Tag Archives: mania

Subthreshold (Hypo)Mania As A Precursor To Bipolar Disorder

The new Bipolar Spectrum.

“There is growing clinical and epidemiologic evidence that major mood disorders form a spectrum from major depressive disorder to pure mania.”

Subthreshold mania can be seen as a precursor to Bipolar Disorder, subthreshold Bipolar Disorder is defined as “recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania” (Merikangas et al, 2007). Bipolar disorder should be suspected if prominent behavior problems, anxiety, and substance abuse were present during childhood in someone with recurrent depression and a family history of affective disorders. For example, the prevalence of anxiety in children may be prominent in early-onset Bipolar Disorder and may predate affective symptoms. Children with a parent with Bipolar Disorder are more likely to be at risk for early-onset Bipolar Disorder, along with anxiety, depression and other disorders.

Studies have shown that offspring of people with Bipolar Disorder are at high risk for developing Bipolar Disorder because they have a parent with the disorder and generally have significantly higher rates of subthreshold mania or hypomania (13.3% versus 1.2%) or what is known as bipolar disorder not otherwise specified (BP-NOS); manic, mixed, or hypomanic episodes (9.2% versus 0.8%); major depressive episodes (32.0% versus 14.9%); and anxiety disorders (39.9% versus 21.8%) than offspring of parents without the disorder. Subthreshold episodes of mania or hypomania (those that resemble but do not meet the full requirements for bipolar disorder in terms of duration) were the best predictor of later manic episodes.

It should be noted that the American Journal of Psychiatry has a multitude of studies that suggest that people who suffer from Major Depressive Disorder (MDD) have a higher susceptibility to Bipolar Disorder and that subthreshold hypomanic symptoms that are found in people suffering from MDD should be taken into consideration when diagnosing. Placing these people instead on a bipolar spectrum, hence altering their treatment plan by incorporating a mood stabiliser which can also assist with the present MDD.

 

 

Advertisements

The ‘Poster Patient’ of Bipolar Disorder.

When you’re considered the ‘poster patient’ of Bipolar disorder…

I see all my doctors at regular intervals and I take medication daily. That’s the simple side of things, the easy routine and foundations that you are required to build. Depression and hypomania have accompanied me at different interludes, always waiting backstage for the next show to begin. I see myself as so dysfunctional. So haphazard and incapable of maintaining all the demons in check. I’m writing this post because I see myself as all those things, maintaining complete control of my emotions and rhythm is beyond my control, yet my psychologist insists that I’m a ‘poster patient’ for Bipolar Disorder, my ability to be functional when everything has turned on its head. I was so confused when she originally said this. I know my dysfunction, mismanagement and self-sabotage run deep, hence my confusion to the compliment. She referred to how she used me as an example to other patients about what can be achieved. The facts that she presented were right: I have completed a university degree and I am half way through another, I do have a full time job (I work full time as a secondary teacher), exercise, eat regularly and maintain some semblance of social interactions with friends. It hadn’t hit me that this is what is considered to make me less dysfunctional. My moods don’t generally have repercussions on my life, they are damn high mountains to climb over in order to find solace again, but the hike and lightheadedness of the ‘mood mountain’ doesn’t necessarily interfere with my outer world.

I don’t see these facts as things which make me more managed. I am dysfunctional. My ability to manage my life doesn’t make me any less so. As my depression deepened a few weeks ago, I started to have regular suicidal ideations again. Obviously the recognition that the severity of my depression was getting worse, I acted. I wanted to flip the switch. Anything had to be better than those tendencies, those ideations. I have done a lot of research into the vitamin 5-HTP, simply put it can potentially alter the levels of serotonin in your brain which can result in a hypomanic episode. High is much better than being low. Until you’re high….

Then it’s hell, again.

