Questions?   Comments?    I'd love to hear from you!      > > >
Good Mood Bad Mood
  • Home
  • Purchase
  • Endorsements
  • Resources
  • Contact
  • Blog

Chemical Imbalances: True or False?

1/7/2023

0 Comments

 
In the past two months, a really interesting study has been published by a group of researchers in the United Kingdom, including Joanna Moncrieff of the Division of Psychiatry at the University College London.[1] The article was the product of research that examined a large number of studies dealing with the chemical imbalance theory of depression. Specifically, the article discussed whether or not a lack of serotonin can be demonstrated to be the cause of depression.
For the last 50 years, the popular explanation for persistently sad moods was a lack of serotonin in the human brain or at least an imbalance in the chemicals that allow our nervous system to function. I can remember the print and television commercials showing the empty balloons in our heads that the medication was supposed to fill. Correcting our lack of serotonin was supposed to cure the sadness. It was a simple explanation that all of us could understand. The only problem with it was a lack of proof.
After searching published studies, the researchers concluded that “The main areas of serotonin research provide no consistent evidence of there being association between serotonin and depression and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations. Some evidence was consistent with the possibility that long term antidepressant use reduces serotonin concentration.”[2] And just like that, the curtain fell on the era of the chemical imbalance theory of depression.
There have been many responses in the news. Noted psychiatrist Dr. Ronald Pies took the opportunity to state that psychiatry was not responsible for the spread of the chemical imbalance theory. He more or less denied they had ever said it.[3] At the same time, The American Psychiatric Association has the following statement on its website: “Brain chemistry may contribute to an individual’s depression and may factor into their treatment. For this reason, antidepressants might be prescribed to help modify one’s brain chemistry.”[4]
Twitter has been ablaze with 300 keystroke criticisms from secular critics in terms that few would call speaking the truth in love. Another group is calling for a class action lawsuit against the APA, alleging that they promoted the theory to the hurt of patients/clients.[5] All told, it seems like a dark day for medicine in general and psychiatry specifically.
So, what does this mean for all of us, and how should we respond? How is this important to those who counsel from the Scriptures? What does it mean for patients and physicians? How will it affect those who deal with sad moods and their loved ones?
Let’s start with those of us in biblical counseling. For most of us, it really does not change how we understand the societal definition of depression or the way we approach it. In twenty-five years of teaching biblical counseling, I’ve been saying that there is no substantiating evidence that chemical imbalances cause depression. I suppose we can feel vindicated without taking a victory lap.
More important than being correct, knowing that the serotonin hypothesis is not true does do one important thing. This theory can no longer be used to say that everyone who struggles with a sad mood has a disease. And it cannot be used to support the idea that the only appropriate place for care for depression is in a doctor’s office.
This research should turn our attention away from a neuro-biological theory and back to the life circumstance causes that surround sadness. For those of us in biblical counseling, it should focus our attention on the old concept of normal versus disordered sadness. Horwitz and Wakefield made a great case for this in their research, which showed that 90% of those labeled with a depression diagnosis were grieving the loss of something important to them.[6]
As one of the authors of the study, Mike Horwitz, said, “The endless search for a single chemical that causes depression is probably looking in the wrong place because there’s such strong evidence that circumstances of our lives—stressful life events, poverty, work, insecurity, relationships—have a strong effect on the risk of depression.”[7] Biblical counseling has hope and answers for those who struggle with sadness over lost things, relationships, jobs, and anything else we think we cannot live without. We should pursue the opportunity to help those who suffer.
What Does This Mean for Physicians and Patients?Without a doubt, this research will affect the way physicians and patients view antidepressants. But first, it is important to ask what the research does not do. It is important to note that it does not address the question of whether or not medication for depression is safe and effective. Other research studies have examined this question, and these medications are not nearly as helpful as was hoped.[8]
At the same time, this research does not say that no one benefits from taking an SSRI antidepressant. Research would say that some do. The problem for the last 30 years has been over-prescription of these medications to individuals suffering with normal sadness over an identifiable loss. When antidepressants are given to the 90%, Wakefield and Horowitz explained that nearly 90% of those taking antidepressants do not benefit from taking them more than they would from taking a placebo.[9]
Since it is not clear how they work, physicians and patients should be having detailed discussions about the limitation of benefits and the known side effects of these medicines. And perhaps the best outcome will be that patients will be talking longer with physicians about other options such as counseling. Research has shown that the majority of patients benefit as much or more from counseling in the long run.
What Does This Mean for Medicine?The passing of the chemical imbalance theory is a good thing for medicine. It is not disappointing in the least. When an old, long-held, and incorrect theory bites the dust, it opens up research in a different direction. Instead of being stuck with the one magic bullet theory, now young, eager researchers will be looking for better explanations. And already, research is being published that offers a different explanation for depression.
Perhaps as medicine pursues research, we will come to understand the 10% with disordered sadness. Further, we may be able to find how much of that group has pathologically defined causes for their sad mood and medically correct and cure the problem. Biblical counseling has a role in this as well as we encourage counselees who do not fit the description of normal sadness to see their physician to make certain there is no identifiable, treatable cause for their mood. We also can help them respond to difficult circumstances with scriptural principles.
Serving Those Who Suffer and Their Loved Ones WellThe last question is, how can we best respond to this news in a way that helps those who suffer and those who love them? As biblical counselors, we should be aware that we have counselees struggling with whom they should believe. They may also fear losing what has been an explanation of their struggle. We should approach them in kindness with a heart tendered by Christ’s love.
I rarely talk with counselees about chemical imbalances. It isn’t why they come to counseling. Ninety percent will likely be working in loss recovery, struggling with the sadness that Scripture directly addresses. I would suggest that is what we should be doing. It is equally true in medicine and biblical counseling that if we do a better job of identifying those with normal sadness instead of labeling them as depressed, we will do a far better job helping them.
Questions for Reflection
  1. For the counselee with depression: Have you had a thorough physical with your physician to exclude medical causes of depression?
  2. For the counselor: How will you answer your counselee’s questions about the demise of the chemical imbalance theory?
[1] Joanna Moncrieff, Ruth E. Cooper, Tom Stockmann, Simone Amendola, Michael P. Hengartner, Mark A. Horowitz, “The serotonin theory of depression: a systematic umbrella review of the evidence,” Molecular Psychiatry, 2022, DOI: 10.1038/s41380-022-01661-0.
[2] Ibid.
[3] Ronald Pies, “The Serotonin Fixation: Much Ado About Nothing New,” Psychiatric Times, August 3, 2022, electronically retrieved August 21,  2022, https://www.psychiatrictimes.com/view/the-serotonin-fixation-much-ado-about-nothing-new.
[4] Quote retrieved from the American Psychiatric Association website on August 21,  2022, Psychiatry.org – What Is Depression?.
[5] Robert Whitaker, “Psychiatry, Fraud, and the Case for a Class-Action Lawsuit,” Mad in America, August 13, 2022 retrieved electronically August 21, 2022, https://www.madinamerica.com/2022/08/psychiatry-fraud-and-the-case-for-a-class-action-lawsuit/.
[6] Alan Horwitz, Jerome Wakefield, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, (New York: Oxford University Press, 2007), 19. Also see, Jerome Wakefield, Mark Schmitz, Michael First, Alan Horwitz, “Extending the Bereavement Exclusion for Major Depression to Other Losses” Archives of General Psychiatry, vol. 64 (April 2007), 438.
[7] Batya Swift Yasgur, “No Evidence Low Serotonin Causes Depression?” Medscape, July 22, 2022, Electronically retrieved August 21, 2022, https://www.medscape.com/viewarticle/977753.
[8] Charles Hodges, Good Mood Bad Mood: Help and Hope for Depression and Bipolar Disorder, (Wapwallopen; Shepherd Press, 2013), 48.
[9] Ibid., 48.
0 Comments

