Posted by SLS on May 10, 2000, at 15:05:14
Dear Mark,
Sorry for my inexcusable neglect.
> happily married:-)
> way too much adrenalin (known since teens)
How so?
> dysthymic to bipolar II, borderline hyperactive age 8-9,
Were you ever diagnosed ADD AD/HD? Were you ever treated for it (with what)?
> first depression prob age 10, first hypomania prob age 12, major depression (all this undiagnosed, of course) age 13-14, hypomanic 15, suicidal 16, fluctuations 17-18, hypo 19-20, fairly stable (first marriage) 21-26, moderate to severe depression 26-27, up 28, down 29, up 30-31 followed by big crash 31-32, relatively stable 33-43 (third marriage, continues happily), 43 first diagnosis of major depression, onset at a time when I could not have been happier or less stressed -- great marriage, nice home, happily self-employed, newish cars paid for, no debts, spiritually centered, no exogeneous conflicts, parents alive and healthy, good health, plenty of free time, relaxed lifestyle. What a time to be hit with depression!
Crap.
ADD AD/HD is often associated with bipolar disorder. In addition, there is a great overlap in symptoms. While you were a child, I doubt many clinicians were capable of making a differential diagnosis. Many cases diagnosed as AD/HD were actually childhood onset bipolar disorder.
How would you describe your hypomania?
> Under those circumstances, I didn't even think I was depressed when it hit like a freight train at 43 -- I thought I was getting Alzheimer's disease.
As one ages, the character of depression tends to change from depressed mood or melancholia towards dementia. In fact, depression is often misdiagnosed as dementia in the elderly. The term used for this condition is "pseudodementia". The word "dementia" is a generic term that describes impairments in congnition and memory. Although infrequently chosen to describe features of depression, I feel it is appropriate.
-----------------------------------------------------de·men·tia (d-mnsh)
n.Deterioration of intellectual faculties, such as memory, concentration, and judgment, resulting from an organic disease or a disorder of the brain. It is often accompanied by emotional disturbance and personality changes.
-----------------------------------------------------
> I didn't have any sad affect for the first 3 or 4 years of this depression, nor was I suicidal during that time, not until it had completely worn me down after several years. I had all the other classic symptoms, including constipation, inappropriate guilt, early waking, increasing social phobias (unable to return phone calls, procrastination, avoiding friends, etc. -- I assume that's what's meant by social phobias?),I don't think the term "social-phobia" is applicable based on your description. However, social inhibition is a common theme in atypical depression and bipolar depression.
Do you fall asleep after your early morning awakenings? Do you tend to sleep too late afterwards?
How does your appetite and body weight change when you are depressed?
When depressed, are you worse in the morning or in the evening?
> greatly slowed mental and verbal abilities, memory loss of recent events with heightened memory of long-forgotten earlier-life events,
I experience the same things. During bad times, I want to be anywhere other than the here and now. I want to go to a time and place when things were good, or at least better. It is sort of like having the intense need to pull one's burning hand from the flame. I have been going to these places quite a bit lately. Even my dreams have been composed entirely of pieces of adolescent memories, with the cast of characters being the same ages as they were back then. I think the brain has nothing else to work with after a protracted period of mental or social inactivity. In addition, early memories and memories formed during a euthymic state predominate over those that have been poorly encoded during times of depression and mania.
> bizarre uninvited homicidal and suicidal imagery and fantasies that were like bad movies rather than my own ideas.
I don't think having intrusive thoughts is that uncommon. I have experienced them infrequently. I try not to pay too much attention to them. I have some success ignoring them because I know that they are manufactured spontaneously by a dysregulated brain. These thoughts are not yours. Don't own them. It is not even worth trying to figure out where they come from.
