Raiyyan Tahsan

Raiyyan Tahsan
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TC(848).(06).Psychiatry Case No 59. Monkey Branching

Monkey Branching কী?

Monkey branching হলো এমন একটি relationship behaviour যেখানে কেউ বর্তমান সম্পর্ক শেষ করার আগেই নতুন romantic/emotional partner “ready” করে রাখে—যেন এক ডাল ছাড়ার আগে আরেক ডাল ধরে রাখা। এটি DSM-5-TR/ICD-11 psychiatric diagnosis নয়; তাই “Monkey branching-এর ওষুধ” নেই। চিকিৎসা দরকার হয় তখনই, যখন এর পেছনে anxiety, depression, trauma, attachment insecurity, impulsivity, substance use, bipolarity, বা personality disorder traits থাকে। সম্পর্ক-বিষয়ক literature-এ এটিকে emotional hedging/overlap relationship pattern হিসেবে বর্ণনা করা হয়।

1. Etiology / Cause / Pathophysiology

Common causes / drivers:

  1. Fear of being alone — single থাকা সহ্য করতে না পারা।
  2. Insecure attachment — anxious attachment হলে reassurance-seeking বেশি হতে পারে; avoidant attachment হলে intimacy এড়াতে নতুন option খোঁজা হতে পারে।
  3. Low self-esteem / validation seeking — অন্যের attention দিয়ে নিজের value measure করা।
  4. Conflict avoidance — current partner-এর সাথে সরাসরি breakup conversation এড়ানো।
  5. Impulsivity / novelty seeking — নতুন সম্পর্কের excitement-এর দিকে দ্রুত ঝোঁকা।
  6. Past trauma / abandonment fear — abandon হওয়ার আগে নিজেই backup তৈরি করা।
  7. Comorbid psychiatric conditions — Major depressive disorder, GAD, PTSD, bipolar hypomania/mania, substance use disorder, borderline personality traits/disorder—এসব থাকলে pattern বেশি severe হতে পারে। Personality disorder থাকলে medication primary treatment নয়; psychotherapy first-line। NICE BPD guideline drug treatment কমাতে/বন্ধ করতে বলে যদি clear comorbidity না থাকে, এবং crisis sedative use হলে খুব short-term হতে বলে।

2. Symptoms / Signs

Behavioural signs

  • Current relationship চলাকালীন অন্য কারও সাথে romantic/emotional intimacy তৈরি করা
  • ফোন/চ্যাট লুকানো, sudden privacy increase
  • Current partner থেকে emotional distance
  • Breakup-এর আগেই “next relationship” নিশ্চিত করার চেষ্টা
  • একই pattern বারবার repeat করা
  • guilt থাকলেও honest conversation না করা
  • commitment avoid করা, কিন্তু একা থাকতেও না পারা

Psychological symptoms

  • একা হয়ে যাওয়ার ভয়
  • chronic insecurity
  • impulsive decision
  • attention/validation craving
  • jealousy, possessiveness
  • emptiness feeling
  • anxiety, insomnia
  • depressive guilt/shame

Red flags — urgent psychiatric assessment

  • suicidal thought/self-harm
  • violence risk
  • severe depression
  • mania/hypomania: decreased sleep, grandiosity, risky sex/spending, pressured speech
  • psychosis
  • substance dependence

3. Clinical Diagnosis

Monkey branching-এর কোনো lab test/DSM criterion নেই। Diagnosis হয় clinical formulation দিয়ে।

Specific clinical assessment

  1. Relationship timeline
    • Current relationship কখন শুরু/শেষ?
    • নতুন person-এর সাথে emotional/physical overlap ছিল কি?
    • Pattern repeat হয়েছে কি?
  2. Mental status examination
    • Mood, affect, impulse control, insight, judgment
    • Suicidality/self-harm/violence risk
  3. Screening tools
    • PHQ-9 — depression severity; validated brief depression measure। DOI: 10.1046/j.1525-1497.2001.016009606.x
    • GAD-7 — generalized anxiety severity; DOI: 10.1001/archinte.166.10.1092
    • PCL-5 — PTSD symptom screening; VA National Center for PTSD describes it as a 20-item DSM-5 PTSD self-report measure।
    • AUDIT/AUDIT-C — alcohol misuse screening; WHO AUDIT identifies hazardous/harmful alcohol use।
    • Bipolar screening: MDQ, but positive হলে psychiatrist confirmation needed।
    • Personality assessment: SCID-5-PD/IPDE if available.

