Wellbutrin can help with ruminating thoughts

NAC: the amino acid that is turning psychiatry upside down

One of the most fascinating things about psychiatry for me is the push-pull between certain diagnoses and common factors. Are all psychiatric disorders basically the same or are they radically different from one another?

For example:

The way in which diagnoses are made in the DSM-5 (Diagnostic and Statistics Handbook, 5th Edition) generally gives the impression that each disorder differs in a precise way from the others: a person with five becomes severe depression or more of nine symptoms diagnosed over two weeks or more; While panic disorder requires four or more of a dozen other symptoms.

So if you only have four symptoms of depression you cannot be diagnosed with major depression. And if you only have three panic disorder symptoms, you don't have any The Diagnosis. Fair enough: you have to draw the line somewhere. But is your four symptom depression or three symptom panic really different from that of the person who has the full set of symptoms required?

To make matters worse, many people "meet criteria" to have many DSM-5 psychiatric diagnoses at the same time. You can have panic disorder and Major Depression - along with and specific phobias. Then the question arises: Do you have two, three or four different problems? Couldn't your various diagnoses all be due to a single problem in your brain, a series of circuits or brain centers with abnormally increased or decreased activity that are causing either some or many symptoms?

This may seem like an almost theological argument, similar to the question of the number of angels dancing on the head of a pin.

In the real world, however, this is by no means trivial. If you ignore one of the diagnoses - panic disorder, for example - and treat only the depression, you are likely to have a worse outcome than if both conditions are treated. However, similar treatments often work for both conditions. Both SSRI drugs and cognitive behavioral therapy (CBT) help with depression and panic disorder, although treatments may need to be customized for each disorder.

On the other hand, some treatments help a condition as well Not the other. Bupropion is a powerful antidepressant but not very effective for panic disorder, while lorazepam, a benzodiazepine, helps with panic disorder but can be counterproductive for depression. On the third side, so to speak, if you could identify common circulatory problems that underlie a wide variety of psychiatric disorders, you might find a single treatment that could help a wide variety of problems. On the fourth On the other hand, chances are people with a diagnosis - such as major depression - could have any number of different circulatory disorders, just as your 103 fever could be due to a variety of bacterial or viral infections, or a variety of other causes.

Lumpers vs. splinters

So psychiatry is like many other fields: with competing groups of lumps and splinters. Extreme clumps claim that there is only one dimension of psychopathology (Caspi). Extreme splinters indicate PTSD from combat is different from PTSD from violent assault, which is different from PTSD from sexual assault, and that everyone benefits from different approaches to treatment.

What Does Neuroscience Do I Have To Say For the past decade, researchers have skipped that controversy by focusing on brain circuits thanks to an initiative sponsored by Thomas Insel, MD, Ph.D., former director of the National Mental Health Institute . The 2008 Research Domain Criteria (RDoC) initiative focused on identifying brain circuits that can go wrong in many different medical conditions, common abnormalities that can underlie many different medical conditions.

Overall, research on brain circuits in general supports lumps: it is generally the same circuits that go wrong in almost all psychiatric disorders, albeit with possibly different emphases for different disorders.

Which brings me to N-acetylcysteine.

N-acetylcysteine, or NAC, is an over-the-counter compound that you can buy at your local health food store. As with dozens, if not hundreds, of other associations, NAC has its supporters and critics, enthusiasts and skeptics. (And I am generally a skeptic of the herbal / dietary supplement industry products).

NAC is an amino acid found in many foods. However, nutritional supplements give you a higher dose than you would get on a daily diet. It is usually taken in doses of 1,000 to 2,000 milligrams per day - usually in 600 milligram capsules taken 2 to 3 times a day, and aside from mild gastrointestinal side effects, NAC is usually well tolerated. [Note: Suffice it to say that you should speak to your doctor before taking this or any other supplement to determine if they are suitable for you. In my psychiatric practice, I consider a study with NAC to be similar to any other drug (or therapy) study: you have to put a patient on an appropriate dose for a reasonable period of time and monitor its effects on key symptoms (and monitoring of side effects) carefully measure a sufficient length of time to see if this helps.]

The fascinating thing about NAC for me is that it is of great interest to neuroscientists. There have been many studies of this compound, including neuroimaging studies, and it has been studied in a myriad of disorders - depression, bipolar disorder, OCD, PTSD, schizophrenia, addiction, eating disorders, Alzheimer's disease, and addiction (Berk). NAC has also established medical uses as an anti-inflammatory drug for paracetamol overdose for the prevention of liver failure. Clinical studies have shown promise in many (but not all) of the diseases studied (Berk). It is clear that more research studies are needed, both more clinical studies in various diseases and more basic research, to see how NAC works in the brain.

Why does NAC help many people with psychiatric diagnoses? Why does it work in so many conditions? In my eyes that is the fascinating thing. Are its benefits due to its anti-inflammatory effects? Or some other mechanism? On a clinical level, NAC appears to aid in daily work with ruminant patients with extremely negative self-thoughts that are difficult to control. Such thoughts are common with depression and anxiety disorders and also with eating disorders, schizophrenia, obsessive-compulsive disorder, etc. I have seen that it helps patients with such disorders when many other things, medication or psychotherapy, have not helped much.

NAC doesn't always work, but when it does, disturbing irrational thoughts gradually decrease in intensity and frequency, and often go away. Negative thoughts (eg, “I'm a bad person” or “Nobody likes me”) or reflections about other people (“Will the girl like me?”) Or about health problems (“Do I have AIDS?”) That cannot to be reassured by reasonable evidence to the contrary, and which, despite all rational control efforts, invade consciousness hour after hour, day after day, seem to be diminishing. Or, if they continue, they are less distressing and may be observed from a greater distance, with less worry or anxiety, and less likely to cause depression or other adverse effects.

That goes back to the longstanding debates between psychiatric lumps and splinters. Do the benefits of NAC support the clumps more than the splinters? Do you support the RDoC enthusiasts eagerly searching for brain circuits? I think in some ways such results favor the lumps. Improving irrational, hard-to-control negative thoughts with NAC treatment on so many disorders makes it difficult to avoid the conclusion that some common underlying circuitry is involved.

On the other hand, it's not yet time for the shards to go home after a loss. For one thing, NAC doesn't work for everyone. But even if the circuit is the same for ruminants, why do some people with hyperactive ruminant circuits likely develop obsessive-compulsive disorder and others develop bipolar disorder? And others do not yet meet the criteria for despite strong ruminants any mental disorder? It is possible that abnormal activity in certain brain circuits, beginning early in life, leads to the development of various Different disorders over time depending on your life experiences, coping patterns, etc. But how and why do their effects vary so widely from person to person?

To me, the lump-and-splinter debates are most useful when they help advance science - and treatment. In this case, with the advent of NAC as a potentially beneficial treatment for a common symptom of many disorders, the target posts are sensibly shifted downward.


Insel T., Cuthbert B., Garvey M., Heinssen R., Pine DS, Quinn K., Sanislow C., Wang P. Research Area Criteria (RDoC): Towards a New Classification Framework for Research on Mental Disorders.

Caspi A, Moffitt TE. All for one and one for all: mental disorders in one dimension. American Journal of Psychiatry. 2018, April 6; 175 (9): 831-44

Berk M, Malhi GS, Gray LJ, Dean OM. The promise of N-acetylcysteine ​​in neuropsychiatry. Trends in the Pharmacological Sciences. 2013, March 1st; 34 (3): 167-77