Medicine and Counseling: Running from Depression

12/4/2019

1 Comment

 
Medicine and Counseling: Outrunning Depression.
Depression is a common problem today with estimates that one in ten of us have it. At the same time, one fourth of our population is taking medication for a psychiatric diagnosis. As a physician and Biblical counselor, I would guess that after marital family problems, depression is one of the more common things for which people will come to counseling.
Early in my career as a physician, I read an article by Dr George Crane, a noted physician and newspaper columnist, about the way he helped those who came to his office with depression. Crane said that his approach was borrowed from an older physician who had treated depressed individuals for years. The elder doctor advised patients to do the following things when faced with sadness that just would not go away.
First, he would send them back to work because staying at home with their sorrow, just made for long days. He told them to go to church and to read a chapter daily of the gospel according to Luke, a fellow physician. He also told them to go walk a couple of miles a day.
Seems simple enough and I am certain some will say too simple. However, this past month a research study was published that once again says the old doctor was right. There was good news in Runners’ World magazine about depression and running.[i] It has long been held that depression is in some way genetically determined. Many have considered themselves destined to depression because they have several family members who struggle with sadness and depression. Well, it appears that family history does not make us a sitting target.
Research published in the journal “Depression and Anxiety” looked at the question of how physical activity affects the rate of depression for those who have a family history of it.[ii] What they found was that individuals who are more physically active are less likely to become depressed. The effect was enough that individuals who exercised were 20% less likely to be depressed than those who did not exercise. The benefit of exercise was significant enough to offset the effect of having a family history of depression. The research concluded that 35 to 45 minutes of exercise a day would be a benefit to our mental health.
Of course, I would be the first to agree with findings of this research. They don’t call me runningdoc for no reason. I have been running for 50 years. When I started it was simply a plan that would allow me to eat cherry or coconut cream pie anytime I wished. Eventually, it became obvious to those who knew me that my emotional well being was tied to my mileage. I ran at lunch time because it broke the day up and my nurse would testify that it calmed me down. I can’t say that I avoided depression because of running.  However, I can say that when I cannot run, I miss it.
As I seek to help people who struggle with sadness or worry, exercise has always been a significant part of the “prescription.” For most people, it is as effective as the current crop of medication. It has very few side effects and the costs are negligible. The old doctor was taking care of patients decades before there were medications to treat it. And, he was correct. That two-mile walk helped.
 
 


[i] Elizabeth Millard, Runners World, 11/22/2019. Electronically Retrieved.

[ii] Karmel W Choi, et al. Physical activity offsets genetic risk for incident depression assessed via electronic health records in a biobank cohort study. Depression and Anxiety, 11/5/2
019.
1 Comment

Biblical Counseling and Medicine: CBD Oil

11/23/2019

5 Comments

 
Biblical Counseling and Medicine: CBD oil. 
 
This week my search for something interesting and useful to blog about has landed in the Journal of the American Medical Association with an article titled, “Cannabidiol Products Are Everywhere, but Should People Be Using Them” by Rita Rubin MA.[1]  Anyone who has read my blog or tweets knows that I hold a dim view of recreational marijuana use. Marijuana is an addictive drug with significant side effects. This article does not deal with cannabis for recreational or medicinal use, but does look at the growing popularity of cannabidiol or CBD oil products. 
 
As I drive through my midwestern suburb, I see signs advertising the sale of CBD oil and CBD containing products most everywhere. Drug stores, convenience stores, video stores, and pizza parlors all seem to be attempting to supplement their income by selling CBD. As I see patients, many of them have added CBD to their medicine lists without a great deal of thought about the effectiveness, safety or even the legality of doing so. Most of them swear it works and who am I to question their truth? Well, this article does just that. 
 
The first question to ask ought to be, is CBD safe? The answer is no one really knows. We lack well designed controlled studies that look at what the adverse effects might be. What we do know is that for the one FDA approved prescription form of CBD oil used to treat intractable seizures, there are side effects. They include adverse effect on the liver, diarrhea, somnolence and decreased appetite. The effect included elevation of blood tests that would indicate damage to liver cells. [2]
 
Another problem is that the content of nearly all over the counter CBD products is not regulated by anyone. Some may think that is a great idea, but the problem is that those who buy these products have no guarantee what is in them. One study in the article noted that of 20 different popular CBD products “only 3 contained what the label said.” Eight had 20% less CBD in them than labeled and 2 contained no CBD at all. [3]The author suggested that people who choose to use CBD buy only from suppliers that they trust. Certainly it appears that the buyer should beware. 
 