> Anecdotally, here are two examples: waking up at 3:30 a.m. racked with guilt that I hadn't been able to prevent the Polly Klaas kidnapping, even though I knew the thought/feeling was delusional and grandiose. The other, being in Monterey a year later (during a TCA trial) while my wife attended a tax conference, and recalling that on March 17, 1968, I had had a glass of Krug Gamay in a crystal goblet I had purchased at the May Company, but being unable to remember or tell my wife how I had spent that morning or early afternoon (in 1994).
Most of the tricyclic antidepressants impair the function of neurons that use acetylcholine as their neurotransmitter. Cholinergic neurons are a critical component of memory function, along with aspects of cognition. Perhaps the anticholinergic effects of the drug acted synergistically with the dementia produced by your altered biopsychiatric state.
> Effexor was the first drug to work, and it worked fairly well for one year,
This is not surprising, given that you are bipolar. Effexor was initially thought of as being a non-MAOI MAOI. Bipolar depression is particularly responsive to MAO inhibitors, Parnate being the one more often chosen. Perhaps your response to Effexor indicates that you would respond to an MAO inhibitor. Using a mood stabilizer here would be a good idea. When treating bipolar II, Depakote is usually the first choice. Actually, if you haven't explored the other mood stabilizers, I would suggest that you do.
Although Depakote did not seem to work, did it actually make you feel worse? How much did you take. Doctors are now being told to push the dosages up to 3000mg/day.
Have you ever tried Lamictal? Although an anticonvulsant, it has demonstrated antidepressant properties beyond its effect as a mood stabilizer. It has consistently shown efficacy in clinical trials in the treatment of bipolar depression. My doctor has had success combining it with Parnate.
> but I had to take ever-increasing dosages to maintain the AD effect, and it had the annoying side effect of causing me to repeat everything I said as though I thought no one would believe me until I had made my point at least three times. By the time I quit taking it, in October 95 on an up-swing, it took me 6 weeks before the severe flu-like symptoms finally ceased. My doc and I thought we'd try other things instead in subsequent cycles.
Stop the cycles.
You should probably be taking a mood stabilizer long-term.
> Over four years, we tried 26 or 28 different ADs and adjunctives and over-the-counter-type remedies based on his experience and my research, including at least 20 different prescription drugs. I am my psychiatrist's poster-middle-age-guy for "don't give up."
That's so easy for others to say.
Have tricyclics, particularly desipramine, ever produced any improvement at all (regardless of how brief)?
> Three years ago, I was so near death (during a bout of flu in March 97 I got down to 135 pounds at 6 foot 3), so despondent, so worn down by depression and multiple drug failures, having near-psychotic depressive episodes on stuff like Remeron and Wellbutrin and Buspar and Lithionate and others I don't even remember, that as a last resort we decided to put me back on Effexor, side effects and withdrawal symptoms notwithstanding.
Has lithium ever been of utility? Did your seasonal fluctuations diminish while you were taking it?
> I had been taking Cytomel (thyroid suppl) for 3 years, the only thing that consistently helped with my energy and focus. Because adrenalin overproduction seemed to be one piece of the puzzle in my case, we finally added a beta blocker (Pindolol), which cuts my wind horribly but does blunt the effects of adrenalin successfully and keeps me from long-range exhaustion. We took me off whatever the latest AD was, which was giving me nausea and sweats and necessitating lying on the floor at work with a bottle of Pepto for at least an hour every day, and started me back on Effexor.
If I remember correctly (never guaranteed), thyroid hormone increases the sensitivities of both adrenergic and noradrenergic (norepinephrine) receptors. That Ritalin and Cytomel are helpful seem to me inconsistant with the notion that you are experienceing an overproduction of adrenaline. Have you ever been tested for it? Dysautonomia is often a symptom of depressive disorder. It involves a disturbance in the balance between sympathetic (fight or flight) and parasympathetic (inhibits fight or flight) components of the autonomic nervous system. It seems that there ends up being too much "fight or flight". This might appear as if there is too much of an adrenaline thing happening. One may experience anxiety, heart palpitations, constipation, rapid-pulse, dry mouth, reduced pupillary diameter (sometimes causing vision difficulties), sweating, dizziness, and some other stuff that I don't remember.