Without going into specific details of my episode, 5-HTP worked by flipping the switch. The worst part about flipping the switch is when you remember how horrible it is to actually be hypomanic at times. My memory had conveniently let myself forget. My mind has the useful ability to allow me to forget how bad things have been at both ends of my imaginary scale, the thermostat of my mind. It’s a protection mechanism, allowing me to move on and forget the consequences of all my subsequent moods. I took 5-HTP for three days before stopping when my head started to *whoosh*. I find everyone’s interpretation of ‘racing thoughts’ to be different, but then again, each episode I have had resulted in ‘racing thoughts’ which were different from previous occurrences. I see these in the following categories: Actual racing thoughts, when you have too many ideas at once – excitement usually accompanies this variation. Then there is the static or *white noise* head background pressure ‘racing thoughts’ which is usually accompanied by irritation and finally there is *whooshing*, when there isn’t an exact thought but your mind is just doing the simple cycle of the washing machine with your ears blocked, accompanied by a bit of depersonalization. It sounds absolutely nuts. Which it is.

I was never meant to be this broken, popping pills, waiting for the next mountain to climb.

At least I know that I can climb and conquer.

The Rise Of Psychiatry Has Augmented The Rise Of Madness Through Medicalization

When psychiatry is ‘curing’ the deviants of society and is invested in the restoration of normality.

It’s been a long while since I’ve last written, I’m not exactly sure why. Maybe, just maybe it’s because I’m not feeling too high or too low, the lows always lasting longer than the highs. Psychiatry has been playing on my mind lately, pills and potions; we’re overdosing, sick, sick, sick, I hear them say it. The pills fail to fill the void, has the void always been there or are the pills’ telling me that something needs to be fixed.

I was never meant to fix myself, the bruises on my thighs are like my fingertips, eerily matching the darkness that I feel. The darkness is like beautiful cherry blossoms that are always about to bloom, they are always so pretty, but they are always gone too soon. 

An attack on psychiatry: The original rise of asylums has allowed the confinement of madness to be ‘treated’, reclassifying a non-medical problem as a medical problem. Medicalization is the defining of non-medical problems in medical terms, usually as an illness or disorder, and usually with the implication that a medical intervention or treatment is appropriate (Zola, 1972). Medicalization leads to “normal” human behaviour and experience being “re-badged” as medical conditions. Rebadging “deviance” as a series of medical disorders, the engines driving medicalization have been identified as biotechnology (especially the pharmaceutical industry and genetics), consumers, and managed care. The hubris of psychiatry, believing originally that they could cure all psychological problems with psychoanalysis, psychiatry still failing to improve the average levels of happiness and well-being in the general population. Psychiatry is able to pump out psychotropic drugs, not save mankind, attempting to alleviate our ‘age of disenchantment’.

We are treated, analysed and regulated scientifically, living by a manual which fails to understand the sociological impacts and failings of society. Have we potentially been manufacturing our own madness? Postmodern psychiatry seems to have become a tailor-made diagnosis for an age of disenchantment. Are these psychiatrists potentially manufacturing madness? Is the medicalisation of madness reducing creativity, the creative aspects of people commonly misinterpreted as deviants? Centuries of creative people from all modalities have suffered from mental illnesses, resisting treatments which could potentially ease their conditions, fearing that it could cloud or alter their mind, drugging them into submission, proceeding to quash their inner creative impulses.

Edvard Munch: “I want to keep my sufferings. They are part of me and my art.”

Van Gogh: “Men have called me mad; but the question is not yet settled, whether madness is or is not the loftiest intelligence, whether much that is glorious, whether all that is profound, does not spring from disease of thought, from moods of mind exalted at the expense of the general intellect.”

Psychologist Maureen Neihart: associates the shared characteristics amongst creative production and mental illness, which include mood disturbance, a tolerance for irrationality, greater openness to sensory stimuli, restlessness, speed of thinking, and obsessiveness of thought.

Marcel Proust: “everything great in the world is created by neurotics;”

Seneca quoted Aristotle as having said, “No great genius was without a mixture of insanity.”

Many psychologists believe that artists use their work to heal and soothe their minds. But if drugs heal artist’s minds for them, is their work still needed, or would it even be produced, would their work even be needed? I always found that my over-sensitive and stimulated mind would always find so much more beauty in the world, glimpsing the magical and maniacal way of being present. Sometimes the pills keep me from spiralling into the abyss of the rabbit hole, the terror, but also the creative language which comes from seeing both sides, the place that is sometimes so warm and comforting but at the same time cold and hard. We’re definitely a pill popping society, whether it be vitamins or hard core anti-psychotic sedatives (Haloperidol…I’m talking about you, you’re such an exhausting and all-consuming prick). I’m not writing off psychiatry as a professional form of medicine, I just believe that they are infested with conflicts of interest, most commonly the extensive influence of the pharmaceutical industries over modern medicine.