The next question addressed in the article, was whether or not CBD actually works. Information concerning effectiveness is lacking. The author notes that there is one FDA approved form of CBD that is indicated to treat seizures that do not respond to any other treatment. Beyond that, little to nothing is known as to whether CBD actually helps the long list of things that it is claimed to improve. There are studies in progress that are testing effectiveness for treating psychosis, but none for depression, anxiety, Tourette syndrome, or ADHD. [4]
 
The last question the article deals with is whether or not CBD is legal. My state passed a law making it legal to sell. The complication arises that since there is an FDA approved form of CBD oil, it’s illegal by FDA standards. This is a complicated situation that will require further legislation to remedy.[5]
 
So, the question comes down to whether or not you should consider using CBD and whether or not I would recommend it. The author notes that children, pregnant women, and those taking other prescribed medications should not take CBD oil at this time. Not enough is known as to the adverse effects and interactions with other medications to say that it is safe. Until good research is done that establishes using CBD oil to be safe and effective, I would not recommend it’s use.  
 
 


[1] Rubin R. Cannabidiol Products Are Everywhere, but Should People Be Using Them? JAMA. Published online November 20, 2019. doi:https://doi.org/10.1001/jama.2019.17361
All factual information for this blog comes from this article. CBD oil is a derivative of Hemp or the Marijuana plant that does not contain any significant THC, the intoxicating portion of marijuana. 
[2] Ibid. E1
[3] Ibid. E1
[4] Ibid. E2
[5] Ibid. E2
5 Comments

Schizophrenia: Reviewing an Overview

11/13/2019

0 Comments

 
Schizophrenia: Reviewing an Overview.

A friend sent me a message recently asking me to comment on an article published in the JAMA Psychiatry that reviewed the current medical knowledge concerning schizophrenia. The article, Schizophrenia—An Overview was published on October 30, 2019.  Schizophrenia affects about one percent of our population, and eventually those who counsel much will encounter those affected by it.[1]  For many reasons, the subject deserves our attention.  My goal with this blog is to summarize the article and then comment along the way with some conclusions about it and some other articles at the end.
​
For those in the Biblical counseling movement, schizophrenia has always been a conundrum. It is hard at times to think that the behavior of an individual may be connected to a disease process in the body, particularly if that behavior is troublesome.  There is a wide range of opinions about the cause and care of schizophrenia. The disagreement starts at a very basic level. Is schizophrenia a brain-based disease, or is it a spiritual problem? Or, is it someplace in between?

Pathology: Change at the Cell Level that Changes Function.
Most in Biblical counseling have asked for pathology as the standard for calling anything a disease including schizophrenia. That is, for a collection of symptoms, emotions, thinking, or behaviors to be considered part of a disease, there ought to be a change in the physical body that results in the change in function.  And, we should be able to document it.

It is important to remember that while all disease will have pathologic change causing it, we may not be able to demonstrate it. Problems like migraine headaches would be recognized as a disease problem by most physicians although we do not yet completely understand the underlying change in the brain that causes them. Schizophrenia is in the same spot in medicine today. Most physicians and researchers would say it is brain disease.  In the past decade we have seen an increasing number of physical differences discovered in the brains of individuals affected by schizophrenia. The review article documents some of the changes that have been found.

Defining Schizophrenia is important.
First, the authors do a service by setting out the criteria for making the diagnosis of schizophrenia. A recent research study showed that up to 50% of those labeled as schizophrenic do not meet the criteria for the diagnosis.[2] To qualify for the diagnosis an individual must have had two of the following; delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms such as diminished emotional expression or decreased ability to think.[3] These symptoms must be present for a month or longer and one of the first three must be present as well.

Genetics play a part.
The authors divided the paper into three parts that deal with the causes, the change in brain function and treatment. The first section dealt with the family history and genetics. Advances in genome-wide association studies have identified 100 genetic areas or loci in our DNA that are associated with an increased risk of developing the symptoms associated with schizophrenia. A defect in one gene increases the risk to 30 or 40%. For those with this specific genetic change, it places them in a similar situation as those who carry the gene for Alzheimer’s with increased risk to have the problem.[4]

The authors point out that while genetic inheritance appears to play a significant role in having schizophrenia, it does not appear to be the sole cause as it would be in Huntington’s disease, a devastating degenerative brain disorder. Identical twins have a 50% chance of developing the disorder, but not 100%.[5] The authors note that problems during pregnancy and in the time around birth appears to increase the risk for developing schizophrenia by five times that which would be expected in the general population.[6]
 
When our immune systems attack us.
The most interesting portion of the research had to do with the potential role of the immune system in schizophrenia. A change in a gene that affects the human immune system in the complement system (complement C4) appears to result in an increased destruction or pruning of the connecting structures in the brain called synapses. The increased destruction of brain connections (by microglia) appears to be connected to symptoms.[7] This gene defect that affects C4 was identified in a large study in 2016.[8] This research described in the paper offered evidence that there was a physical process doing damage to the brain that was associated with the symptoms of schizophrenia.[9]

There are objective findings of this destructive process. It was noted that problems with the ability to think appeared in affected adolescent patients earlier than hallucinations and delusions.  In adolescent patients, Brain scans done over time showed changes in the brain tissue. They noted that the cognitive/thinking problems appeared to be connected to significant loss in gray matter areas of the brain.[10]

Pathology at a cell level.
Studies performed on the brains of affected individuals after death have shown significant differences which may contribute to abnormal brain function. There are fewer dendritic spines in important areas of the brain that affect thinking. These findings are not seen in normal brains. The changes in the brain tissue would be considered pathological and support the designation of schizophrenia as a brain disease.[11]

Brain Scans: Looking through a glass darkly.
It is easy to be critical of how brain scanning is used to support psychological diagnoses today and I have been at times.[12] However, as time marches on, the scans improve and so does the information. Molecular imaging now allows researchers to look at the concentration of substances inside the living human brain. Studies have been conducted that look at the concentration of dopamine in the brains of schizophrenics and control subjects.[13]

With the molecular imaging, it has been shown that dopamine is elevated in the brains of those with psychotic symptoms as compared to normal control subjects. This was true for those taking amphetamines who developed psychosis[14]. It was also true for those with schizophrenia. The elevation of dopamine correlated with the level of psychotic symptoms of those with schizophrenia.[15] These studies do not tell us why the levels of dopamine are elevated or but they do provide an objective way to identify the difference in the brain of those with schizophrenia that is associated with the symptoms.

