad dreams as well as his need to sleep with his parents. Unfortunately, he developed a bulletproof attitude about adult sanctions. He lied, was imperious rather than bossy, and ignored adult directions. Cutting the fluoxetine to 3 mgs per day has kept the dreams manageable. He's in his own bed 4 nights per week and seems to have developed a list of kids to invite over to the house. There are still moments of his feeling like a misfit but they are transient. He's responsive again to parental and teacher disapproval when it's given. (2)
The two examples are children; however, similar issues also apply to adults but are harder to document given the greater flux in adult lives. On the mild end of the continuum, some adults became less "rule bound" about going to work and attending to details while on an SSRI but remained worried and sharply reactive to family rejection issues. Other clients, however, moved clearly into the realm of pursuing immediate, personal goals despite costs to family.
More than a little speculation: Antisocial Behavior and Mania.
There has long been speculation and a complex literature about sociopathy being related to a deficiency in anxiety and a lessened sensitivity to pain or painful consequences. It may be useful to make a distinction between clients whose antisocial behavior occurs solely for instrumental reasons and those with other social or emotional problems. The former group may have too little RS as well as perhaps too little anxiety. They may be completely motivated by personal physical and economic gains with little concern for acceptance by other people. If so, trials with serotonin blockers may have beneficial outcomes.
Mania sometimes is reflected in an expansive, confident manner suggestive of too much self esteem and too little sensitivity to interpersonal consequences. People who don't agree with the manic's schemes are evaded, manipulated, or discounted. Critics are ignored if at all possible. If not possible, then critics often become targets for retribution and for prolonged feuds. It should be interesting to see whether agents, such as risperidone that blocks a particular set of serotonin receptors, will make a manic more sensitive to interpersonal sanctions without affecting their energy level.
Impulse Issues and Social Brakes:
There are adult cases in which the RS problems overshadow other difficulties such as those associated with impulse control. Impulsive people get in trouble with expenses, handling personal relationships, and driving recklessly. They may gamble or initiate insupportable business ventures. They appropriately get depressed when they lose and when their family experiences embarrassment or poverty.
To the extent that depressed behaviors are conspicuous, the family practitioner, neglecting the impulse issues, may look first to an SSRI in order to provide relief to the patient. Even the verbal support aspect of therapy may focus more on automatic thoughts of "abandonment, losing control, not fitting in, screwing up one more time" while neglecting blatant maladjustments in planning and problem solving skills. Treatment, whether behavioral or chemical, for the depression entails weakening the clients social "brakes" represented by guilt and shame!
The subtle danger is that SSRIs are freely prescribed without consideration for questions of organizational and motivational persistence. So long as the client is happier, there is some risk of his and his family's accepting erratic personal decisions about home or work. The client becomes more pleasant and better liked on the job but less vigilant about deadlines; the husband becomes more cavalier when his wife is upset and she misreads him as not caring for her.
There is also a chance that a client, kept in a marriage or a job by feelings of obligation, will leave more freely while taking an SSRI and may regret the decision once the SSRI is discontinued. (3,4) Thus, there is a significant possibility of mistreatment with SSRI. Many people, now being treated for mild "depression" by their family doctors (an event even more likely because of the low physical risks of using an SSRI) might be affected in their marriages and in their careers in ways not anticipated, not explained, and certainly not warned of, by their physician. Self esteem, like many things human, seems best in our culture when present in moderation.
1 Names changed, of course.
2 Both Suzy and Chuckie moved into classes with lively but supportive teachers who liked them and who varied assignments, gave fair but relevant, consistent consequences, and were a lot of fun. These teachers certainly had as much positive impact on these kids as medication and certainly more than "counseling."
3 To the extent that SSRIs make it easier to terminate relationships or to the extent that serotonin is involved in conduct disorders, the SSRIs may come to be known as "bonding pills" and serotonin as the "bonding chemical."
4 Hollywood has discovered this phenomenon. A recent film shows a city auditor, normally a timid fellow, who agreed to testify against the mob but retracted on the basis that his "medication was unregulated."