End note: I do not mean the use of the word “madness” to be taken in any offensive way; it is used in the same way that sociology and psychology have referenced it in academic journals.

New Research On The Aetiology Of Bipolar Disorder.

John D. Pettigrew and Steven M. Miller argue that the underlying pathophysiology for Bipolar Disorder remains elusive, the disorder being strongly heritable but acknowledging that genetics are complicated. Pettigrew and Miller use the term inter-hemispheric switching which looks at trait-dependent biological markers associated with bipolar disorder. Proposing that bipolar disorder is the product of genetic propensity of slow inter-hemispheric switching mechanisms which can become ‘stuck’ in one particular state. Pettigrew and Miller state that slower switches are more ‘sticky’ in contrast to faster switches, hypothesising that the clinical manifestations of bipolar disorder can possibly be explained by hemispheric activation, which could be caught on the right (depression) or the left (mania). The research is based on rates of perceptual alteration in binocular rivalries that appears to be slower in bipolar disorder subjects who are in euthymic states in contrast to the normal controls.

portable_mood_by_alephunky-d5c536zThe research data showed that bipolar disorder patients clustered on the tail end of the distribution indicating a slower alternation rate. The Rivalry Alternation Rates: Bipolar Affective Disorder (n = 18) vs  Non-Clinical Controls (n = 49). Subsequently the euthymic state of the bipolar subjects at the time of testing suggests that slower rivalry rates can be a trait marker for bipolar disorder. Limitations of this study are related to subjects that have unipolar depression who demonstrated slower rivalry rates, although these subjects were to a lesser extent in contrast to bipolar subjects. The model of “bipolar disorder slow switches are ‘sticky’ switches because the intrinsic channel abnormalities that cause the slow oscillation rate also make the switch more likely to be held down in one state by external synaptic inputs”. A neuronal sensitivity with bipolar disorder argues that it would “lead to increased hemispheric output (in response to a stressor) and might therefore increase the likelihood that the switch will be held down (‘stuck’) on the side favouring that hemisphere”.

Pettigrew and Miller propose that the data suggests that bipolar patients have an increased ‘stickiness’ due to reduced intrinsic currents and greater extrinsic synaptic inputs from stressors, resulting in the patients being ‘stuck’ in a depressive or manic episode as a consequence of a stressor. The research proposes that the wide variety of data is indicative of hemispheric asymmetries of mood and mood disorders. Overall the results of the tests in inter-hemispheric switching might also be applicable to understanding the physiological rhythms of mood, cognitive style and other aspects of human brain function. Pettigrew and Miller outline that there have been reports that creativity is enhanced in subjects with mood disorders and also their relatives in contrast to the general population.  The controversial reports of increased creativity raise the potential for an understanding of the consequences associated with slower inter-hemispheric switching and the rhythms of cognitive style that could reveal neural mechanisms of human creativity.

Please note: this is not an academic essay merely a series of different research I found interesting.

Related/interesting sources:

Altshuler, L., Suppes, T., Black, D., Nolen, W., Leverich, G., Keck, P., Frye, M., Kupka, R., McElroy, S., Grunze, H., Kitchen, C. and Post, R. (2006). Lower Switch Rate in Depressed Patients With Bipolar II Than Bipolar I Disorder Treated Adjunctively With Second-Generation Antidepressants. AJP, 163(2), pp.313-315.

Bost-Baxter, E. (2013). ECT in Bipolar Disorder: Incidence of Switch from Depression to Hypomania or Mania. Journal of Depression & Anxiety, 01(05).

Bottlender, R., Sato, T., Kleindienst, N., Strauß, A. and Möller, H. (2004). Mixed depressive features predict maniform switch during treatment of depression in bipolar I disorder. Journal of Affective Disorders, 78(2), pp.149-152.

Buckley, P. (2012). The Neurobiology of the Switch Process in Bipolar Disorder: A Review. Yearbook of Psychiatry and Applied Mental Health, 2012, pp.388-392.