One last bit of observable information comes in the form of brain wave patterns as observed with electrophysiological studies. The authors described research that measured gamma brainwave activity in normal individuals and those with schizophrenia and they were different.[16] The differences were thought to accompany or be caused by the damage resulting in the decline in the thinking ability of the patient. (cognitive function)

The last section of the review article dealt with treatment. Current treatment centers around reducing the psychotic symptoms. Most all of the medications used block the D2 receptor for dopamine in the brain and by doing that, decrease the effect of dopamine and the psychosis. The effect of these medications can be seen today with positron emission tomography brain scans that can measure the amount of blockade that occurs at the receptor site. It is known that a 60% level of blockade needs to occur to lower the psychotic symptoms and that at 80% side effects occur.[17]

The fact that we can see the area that is blockaded by the medication and the level of the blockade that is required in order to stop the psychosis, is useful. It becomes a measurable piece of information that supports the designation of schizophrenia as a brain disease.

Medicine and Counseling: What Helps?
While current medicines seem to help the psychotic symptoms, they do not help the problems with declining cognitive abilities. Approximately one third of those with schizophrenia do not respond to dopamine receptor blocking medications. These individuals may be helped by other medication.[18]

The authors noted that counseling seemed to benefit those who had the psychosis symptoms of schizophrenia. They did not say what kind of counseling was used. They indicated that counseling helped the affected individual to understand and deal with the psychotic episodes better.[19]

Comments.
This review article has documented several important points which would lead most of us to the conclusion that schizophrenia is a brain disease or at the least has a significant medical/physical component. The connection between genetic defects and our immune system appears to offer a promising explanation for the damage that occurs in the brain. It may lead to the ability to validate the diagnosis with blood testing and to treatment.

The brain scans that can now measure the activity of dopamine offer an explanation for the psychotic symptoms. The autopsy reports on brains of schizophrenics confirm the presence of an ongoing destructive disease process. All of this information would point to schizophrenia being a brain disease process and among physicians, there would be few who would disagree.

It is still true that the absolute definition of the cause of symptoms in schizophrenia has not been defined. A great deal of research exists that demonstrates pathological change in the brain among those who are affected. Those of us in Biblical Counseling should approach the counseling of individuals who present with the diagnosis with a 1Thessalonians 5:14 attitude. “Admonish the unruly, encourage the fainthearted, help the weak, be patient with everyone.”

Other Research.
In the past year there have been several interesting research papers and case reports published about this subject. The one that interested me the most connects some of the dots between the genetic and pathological studies. It is a case report published in the Psychiatric Times that documented the history of two individuals who needed a bone marrow transplant for leukemia.[20] In one case the individual received a transplant from a sibling who had symptomatic schizophrenia. While he was cured of his leukemia, he developed the symptoms of schizophrenia. In the second case an individual who had schizophrenia received a bone marrow transplant from an individual who did not have schizophrenia. He was cured of his leukemia and his schizophrenia.

What does the case study imply? Bone marrow transplants require that the individuals current bone marrow be replaced. It is the source of the cancer, and to cure, the old bone marrow must go . In essence the individual receives an immune system transplant. It may well be the case that schizophrenia is an autoimmune disorder much like other autoimmune diseases that affect the brain.  
There are other auto-immune disorders that affect the brain and can be treated.[21] If schizophrenia turns out to be caused by an immune disorder that attacks the tissue of the brain, then there is great potential that we will be able to test for it and eventually treat it. Currently it exists in much the same realm as Alzheimer’s disease, where we have a growing understanding of the pathology, but are struggling to create drugs that cure it.

Conclusions.
We started with the question, is schizophrenia an outcome of spiritual problems or is it a medical problem, a disease of the brain that results in the symptoms.
We are not the first to grapple with this question. Freud considered it and decided that schizophrenia was a result of unresolved conflicts in the individual’s life usually with a parent. Kraepelin believed that schizophrenia was a biological brain disorder for which there was no cure or treatment. In either case neither of them had much success in the care of those affected.

What can we say then about the cause and care of schizophrenia from the articles we have examined? First, there is a growing body of medical evidence that supports the idea that schizophrenia is a brain-based disease. Few physicians would say anything different. As we noted above, it is important to remember that schizophrenia is often over diagnosed. And, psychosis from drug use and other disease can certainly be mistaken for it.

Second, is schizophrenia primarily a spiritually caused problem?  The more we know about it from a medical viewpoint, the less likely this seems. Is it a medical problem with spiritual implications? This seems to be more likely.

In either case, at this time the answer is not absolutely certain. As one writer said, the truth is probably somewhere in the middle. As a physician and Biblical counselor, I believe schizophrenia will prove to be a medical problem that will eventually have a cure. However, that is just my opinion. I do believe that opinion rests on a growing body of research findings. Current medical treatment for the psychotic symptoms can be helpful to many, but not all. I also think that individuals who struggle with the symptoms of schizophrenia will need the kind of care that comes from scripture as might anyone with a chronic medical problem.
 
 
 
 
 


[1] McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia—An Overview. JAMA Psychiatry. Published online October 30, 2019. doi:https://doi.org/10.1001/jamapsychiatry.2019.3360

[2] Coulter, Chelsey, Baker, Krista K., Margolis, Russell L. Specialized Consultation for Suspected Recent-onset Schizophrenia Diagnostic Clarity and the Distorting Impact of Anxiety and Reported Auditory Hallucinations. Journal of Psychiatric Practice, 2019 DOI: 10.1097/PRA.0000000000000363

[3] Schizophrenia, McCutcheon, E2.

[4] Ibid, E2.

[5] Ibid, E2

[6] Ibid, E2

[7] Ibid, E2

[8] Aswin Sekar, Allison R. Bialas, Heather de Rivera, Avery Davis, Timothy R. Hammond, Nolan Kamitaki, Katherine Tooley, Jessy Presumey, Matthew Baum, Vanessa Van Doren, Giulio Genovese, Samuel A. Rose, Robert E. Handsaker, Mark J. Daly, Michael C. Carroll, Beth Stevens, Steven A. McCarroll. Schizophrenia risk from complex variation of complement component 4. Nature, 2016; DOI: 10.1038/nature16549

[9] Broad Institute of MIT and Harvard. "Genetic study provides first-ever insight into biological origin of schizophrenia: Finding explains clinical observations, opens new therapeutic avenues." ScienceDaily. ScienceDaily, 27 January 2016. <www.sciencedaily.com/releases/2016/01/160 This is the summary in ScienceDaily of the article noted in 7.