> My wife and I spent our Sierra vacation discussing the details of my suicide and her future; I was only willing to give this condition one more year if it didn't improve, and I wasn't willing to stick around and destroy her quality of life. An odd side note: when sick, I'm obsessed with cutting off my own head, but I get bogged down in the details of turning off the saw, not disturbing the neighbors, having the blood not make a mess, etc. etc. etc. It's all just too much bother!
Do you experience intense episodic impulses to commit suicide or do you contemplate suicide as a rational decision to be made based upon the situation you are faced with?
> A few years before, methylphenidate had helped some in the summer. So on June 20, 1997, my doctor added some Ritalin to the mix and suggested I try a night of sleep deprivation. On June 21, 1997, with the combination of Cytomel (25mcg morning), Pindolol (2.5mg morn/eve), Effexor (150mg morning after breakfast), and methylphenidate (10-20 mg day), my severe depression lifted suddenly and I began putting my life back together with lots of therapy (which had been a waste of time while I was so sick).
> This mix has worked effectively for the last 2 years and 10 months, without needing to increase the Effexor. I have had to increase the Ritalin, especially in the last six months of extreme hypersomnia. I would not be able to work or drive without methylphenidate. The most Ritalin I've taken in a day has been 80mg, and that in hot weather while travelling (for reasons unknown, I become overwhelming sleepy in temperatures above about 75 degrees). Happily for us, we live in one of the most moderate climates in the US, where summer temps rarely top 70 degrees and winter temps rarely reach freezing. I currently take 30 to 60 mg of methylphenidate a day, which is more than I would like (but as my doc says, less than many 12 years olds take who have ADD).
> About being bipolar: KarenB's referral today to the ADD site was helpful, especially the article about "296 vs. 314," which addresses how to tell the difference between bipolar and ADD. Although I might be 5 percent ADD, I fit 95% of their bipolar descriptions. It's the best fit I've ever read.
So what did you come up with? Do you think AD/HD was ever displayed prominently?
> I'm dxed Bipolar II, although Cam mentioned III, and I don't know what that is.
Bipolar III has been proposed as a diagnostic specification, although it does not appear in DSM IV. It represents a scenario in which manic episodes never occur spontaneously, but rather, are produced by medication.
> Another anecdote: My fourth day on Prozac, I did feel like jumping out of bed and dancing in the streets, but I controlled it and it went away and I was able to sleep. It changed my perception of color for the first two days, and otherwise I spent a month or so chasing side effects around my body, while my depression did not improve. Other drugs have caused "zooming," which is where, when driving, other cars seem to come faster or slower than they really are. Not pleasant.
Sort of like the warnings on side-view mirrors?
> Depakote was no good, as you predicted.
Actually, I was wondering if it had made you worse.
> Wellbutrin caused alarming memory problems -- scared the hell out of everybody. Lots of things caused "change" that could be interepreted as mild improvement for up to two weeks but then sent me into a tailspin. Remeron was a killer.
> Benzodiazepines work differently at different times in my cycle -- Xanax good sometimes, very depressing other times; rarely use it. Clonazepam, which I take for PLMS and a REM disorder, is great: easy to get off of, no side effects or hangover, etc. I take 0.25 mg a night -- taking it or not taking it doesn't affect my depression or hypersomnia one way or the other. Ativan is too good -- I save it for days when I really need it, maybe once a month. Diazepam still the best for muscle spasms. Again, less than once a month. My doc knows I won't abuse these meds, so he lets me keep them on hand and gives me the discretion to use them when I just need to "get through the day," which fortunately isn't too often.
> You asked me a surprisingly important question: how am I doing? I don't know -- I think I'm in a mixed state or a controlled hypomanic state.
I would consider the use of a mood stabilizer paramount in treating your condition.