4. Investigations

Monkey branching diagnose করার জন্য

No specific investigation.

Medication শুরু করার আগে useful baseline tests

  • CBC
  • TSH
  • Fasting glucose / HbA1c
  • LFT, RFT, electrolytes
  • Vitamin B12/Vitamin D if clinically indicated
  • ECG — especially escitalopram/citalopram, QT risk, cardiac disease, elderly
  • Pregnancy test if relevant
  • Urine toxicology if substance use suspected

5. Differential Diagnosis

ConditionKey clue
Normal breakup / immature relationship behaviourNo significant functional impairment
Infidelity without psychiatric disorderPlanned secrecy but no mood/anxiety syndrome
Adjustment disorderStress-triggered anxiety/depression within relationship stress
Major depressive disorderLow mood, anhedonia, guilt, sleep/appetite change
Generalized anxiety disorderExcessive worry, reassurance seeking
Bipolar hypomania/maniaRisky sexual behaviour, decreased sleep, impulsivity
Borderline personality disorder traitsAbandonment fear, unstable relationship, emptiness, self-harm
Narcissistic traitsValidation seeking, entitlement, low empathy
PTSD/complex traumaabandonment fear, hypervigilance
Substance use disorderdisinhibition, impulsive relationship choices
Relationship OCDobsessive doubt about partner/relationship

6. Management / Treatment

A. Core treatment — Non-pharmacological

  1. Psychoeducation
    • এটি disease label নয়; এটি unhealthy relationship coping pattern।
    • Accountability, honesty, boundary-setting শেখানো জরুরি।
  2. CBT
    • Automatic thought: “আমি একা থাকলে ভেঙে পড়ব”
    • Cognitive restructuring + behavioural experiment
  3. DBT
    • impulsivity, emotional dysregulation, abandonment fear, self-harm থাকলে বেশি useful।
    • DBT skills: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness। Psychotherapy is the core treatment for BPD-type emotional dysregulation; medication is not primary treatment।
  4. Schema therapy / attachment-focused therapy
    • abandonment schema, defectiveness schema, mistrust schema কাজ করা।
  5. Couple therapy
    • শুধুমাত্র যদি violence/coercion না থাকে এবং দুইজনই willing হয়।
  6. Behavioural rule
    • New relationship শুরু করার আগে previous relationship ethically close করা।
    • “No overlap dating” contract.
    • 30–60 days single reflection period if repeated pattern.

7. Pharmacological Treatment — Point আকারে

Important: Monkey branching-এর জন্য কোনো direct medicine নেই। নিচের ওষুধগুলো কেবল confirmed comorbid depression/anxiety/panic/PTSD/OCD থাকলে registered physician/psychiatrist-এর prescription অনুযায়ী। Bangladesh brand list বাজারে পরিবর্তনশীল; নিচে MedEx-listed commonly available examples দেওয়া হলো, “সব brand” নয়। Sertraline, escitalopram, fluoxetine, clonazepam, propranolol-এর Bangladesh brand/strength MedEx-এ listed আছে।

1) Sertraline

  • Generic: Sertraline hydrochloride
  • Class: SSRI
  • কেন use হয়: Depression, GAD/panic/social anxiety, PTSD/OCD symptoms থাকলে। Sertraline-এর adult starting dose depression/OCD-এ 50 mg এবং panic/PTSD/social anxiety-এ 25 mg থেকে শুরু করা যায়; therapeutic range 50–200 mg।
  • Dose:
    • Start: 25 mg daily for 1 week if anxiety prominent
    • Then: 50 mg daily
    • Titrate: every 1–2 weeks
    • Max: 200 mg/day
  • Duration: remission-এর পর অন্তত 6–12 months; recurrent illness হলে longer.
  • Bangladesh brands with strength: Repose 25/50/100 mg, Serolux 25/50/100 mg, Seronex 25/50/100 mg, Sertal 25/50/100 mg, Andep 25/100 mg.
  • Side effects: nausea, loose stool, headache, insomnia/somnolence, sexual dysfunction, sweating, tremor.
  • Important interactions: MAOI/linezolid/tramadol/other serotonergic drugs → serotonin syndrome risk; NSAID/aspirin/warfarin → bleeding risk; alcohol avoid.