Calabrese, J. (2001). Drug-induced switch rates and their impact in bipolar disorder. European Neuropsychopharmacology, 11, pp.S95-S96.

Goldberg, J. (2010). Substance Abuse and Switch From Depression to Mania in Bipolar Disorder. AJP, 167(7), pp.868-869.

Kauer-Sant’Anna, M. and Yatham, L. (2007). Comment on “antidepressant treatment-emergent switch in bipolar disorder: a prospective case-control study of outcome”. Rev. Bras. Psiquiatr., 29(1), pp.86-87.

Koszewska, I. (1995). P-2-65 Pharmacotherapy in depression during switch from depression to mania in patients with bipolar affective disorder (BD). European Neuropsychopharmacology, 5(3), p.296.

Niitsu, T., Fabbri, C. and Serretti, A. (2014). P.2.d.031 Predictors for manic switch at depressive episodes in bipolar disorder: the Systematic Treatment Enhancement Program for Bipolar Disorder. European Neuropsychopharmacology, 24, pp.S431-S432.

Pettigrew, J. and Miller, S. (1998). A ‘sticky’ interhemispheric switch in bipolar disorder?. Proceedings of the Royal Society B: Biological Sciences, 265(1411), pp.2141-2148.

The Blame Game: Antidepressants Cause Bipolar Disorder?!

Previously the older anti-depressants were notorious for triggering or precipitating (hypo)manic episodes in Bipolar patients, newer antidepressants such as SSRIs, bupropion and venlafaxine, do not appear as likely to precipitate mania. Both the mood stabilisers lamotrigine (Lamictal) and Topiramate (Topamax) don’t carry a risk of inducing mania.  In the DSM-IV and DSM-V (Diagnostic and Statistical Manual of Mental Disorders) stipulates that diagnosing a person with Bipolar Disorder has to fit these criteria:

Criteria F: The episode is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication, other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g. medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence of a hypomanic episode diagnosis(My note: most* antidepressants other than Prozac are out of your system in a week). However, caution is indicated so that one or two symptoms (particularly in creased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, not necessarily indicative of a bipolar diathesis.

Very sneaky phrasing of words.

It has been asserted that antidepressants can act as triggers for (hypo)manic episodes in people who have a higher likelihood of Bipolar Disorder (depression, history & environmental factors etc.). It has been argued that having a (hypo)manic reaction to an antidepressant is not necessarily a symptom of Bipolar Disorder, arguing it’s a manic reaction to the antidepressant. This form of argument can only be assessed by being aware of what antidepressant you’re taking, newer antidepressants have very little chance of inducing mania (rare side effect : <0.1% chance mostly). I had initially blamed the antidepressant for causing my ‘bipolar symptoms’, this has now been changed, I was on Mirtazapine (given to me because of a family history of Bipolar I – this antidepressant had the <0.1% chance of inducing hypomania, agitation, aggression, risk taking, confidence, confusion and insomnia. All of which I experienced long after the antidepressant had left my system).

Symptoms of (hypo)mania need to persist after the life of the antidepressant: A manic reaction to antidepressants is not a symptom of bipolar, it’s a manic reaction to antidepressants. Therefore people who have a diagnosis of Bipolar Disorder who have a manic reaction to anti-depressants, doesn’t consequently mean that it’s Bipolar Disorder.  Symptoms of bipolar (hypo)mania are sometimes about being more irritable, edge and agitated, but these symptoms don’t mean it’s bipolar, they are generally symptoms of the antidepressant or its withdrawal. Sometimes it’s about surviving psychiatry. A test study about the activation of (hypo)mania states that it occurred approximately 0.2% (3/1299 patients) of Remeron-treated patients in US studies. Although the incidence of mania/hypomania was very low during treatment with mirtazapine, it should be used carefully in patients with a history of mania/hypomania.

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in people treated with (older)antidepressants for major depressive disorder. Before being prescribed antidepressants your doctor should be aware of your medical history or family history of psychiatric disorders (e.g., bipolar/manic-depressive disorder), history or family history of suicide attempts. To be diagnosed with Bipolar Disorder the new DSM-V has included the criteria that the person has to not only have the presence of elated or irritable mood but also the association of these symptoms with increased energy/activity.