[10] Schizophrenia, McCutcheon, E3.

[11] Ibid, E4.

[12] For an interesting read on the pitfalls of brain scanning see “Brainwashed: The Seductive Appeal of Mindless Neuroscience,” by Sally Satel. Basic Books, New York. 2013.

[13] Ibid, E5.

[14] Lauren V. Moran, Dost Ongur, John Hsu, Victor M. Castro, Roy H. Perlis, Sebastian Schneeweiss. Psychosis with Methylphenidate or Amphetamine in Patients with ADHD. New England Journal of Medicine, 2019; 380 (12): 1128 DOI: 10.1056/NEJMoa1813751

[15] Schizophrenia, McCutcheon, E5.

[16] Schizophrenia, McCutcheon, E4.

[17] Ibid, E6.

[18] Ibid, E6.

[19] Ibid, E6.

[20] Immunotherapy as Personalized Medicine for Schizophrenia, Brian Miller, MD, Psychiatric Times, February 28, 2019, Vol 36, Issue 2. https://www.psychiatrictimes.com/special-reports/immunotherapy-personalized-medicine-schizophrenia

[21] An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models,
Josep Dalmau, PhD, Thais Armangué, PhD. Et. Al. Lancet, Published:July 17, 2019DOI:https://doi.org/10.1016/S1474-4422(19)30244-3
0 Comments

Blogs today at biblicalcounselor.com

10/26/2019

1 Comment

 
Hello Friends, 

I am currently working on my blog site tonight and intend to resume blogging this week about Medicine and counseling. Until I get things straightened out you can find two of my recent blogs at biblicalcounselors.com. One blog on worry is in the Faith Biblical Counseling Ministry space and another on research on dating is found in the Biblical Counseling Coalition column.  

​Writing more soon! 

Charles Hodges MD 
1 Comment

People Change: New Research Shows That Personalities Change

1/7/2017

1 Comment

 
People Change: New Research Shows Personalities Change!
There is good news to start the new year with today in psychological research. An analysis of 207 research studies that included 20,000 patients has found that people who are characterized by neurotic behavior change as a result of psychological and medical care they receive. In an article published in Psychological Bulletin, researchers from the University of Illinois, have found that people can change.[i]
Now this seems almost like a self-evident truth, but according to lead researcher Brent Roberts many “subscribe to the idea that once someone reaches adulthood their personality is set for life.”[ii] This is particularly true of individuals who are described as neurotic, who struggle with depressed moods, and feelings of guilt, envy, anger, and anxiety.
The research found that individuals who were cared for with cognitive behavioral therapy, counseling or medical treatment over 24 weeks changed! Those who struggled with anxiety benefited the most. Emotional improved by half and persisted long after the care was over.
Should we be surprised by this? Not at all, in fact it is really great when science tells us something that we have known for millennia. The Apostle Paul told us in his letter to the Corinthians that if “any man be in Christ, he is a new creature, the old things have passed away, new things have come.”
It is not a bit surprising that people with anxiety would benefit the most from counseling. Jesus told us repeatedly to trust Him and to not worry. 3"Do not worry then, saying, 'What will we eat?' or 'What will we drink?' or 'What will we wear for clothing?...for your heavenly Father knows that you need all these things. But seek first His kingdom and His righteousness, and all these things will be added to you. So do not worry about tomorrow…” (Mat 6:31-34 NAU) Jesus came as the solution to the things that make us worry.
From the time that the gospel was announced, it has always brought hope that men and women did not need to spend the rest of the lives as slaves to fear, worry and sadness. It is good to know that secular researchers have “discovered” this truth. As Jesus said, "Come to Me, all who are weary and heavy-laden, and I will give you rest. Take My yoke upon you and learn from Me, for I am gentle and humble in heart, and find rest for your souls. For My yoke is easy and My burden is light."  (Mat 11:28-30 NAU)
People who struggle with fear, worry, sad moods and other emotional problems do no need to spend their lives believing that there is no hope for change. Current research tells us they can change. This has always been an essential part of the gospel message.
 
[i] Brent W. Roberts, Jing Luo, Daniel A. Briley, Philip I. Chow, Rong Su, Patrick L. Hill. A Systematic Review of Personality Trait Change Through Intervention.. Psychological Bulletin, 2017; DOI: 10.1037/bul0000088
 
[ii] University of Illinois at Urbana-Champaign. "Counseling, antidepressants change personality (for the better), team reports." ScienceDaily. ScienceDaily, 6 January 2017. <www.sciencedaily.com/releases/2017/01/170106130918.htm>.
1 Comment

What's New About Bipolar Disorder: Student Notes

10/6/2015

0 Comments

 
​What’s New in Bipolar Disorder?
 
 
  1. Introduction:  Surge in Diagnosis since 1980.
  1. Epidemic?
 
B.        Changing criteria?
 
C.        Root of the problem is in diagnosis and treatment of depression.
 
D.        Similar subjective criteria method used to diagnose BPD as is in depression.
 
 
  1. Definitions.
  1. Bipolar disorder categories:
  1. BPD 1, the old manic depression;
  2. BPD 2;
  3. Cyclothymia;
  4. Depression with family history of BPD;
  5. Mania alone;
  6. BPD, other specified bipolar and related diseases.
 
  1. Criteria for BPD 1 (old manic depression):
    1. Period of more than one week of improved mood;
 
  1. Irritable, inflated sense of self-esteem with decreased need for sleep;
 
  1. Easily distracted with a pressing need to get things done;
 
  1. Spending money they do not have.  Disastrous sexual or moral choices are made;
 
  1. Mania is followed by depression.  Diagnosis of depression is required.
 
 
  1. Significant changes:
    1. A week long episode of mania is no longer required for hospitalization;
 
  1. Criteria for BPD2 are less restricted:
    1. Presence of one or more major depressive episodes;
    2. Presence or history of at least one hypomanic episode;
    3. No prior manic episode or mixed episode;
    4. Symptoms are not better accounted for by another disorder;
    5. The symptoms cause significant clinical distress or impairment in social, occupational or other areas of function.
 