2) Escitalopram

  • Generic: Escitalopram oxalate
  • Class: SSRI
  • কেন use হয়: Depression/GAD with persistent anxiety, rumination, insomnia. MedEx lists GAD initial dosage 10 mg once daily, max 20 mg/day।
  • Dose:
    • Start: 5 mg daily for 4–7 days if sensitive
    • Usual: 10 mg daily
    • Max: 20 mg/day
  • Duration: 6–12 months after remission.
  • Bangladesh brands with strength: Oxapro 5/10 mg, Recita 5/10 mg, S-Citapram 5/10 mg, Sencital 10 mg.
  • Side effects: nausea, fatigue, insomnia, sexual dysfunction, sweating, QT prolongation risk.
  • Interactions: other QT-prolonging drugs, MAOI/linezolid/tramadol, NSAID/anticoagulant. ECG consider if cardiac risk.

3) Fluoxetine

  • Generic: Fluoxetine hydrochloride
  • Class: SSRI
  • কেন use হয়: Depression, OCD, panic symptoms; long half-life থাকায় withdrawal comparatively কম, কিন্তু drug interaction বেশি হতে পারে। MedEx notes 20 mg/day in morning as initial antidepressant dose।
  • Dose:
    • Start: 10–20 mg morning
    • Usual: 20 mg/day
    • OCD/severe cases: specialist may titrate 40–60 mg/day
  • Duration: 6–12 months after remission.
  • Bangladesh brands with strength: Modipran 20 mg, Nodep 20 mg, Nodepress 20 mg, Oxetin 20 mg.
  • Side effects: insomnia, anxiety activation initially, GI upset, sexual dysfunction, sweating, weight change.
  • Interactions: MAOI contraindicated; CYP2D6 inhibition—TCAs, antipsychotics, some beta-blockers; tramadol/linezolid/other serotonergic drugs avoid.

4) Propranolol — only situational physical anxiety

  • Generic: Propranolol hydrochloride
  • Class: Non-selective beta-blocker
  • কেন use হয়: performance/situational anxiety-এর physical symptoms—tremor, palpitation, sweating. Core relationship behaviour treat করে না।
  • Dose:
    • 10–20 mg PRN, anxiety-provoking situation-এর 30–60 min আগে
    • Routine daily use only if clear indication and physician supervision
  • Bangladesh brands with strength: Indever 10/20/40 mg, Propranol 10/20/40 mg, Adlock 10/40 mg, Betacap TR 40 mg.
  • Side effects: bradycardia, hypotension, fatigue, cold extremities, sleep disturbance.
  • Avoid/contraindication: asthma/COPD bronchospasm, heart block, severe bradycardia, uncontrolled heart failure; diabetesে hypoglycemia warning signs mask করতে পারে।
  • Interactions: verapamil/diltiazem/digoxin → bradycardia risk; insulin/sulfonylurea caution.

5) Clonazepam — short-term crisis only

  • Generic: Clonazepam
  • Class: Benzodiazepine
  • কেন use হয়: severe acute panic/insomnia crisis short-term; routine relationship problem বা chronic anxiety management-এর জন্য নয়। NICE BPD guideline crisis sedative use হলে duration agreed এবং 1 week-এর বেশি নয় বলেছে।
  • Dose:
    • 0.25–0.5 mg at night or BD short-term
    • Use: 3–7 days; rarely up to 2 weeks under psychiatrist
  • Bangladesh brands with strength: Arotril 0.5 mg, Cloron 0.5/1/2 mg, Leptic 1/2 mg and Leptic ODT 0.25/0.5 mg, Lonazep 0.5/2 mg.
  • Side effects: sedation, dizziness, impaired driving, memory impairment, falls, dependence, withdrawal.
  • Dangerous interactions: alcohol, opioids, sedatives, antihistamines—respiratory depression/coma risk. MedlinePlus warns clonazepam can cause serious breathing problems, drowsiness or coma with certain medicines.

8. Prevention

  1. Relationship closure rule: নতুন relationship শুরু করার আগে আগের সম্পর্ক ethically close করা।
  2. Single tolerance training: সপ্তাহে নির্দিষ্ট সময় একা থাকা practice; loneliness trigger journal.
  3. Boundary plan: opposite-sex/romantic communication boundary লিখে রাখা।
  4. Delay rule: নতুন attraction হলে 72 hours কোনো romantic action না নেওয়া।
  5. Honest conversation script: “আমি confused; overlap না করে relationship status clarify করতে চাই।”
  6. Therapy: repeated pattern হলে CBT/DBT/schema therapy.
  7. Substance control: alcohol/drug use থাকলে impulsive relationship behaviour বাড়ে।
  8. Relapse prevention: trigger—loneliness, conflict, rejection, boredom—identify করে coping plan.