Personal analysis: I’m not sure if I had suffered from hypomania before, every summer I would work out excessively and sleep little, this was only for the past 2years, but after Remeron (Mirtazapine) everything changed. My research was carried out on the premise of proving my psychiatrist wrong in my diagnosis. I had slowly put together my argument until I had looked up my antidepressant and the time it takes to leave my body. I now have to acknowledge that I no longer have an argument; my hypomania lasted well after the antidepressant had left my system and later returned when my mood stabiliser dose was reduced so that I could change medications. If anyone else has doubts about their diagnosis it is well worth the research into the causation of your (hypo)manic episode, if it was from an antidepressant find out how long your episode lasted and the time is takes for the antidepressant to leave your body.

Blame_by_umbra_rockchick

To make up for this realization is the knowledge that I had an awesome day in Luna Park at Sydney, here is some snaps 🙂

1476068_10152917804019806_7917392456868185958_n 10849899_10152917804229806_7035654910976126176_n 10849987_10152917804134806_6557675327053521344_n

Analysis Of Happiness & Mania. Part I

Analysis of Happiness & Mania

Defined:

To first understand happiness it needs to be defined. Happiness is seen as a complete, lasting and justified satisfaction with one’s life. Although if one has to justify their happiness it is no longer experienced subjectively, becoming objectively grounded. It has to be understood that there is no standardised rules to measure a person’s happiness as they are dependent on a person’s pre-dispositions.

Background:

Two philosophical schools who look at the concept of happiness, the ancient, which arose in Greece and survived until the 18th century, and the modern, which was created in the 19th century in Europe. Happiness was originally perceived as the possession of the highest goods, whether of a material or spiritual kind. Happiness later became subjectivized and relativized, based on a person’s overall satisfaction with life.

Happiness & Mental Health: The Darker Side of Happiness.

Happiness is usually conveyed as a source of good outcomes, highlighting the pursuit of important goals, social bonds, well-being and psychological health. In some instances the pursuit and experience of happiness can create negative outcomes. Happiness is generally highly beneficial but this is completely reliant on the context it is experienced in and the level of happiness.

“Getting angry . . . is easy and everyone can do it; but doing it . . . in the right amount, at the right time, and for the right end, and in the right way is no longer easy, nor can everyone do it.” —Aristotle, Nicomachean Ethics (II.9, 1109a27)

Potentially high levels of happiness can become a source of dysfunction, research often highlights that happiness is beneficial, yet psychologically it can become maladaptive. The maladaptive nature of happiness suggests that it has a possible ‘dark side’. People have argued that excessive levels of any mental state or experience—including happiness—can be undesirable and unhealthy. In relation to mania and the euphoric or heightened level of happiness (which is also experienced in hypomania) individuals are more inclined to engage in riskier behaviours, such as alcohol consumption, binge eating, and drug use. Extreme levels of happiness become a marker for emotional dysfunction.

The extremely positive emotion that is associated with mania undermines the person’s ability to experience negative emotions, trapped in a form of happiness overdrive and incapable of downshifting happiness. Excessive happiness leads to risky behaviour and neglect of threats and consequences. Extreme happiness seen through the lens of mania suggests that the emotion creates dysfunctional behaviours which result in poorer clinical functioning. The pursuit and achievement of happiness can no longer be seen as a hallmark for psychological health.

Subjective Bipolar Perception:

I had always imagined that happiness was a sign that I was getting better. After recently getting better from the pit that is depression, I keep wondering if this new happiness is real, or a daydream or merely a new page to living with bipolar. I have to remember that bipolar is part of who I am and why I feel things, but it never stops me from questioning the reasons for my emotional experiences and whether the emotions are manifestations of my illness or the signs of getting better. How can anyone fully differentiate between the two? It’s frustrating to say the least. To me there is great value in experiencing depression, without experiencing the worst aspects of your life you will never be able to completely appreciate the positive times. I can understand and relate to the all-consuming mania or hypomanic emotional overdrive, my personal experiences with hypomania made me incapable of understanding the consequences or perceive the drastic contrasts between my current state and depression, there was no room to understand other emotions.