  1. The key difference is between mania and hypomania, which makes applying the diagnosis much less difficult.
    1. A distinct period of persistently elevated, expansive, or irritable mood, lasting at least four days, that is clearly different from the usual non-depressed mood.
    2. During the period of mood disturbance, three or four of the following symptoms have persisted (four, if only irritable) and have been present to a significant degree:
      1. Inflated self-esteem or grandiosity;
      2. Decreased need for sleep (feels rested after three or four hours)
      3. More talkative than usual or feels pressure to keep talking;
      4. Flight of ideas or subjective experience that thoughts are racing;
      5. Distractibility;
      6. Increase in goal-directed activity (social, work, school, sexually) or psychomotor agitation;
      7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (buying sprees, sexual indiscretions.

 
  1. Represents change in function level, observed by others.
  2. Not severe enough to cause marked impairment in social or occupational functioning and does not have psychotic features.
 
  1. This is the important dividing line!
    1. Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (medication, ECT, light therapy) should not count toward a diagnosis of BPD2 disorder.
    2. The problem is that most people labeled with depression are on antidepressant medication when labeled with BPD2.
  • “Instead of treating a new disease, we may simply be treating the side effects of a drug used to treat an old one.”
 
 
  1. What’s New in Research?
  1. Understanding bipolar disorders is important.  It shortens life!
 
  1. BPD is over-diagnosed.
  1. Most making the diagnosis fail to use the criteria;
  2. Not confirmed later;
  3. More likely to diagnose something treated with medication;
  4. Mood swings common to many DSM5 diagnoses.
 
  1. Pathology.
    1. Stem cell research;
    2. Schizophrenia and BPD have common pathology;
    3. MRI scanning with changes in the cerebellum, understanding lithium;
    4. Risk takers and MRI changes.
 
  1. Treatment.
    1. Lithium and non-responders;
    2. Counseling helps!  CBT and BPD;
    3. Anti-psychotic drugs change brains.
  2. Genetics.
    1. Connection between BPD and schizophrenia;
    2. Creativity, BPD, and genes;
    3. New genes.
 
  1. Marijuana, schizophrenia, and bipolar disorder:
    1. Which comes first?  BPD or pot?
    2. How does marijuana affect BPD course?
 
  1. Symptoms:  fuzzy thinking and BPD.
 
  1. Other.
 
 
  1. What can we do to help?
 
  1. Understand the difference between BPD1 and BPD2.
    1. Mania and hypomania;
    2. BPD1 is a disease;
    3. BPD2 is more likely a side effect.
 
  1. Understanding the importance of medication.
    1. BPD1 may require medication indefinitely;
    2. BPD2 may not benefit much from medications currently used;
    3. Side effects are very real.
 
  1. BPD1:
    1. Counseling from a chronic medical disease viewpoint;
    2. Need a John 11 view of suffering;
    3. Motive must change.  2 Corinthians 5:9;
    4. Growth and change;
    5. Anger;
    6. Worry;
    7. Gratitude;
    8. Christian service;
    9. Christian responsibility in health care.
 
  1. BPD2:  in the absence of classic mania:
    1. Look for a historical source;
    2. Consider over-diagnosed depression with medication side effects.  Remember 90/10.
    3. Look for behavior, thinking, and emotional responses to adverse events of life, and examine them through the lens of scripture;
    4. Look for the difference between normal and disordered sadness;
    5. Help the counselee see that difference;
    6. See point III, A-H.
    7. Help the counselee see the opportunity in the trial.
 
 
 
 
 
Complete bibliography available at www.goodmoodbadmood.com
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
0 Comments

What's New About Bipolar Disorder: Bibliography

10/6/2015

0 Comments

 
Bibliography for “What’s New in Bipolar Disorder.”
III. A. University of Oxford. "Many mental illnesses reduce life expectancy more than heavy smoking." ScienceDaily. ScienceDaily, 23 May 2014. <www.sciencedaily.com/releases/2014/05/140523082934.htm>.

B.1-3 Lifespan. "If Bipolar Disorder Is Over-diagnosed, What Are The Actual Diagnoses?." ScienceDaily. ScienceDaily, 29 July 2009. <www.sciencedaily.com/releases/2009/07/090729100936.htm>.

B4. Rashmi Patel et al. Mood instability is a common feature of mental health disorders and is associated with poor clinical outcomes.BMJ Open, May 2015 DOI: 10.1136/bmjopen-2014-007504
King's College London. "Mood instability common to mental health disorders, associated with poor outcomes." ScienceDaily. ScienceDaily, 21 May 2015. <www.sciencedaily.com/releases/2015/05/150521210637.htm>.

C.1 H M Chen, C J DeLong, M Bame, I Rajapakse, T J Herron, M G McInnis, K S O’Shea. Transcripts involved in calcium signaling and telencephalic neuronal fate are altered in induced pluripotent stem cells from bipolar disorder patients. Translational Psychiatry, 2014; 4 (3): e375 DOI: 10.1038/tp.2014.12
University of Michigan Health System. "First stem cell study of bipolar disorder yields promising results." ScienceDaily. ScienceDaily, 25 March 2014. <www.sciencedaily.com/releases/2014/03/140325113226.htm>.

C.2 Glenn T. Konopaske, Nicholas Lange, Joseph T. Coyle, Francine M. Benes. Prefrontal Cortical Dendritic Spine Pathology in Schizophrenia and Bipolar Disorder. JAMA Psychiatry, 2014; DOI:10.1001/jamapsychiatry.2014.1582
The JAMA Network Journals. "Schizophrenia, bipolar disorder associated with dendritic spine loss in brain." ScienceDaily. ScienceDaily, 2 October 2014. <www.sciencedaily.com/releases/2014/10/141002092428.htm>.

​C.3 Children vs adults
Ezra Wegbreit, Grace K. Cushman, Megan E. Puzia, Alexandra B. Weissman, Kerri L. Kim, Angela R. Laird, Daniel P. Dickstein.Developmental Meta-analyses of the Functional Neural Correlates of Bipolar Disorder. JAMA Psychiatry, 2014; DOI:10.1001/jamapsychiatry.2014.660
 Lifespan. "Difference found in way bipolar disorder affects brains of children versus adults." ScienceDaily. ScienceDaily, 18 June 2014. www.sciencedaily.com/releases/2014/06/140618165113.htm
 
C.3 MRI scans and Lithium.
C P Johnson, R L Follmer, I Oguz, L A Warren, G E Christensen, J G Fiedorowicz, V A Magnotta, J A Wemmie. Brain abnormalities in bipolar disorder detected by quantitative T1%u03C1 mapping.Molecular Psychiatry, 2015; DOI: 10.1038/mp.2014.157
University of Iowa Health Care. "Bipolar disorder: New MRI imaging provides new picture, new insight." ScienceDaily. ScienceDaily, 6 January 2015. <www.sciencedaily.com/releases/2015/01/150106081217.htm>.
 