Real Clinical Example

Case: 28-year-old male, 3-year relationship. Partner-এর সাথে conflict হলে সে ex-colleague-এর সাথে late-night emotional chatting শুরু করে। Breakup করার আগে নতুন relationship confirm করতে চায়। PHQ-9 = 14, GAD-7 = 16, sleep poor, abandonment fear আছে, self-harm নেই।

Clinical formulation: Monkey branching behaviour + moderate anxiety/depressive symptoms + insecure attachment pattern.

Management:

  • Psychoeducation + no-overlap agreement
  • CBT for abandonment belief
  • DBT interpersonal effectiveness
  • If symptoms persistent and functional impairment: Sertraline 25 mg 1 week → 50 mg daily, review 2–4 weeks
  • Suicidality/mania/substance use screen every visit

Quick Clinical Shortcut

Monkey branching suspected হলে 5-step screen:

  1. Pattern: relationship overlap আছে?
  2. Risk: suicide/self-harm/violence/mania/psychosis?
  3. Comorbidity: PHQ-9, GAD-7, PTSD, substance, bipolar screen.
  4. Treatment: psychotherapy first; medicine only comorbidity confirmed হলে।
  5. Prevention: no-overlap rule + boundary + therapy + follow-up.

Overview / Summary

Monkey branching কোনো psychiatric diagnosis নয়; এটি unhealthy relationship coping pattern। এর মূল কারণ হতে পারে fear of abandonment, insecure attachment, low self-esteem, conflict avoidance, impulsivity, trauma, বা comorbid psychiatric illness। Diagnosis clinical interview ও validated screening দিয়ে করা হয়; investigation মূলত comorbidity/medication safety-এর জন্য। Treatment-এর core হলো psychotherapy, boundary work, communication skill, and relapse prevention. Medicine only indicated if depression/anxiety/panic/PTSD/OCD or other confirmed psychiatric condition থাকে।

Actionable Plan / Steps

  1. PHQ-9, GAD-7, substance, bipolar, PTSD screen করুন।
  2. Suicidal/self-harm/violence/mania থাকলে urgent psychiatry referral।
  3. Relationship timeline ও overlap pattern লিখে formulation করুন।
  4. CBT/DBT/schema therapy শুরু করুন।
  5. Medication দরকার হলে SSRI first-line; benzodiazepine only short-term crisis.
  6. 2–4 weeks পর follow-up: symptoms, side effects, adherence, risk reassessment।
  7. Relapse prevention: no-overlap dating rule, boundary plan, trigger journal।

Reference List

Textbooks

  1. Kaplan & Sadock’s Synopsis of Psychiatry, 12th ed. Chapters: Anxiety Disorders, Mood Disorders, Personality Disorders.
  2. Harrison’s Principles of Internal Medicine, 21st ed. Section: Psychiatric Disorders in Medical Practice.
  3. Davidson’s Principles and Practice of Medicine, 24th ed. Chapter: Psychiatry.

Guidelines

  1. NICE NG222. Depression in adults: treatment and management, 2022; last reviewed 2026.
  2. NICE CG78. Borderline personality disorder: recognition and management, 2009.
  3. WHO mhGAP guideline, 2023.
  4. APA Practice Guideline for Borderline Personality Disorder, 2023/2024 draft publication.

Peer-reviewed / DOI

  1. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9. J Gen Intern Med. 2001;16:606–613. DOI: 10.1046/j.1525-1497.2001.016009606.x.
  2. Spitzer RL, Kroenke K, Williams JBW, Löwe B. GAD-7. Arch Intern Med. 2006;166(10):1092–1097. DOI: 10.1001/archinte.166.10.1092.
  3. Blevins CA et al. PCL-5 initial psychometric evaluation. Journal of Traumatic Stress. 2015;28(6):489–498. DOI: 10.1002/jts.22059.
  4. Gartlehner G et al. Pharmacological treatments for borderline personality disorder. CNS Drugs / systematic review source. 2021.

Md.Rafiqul Islam Lipu,Date:-22-05-2026 Friday, Time:-2-31-59 Pm

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