This is truly my wonderland, a handful of pills keeping the bipolar at bay. The pills mediating a mid-line of emotions that are both boring and uninteresting. Unlike the majority of the population, people with Bipolar Disorder can actually reach the usually unobtainable level of happiness that society seems to always be aiming for, our level of happiness only becoming wrong when it makes us dysfunctional.

thumb

A Dark Side of Happiness? How, When, and Why Happiness Is Not Always Good. June Gruber, Iris B. Mauss and Maya Tamir. Perspectives on Psychological Science, Vol. 6, No. 3 (MAY 2011), pp. 222-233

Analysis of Happiness by W. Tatarkiewicz. Review by: E. R. The Review of Metaphysics, Vol. 32, No. 3 (Mar., 1979), pp. 569-570

Analysis of Happiness by Wladyslaw Tatarkiewicz. Review by: Max Rieser. Philosophy and Phenomenological Research, Vol. 38, No. 1 (Sep., 1977), pp. 139-140

quote-can-one-desire-too-much-of-a-good-thing-william-shakespeare-287019

Lamictal (Lamotrigine): A Review. Part II

I haven’t gained any weight from being on Lamictal, it’s a weight neutral mood stabilizer. My psychiatrist has also informed me that it is the only medication I should be on (other than sleep meds), as it targets both mania/hypomania and depression, he also asserts that Bipolar Disorder sufferers shouldn’t also be put on anti-depressants combined with mood-stabilizers. He offered me the quick fix of Lithium when I was on a downward slope, telling me I’d be a ‘new woman’ within a week. I know Lithium is the top-shelf mood-stabilizer, but I’m also shallow and self-conscious enough that I don’t want to get fat. Lithium for me also has negative associations, I use to think of it only being prescribed to those ‘hardcore’ cases, but then again maybe I am a ‘hardcore’ case. Maybe I’m not bipolar, think I might argue with my psychologist on Thursday.

They have increased my dose on Lamictal, it wasn’t doing enough at the time, especially in contrast to Epilim which fixed me quick, but made me gain weight through excessive carb cravings. Overall I think this is a good medication once you get to the right dosage, I think they will slowly titrate my dose up until I have no lows or extreme highs. If you are self-conscious of weight-gain from bipolar medication: THIS is the drug for you, but be aware that you have to increase your dose slowly, so the effects aren’t instantly noticeable. Now I should just focus on losing the weight the other drugs made me gain…not fun.

I have a great appreciation for the ‘crazy meds’ site, giving funny yet knowledgeable and relatable twists on medication. I’ve been diagnosed as Bipolar 2, yet my reaction was more like Bipolar 1. As follows:

4.2  Bipolar 2

Generally considered to be the best drug on the market for bipolar 2. While there are always conflicting data, your mileage may vary, yadda yadda yadda, with its track record for efficacy and other factors, Lamictal should be the first med considered, but not necessarily the first med used, by many, if not most people diagnosed with bipolar 2.

4.3  Bipolar 1

If you take it like the FDA tells you to – after being stable on another med – the chances are pretty good you’ll stay stable. If you start it while manic1 or only mild-to-moderately depressed and aren’t taking, let alone stable, on another med, expect to be bouncing off the ceiling and have your cycling sped up.

________________________

My reaction was exactly like Bipolar 1’s statement, I was taken too quickly off Epilim which was replaced by Lamictal, I guess I migh’t have been completely stable when I made the transition between the two. I was lowering my dose of Epilim and replacing it with Lamictal. I don’t know what happened really, it felt like a low-level hypomania, but with the increased dose I’m starting to feel less agitated, although i sleep extremely poorly and often have night terrors when I do sleep.

________________________

Lamictal’s Pros and Cons

7.1  Pros

The best medication on the market to deal with bipolar depression without the risks of mania or lowering the seizure threshold associated with antidepressants. Weight neutral. One of the safest meds to use during pregnancy. The side effects suck less than the other meds with FDA approval for maintenance treatment of bipolar disorder.

7.2  Cons

That “without the risk of mania” is only after you’re taking enough. You might get a little too happy the first couple of weeks. Easily affected by drug-drug interactions, in spite of being metabolized in such a way that only a few meds should affect it. Can mess with your skin in all sorts of ways that could cause you to panic and stop taking it when you don’t have to.

__________________

331776