C.4 Wael El-Deredy et al. Decision-making and trait impulsivity in bipolar disorder are associated with reduced prefrontal regulation of striatal reward valuation. Brain, July 2014 DOI: 10.1093/brain/awu152
Manchester University. "Why people with bipolar disorder are bigger risk-takers." ScienceDaily. ScienceDaily, 9 July 2014. <www.sciencedaily.com/releases/2014/07/140709095626.htm>.
 
D.1David Gurwitz et al. Insulin-like Growth Factor 1 Differentially Affects Lithium Sensitivity of Lymphoblastoid Cell Lines from Lithium Responder and Non-responder Bipolar Disorder Patients. Journal of Molecular Neuroscience, April 2015 DOI: 10.1007/s12031-015-0523-8
American Friends of Tel Aviv University. "Personalizing bipolar disorder treatment." ScienceDaily. ScienceDaily, 22 April 2015. <www.sciencedaily.com/releases/2015/04/150422121911.htm>.
 
D.2Steven H. Jones, Gina Smith, Lee Mulligan, Fiona Lobban, Heather Law, Graham Dunn, Mary Welford, James Kelly, John Mulligan And Anthony P. Morrison. Recovery-focused cognitive-behavioural therapy for recent-onset bipolar disorder: randomised controlled pilot trial.British Journal of Psychiatry, September 2014 DOI:10.1192/bjp.bp.113.141259
Lancaster University. "Talking therapy for people with a recent bipolar disorder diagnosis." ScienceDaily. ScienceDaily, 11 September 2014. <www.sciencedaily.com/releases/2014/09/140911093328.htm>.
 
D.3Haiming Chen, Nulang Wang, Xin Zhao, Christopher A Ross, K Sue O’Shea, Melvin G McInnis. Gene expression alterations in bipolar disorder postmortem brains. Bipolar Disorders, 2013; 15 (2): 177 DOI:10.1111/bdi.12039
niversity of Michigan Health System. "Do drugs for bipolar disorder 'normalize' brain gene function?." ScienceDaily. ScienceDaily, 11 April 2013. <www.sciencedaily.com/releases/2013/04/130411105833.htm>.
 
E.1Robert A Power, Stacy Steinberg, et.al, Polygenic risk scores for schizophrenia and bipolar disorder predict creativity. Nature Neuroscience, 2015; DOI:10.1038/nn.4040
  King's College London. "Schizophrenia, bipolar disorder may share genetic roots with creativity."   ScienceDaily. ScienceDaily, 8 June 2015.  <www.sciencedaily.com/releases/2015/06/150608120145.
     
      E.2 Mark Weise et al. Biological insights from 108 schizophrenia-associated genetic loci. Nature, 2014; 511 (7510): 421 DOI:10.1038/nature13595
Niamh L. O’Brien, et.al, The functional GRM3 Kozak sequence variant rs148754219 affects the risk of schizophrenia and alcohol dependence as well as bipolar disorder. Psychiatric Genetics, 2014; 1 DOI: 10.1097/YPG.0000000000000050
University College London. "Gene variant linked to schizophrenia, bipolar disorder, alcoholism." ScienceDaily. ScienceDaily, 22 July 2014. www.sciencedaily.com/releases/2014/07/140722091611.htm
 
E.3Thomas W. Mühleisen, et.al,  Genome-wide association study reveals two new risk loci for bipolar disorder.Nature Communications, 2014; 5 DOI: 10.1038/ncomms4339
Universität Bonn. "New gene for bipolar disorder discovered." ScienceDaily. ScienceDaily, 11 March 2014. <www.sciencedaily.com/releases/2014/03/140311123919.htm>.
 
F1. Elizabeth Tyler, Steven Jones, Nancy Black, Lesley-Anne Carter, Christine Barrowclough. The Relationship between Bipolar Disorder and Cannabis Use in Daily Life: An Experience Sampling Study.PLOS ONE, 2015; 10 (3): e0118916 DOI: 10.1371/journal.pone.0118916
Lancaster University. "How cannabis use affects people with Bipolar Disorder." ScienceDaily. ScienceDaily, 13 March 2015. <www.sciencedaily.com/releases/2015/03/150313130855.htm>.
 
F.2 Melanie Gibbs, Catherine Winsper, Steven Marwaha, Eleanor Gilbert, Matthew Broome, Swaran P. Singh. Cannabis use and mania symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 2015; 171: 39 DOI: 10.1016/j.jad.2014.09.016
University of Warwick. "Significant link between cannabis use and onset of mania symptoms." ScienceDaily. ScienceDaily, 10 February 2015. <www.sciencedaily.com/releases/2015/02/150210160101.htm>.
 
G. K.Ryan, et.al, Shared dimensions of performance and activation dysfunction in cognitive control in females with mood disorders. Brain, 2015; 138 (5): 1424 DOI:10.1093/brain/awv070
University of Michigan Health System. "'Fuzzy thinking' in depression, bipolar disorder: New research finds effect is real." ScienceDaily. ScienceDaily, 4 May 2015. <www.sciencedaily.com/releases/2015/05/150504171055.htm>.
 
H. Biblical Counseling Coalition website, Sept.7, 2015. Medication Biblical Counseling, & Depression: What’s New in Serotonin. Charles Hodges MD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0 Comments

ADHD: New Research! Moving Matters in Learning! 

4/29/2015

0 Comments

 
ADHD: New Research 

In the last decade the diagnosis of ADHD grew among children by 53%. Twenty percent of high school aged boys carry the diagnosis as do eleven percent of children and teens. Much of what our society does about the problem centers around the prescription of amphetamine derivative medication. The goal of the medication is to focus their attention and reduce their hyperactivity. And, it appears that the goal may be wrong.

New research published in the Journal of Abnormal Child Psychology, conducted at the University of Central Florida indicates that current thinking about hyperactive children may be wrong. Instead of making it difficult or impossible for them to learn, movement maybe an important key to their learning.[i] “The foot-tapping, leg swinging, and chair-scooting…are actually vital to how they remember information and work out complex tasks.”[ii] It appears that if they aren’t moving, they may not be learning!

“The typical interventions target reducing hyperactivity. It’s exactly the opposite of what we should be doing.”[iii] Instead the researchers said that educators should be facilitating the child’s movement. The study included 52 boys ages 8 to 12. Out of that group 29 boys had the label of ADHD, and 23 did not.

The boys were video recorded and their movements were recorded by observers as they performed a math problem. What they found was very important to the children and learning. The boys who were labeled with ADHD were not hyperactive continuously. Instead they developed the excessive movement when they were performing the math problem. When they were using the part of our brains that allows us to make memories, they were moving. Instead of being a problem, the movement was needed in order to do the task.

Boys without ADHD, did not increase their movement when they were asked to do the math problem. And, if they did increase their movement their performance of the problem worsened. The study showed that in order to help children who meet the behavior criteria for ADHD, we need to rearrange the learning environment. These students may perform better if they do their work sitting on exercise balls or exercise bicycles instead of traditional chairs and desks.

This is great research! Someone has finally stood up and said what I have been saying about ADHD for a decade. These children certainly are different. They learn differently. Instead of trying to force them into a one size fits all form of education by medicating them, we should be changing the classroom. We need to educate children in the best way they can learn.

Reminds me of something the writer of Proverbs said. “Raise up a child in the way that he should go…” That may not always be the way every child goes or the way that the majority of those in medicine and education think best. 



[i] Dustin E. Sarver, Mark D. Rapport, Michael J. Kofler, Joseph S. Raiker, Lauren M. Friedman. Hyperactivity in Attention-Deficit/Hyperactivity Disorder (ADHD): Impairing Deficit or Compensatory Behavior?Journal of Abnormal Child Psychology, 2015; DOI: 10.1007/s10802-015-0011-1


[ii] University of Central Florida. "Kids with ADHD must squirm to learn, study says." ScienceDaily. ScienceDaily, 17 April 2015. <www.sciencedaily.com/releases/2015/04/150417190003.htm>.


[iii] Ibid.


0 Comments

"Punishing Kids for Lying Just Doesn't Work” New Research!

2/28/2015

0 Comments

 
Headlines like this always catch our attention. I suppose the writer thought we might all read it and decide that spanking Johnny for telling whoppers was useless. I am certain that the writer for ScienceDaily[i] meant well, but the headline misses the point of the study. One of the hazards of journalism is writing about research that you might not understand.

The research published in December in the Journal of Experimental Child Psychology was titled “The effects of punishment and appeals for honesty on children’s truth-telling behavior.”[ii] And, it does not exactly say that the threat of punishment has no effect on whether or not children will lie.

What it did say was that for children who choose to disobey, two thirds will choose to lie about it. And, that this number is increased when the child expects to be punished. It also said that when children are reminded that it is important to tell the truth, and that others will be pleased if they do, that they are less likely to lie.

The study included 372 boys and girls ages 4 to 8 years who agreed to be a part of an experiment in which they were supposed to guess the identity of a toy that they could not see, but could hear a sound that it made. In the middle of the experiment the adult would leave and tell the child not to peek at the toy. When the adult returned the child would be asked if they peeked. Of those 372 children, 251 peeked (68%) and 121 did not. (32%) Of those who peeked, 167 (67%) lied about it and 84 (33%) did not.

The important thing the study did not address was why the 121 obeyed. It is reasonable to assume that children who are disobedient will also lie about it. This raises three important questions. Why does punishment not deter them? Why did the other children choose to obey? Why did a third of the children who peeked choose not to lie about it?

The answer to the first question is found in the fact laws and punishment do not keep people from breaking them. Watch the news tonight and you will see this lived out. Paul in his letter to the Romans spoke of the sin of envy and coveting. The law said, “you shall not covet…but sin taking opportunity through the commandment, produced in me coveting of every kind…” (Romans 7:7-8) Paul describes what every parent knows. Tell the child “no” and you can often expect that they will do exactly what you told them not to do.   

The solution is not punishment. Paul says later, “Who will set me free…” from this? “Thanks be to God through Jesus Christ our Lord…” The solution is first the grace of salvation to be found in Christ.

Then as the second question asked, why do some children chose to obey? The answer can be found in scripture. Paul would tell parents and fathers in particular to “…bring children up in the discipline and instruction of the Lord.” (Ephesians 6:4) After grace, training and instruction are vital for a child to grow morally. I suspect that the children who obeyed had parents who had taught them that it was important.

The third question, why did some children even when they had disobeyed chose not to lie about it? One thing the study saw was that children who were told that it would please the adult if they told the truth were less likely to lie. Respect for adult authority is an important part of a child’s behavior. But, it is small when compared to love.

The love that a child has for a loving parent and eventually the love that child has for God will eventually decide their behavior in a way that punishment of any kind cannot match. As Paul said to the Corinthians, “the love of Christ controls us…!” (2Corinthians 5:14) If pleasing adults can change the behavior of children, think what loving God will do. Children begin the march to adulthood and learn not to lie when they make faith in Christ their own. In that process when by grace they make the truth of scripture their own, then glorifying God, not avoiding punishment becomes their reason not to lie.

 [i] McGill University. "Punishing kids for lying just doesn't work." ScienceDaily. ScienceDaily, 8 December 2014. <www.sciencedaily.com/releases/2014/12/141208144150.htm>.


[ii]Victoria Talwar, Cindy Arruda, Sarah Yachison. The effects of punishment and appeals for honesty on children’s truth-telling behavior. Journal of Experimental Child Psychology, 2015; 130: 209 DOI: 10.1016/j.jecp.2014.09.011


0 Comments
<<Previous

    Author

    Charles D Hodges Jr. MD
    I have been counseling people with mood problems and other family issues  for 25 years.  

    Archives

    December 2019
    November 2019
    October 2019
    January 2017
    October 2015
    April 2015
    February 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    December 2013
    November 2013
    October 2013
    September 2013
    August 2013
    July 2013
    June 2013
    May 2013
    April 2013
    March 2013
    February 2013
    January 2013

    Categories

    All

    RSS Feed

Powered by Create your own unique website with customizable templates.