> Reading the 296 v 314 article today was helpful, because I realized how little work I'm getting done is probably due to being more sick right now than I realize. At the same time, I've never written more about myself or my illness. It's as though I'm paralyzed with regard to work, and energized with regard to mental health inquiry. I have lots of energy for participating in Psycho-Babble discussions, but no energy or focus for even the most straightforward tasks pressing me at my job.
> I'm actually quite fearful that they're going to fire me -- I'm just not performing to minimum specs by any standard -- and at the same time, I know it's my illness. I'm scared and "I don't give a f***" at the same time. I should be at work now, since I have a cabinet meeting in the morning with our pres. My wife recently asked, "Are you trying to lose your job?"
> It would be nice if I could choose to focus on work. Any suggestions? Sue's gone this weekend, and without her steadiness, I'm sleeping all day and up half the night and all I want to do is have intimate and passionate conversations about mental health with my friends on Psycho-Babble. How AM I doing?
It is very easy to become addicted to something that produces small amounts of reward continually. It makes for a distraction from discomfort and fills time. On the other hand, work is (can be) a chore that one is forced to perform with great difficulty against the obstacles imposed by depression. It is sort of like experiencing mild punishment continually.
Although guilty of being somewhat addicted to Babble myself, I understand the behavioral dynamics behind it. Perhaps this kind of understanding can help you. It gets easier to stay away from Babble the longer you stay away from it. Try taking a two-day break from Babble. Afterwards, you will probably find it easier to set up rules to govern the time you spend at your computer.
We are all just prisoners, trapped in a cyber-Skinner box.
> Scott, thank you so much for your help and insight. I'm heartened that you have a friend on the same cycle -- what's going on with us? Sue and I attended a drubchen last October -- a powerful 8-day Buddhist intensive practice -- and since then I've been sleeping 12 hours a day and 14 hours or more a day on weekends. I've just been coming out of that within the last couple of weeks.
It might be a good idea to limit the amount of unnecessary stress you subject yourself to until you are more stable.
> I expect to be on this drug regimen for the rest of my life (or as long as it works reasonably well).
This is pretty much considered a requirement for cases like ours.
> I've given up the idea that I'll just stop taking all this stuff when I feel better some day. Still, although my lama has never said anything other than "keep taking your meds," there's something in his eyes that says, "maybe someday."
Maybe someday.
For now, I would be ecstatic to be in a position where I would be required to remain on an effective drug regimen for life.
You may have enough information to work with to make some treatment decisions. There are some similarities between your case and that of my friend. I recently convinced her to try Provigil combined with Lamictal. She is somewhat responsive to Effexor, Ritalin, and thyroid hormone. She has also been responsive to both Parnate and Nardil. She has been on Provigil for about a week, and has reported feeling better. I will be keeping track of her progress. I told her that she makes a fine guinea pig. I may be making decisions based upon how things go with her.
Like me, she had a negative experience with reboxetine. It made her feel worse. From the few cases I know about, there seems to be a negative correlation between experiencing a positive response to reboxetine versus Provigil or adrafinil.
I think you should head in the direction of using an antidepressant (Effexor or MAOI) plus a stimulant (Ritalin or Adderal) plus thyroid hormone plus mood stabilizers.
You gotta' find a mood stabilizer regimen. It might be appropriate to reconsider Depakote if it did not make you feel worse. Lithium, although not generally considered a high-percentage treatment for bipolar II, may be a good choice if you experience seasonality.
Try to identify which drugs or drug combinations may have been partially effective, and which ones have been exacerbating. You can make decisions keeping these observations in mind. This is sort of like what JohnL has described, only here, you have already performed your drug screenings.
Just a few ideas: I don't mean these to be rigid prescriptions, but rather suggestions of what sorts of drugs might be employed in the roles I think are necessary.
1. ((Effexor or (Parnate or Nardil)) + (Ritalin or Adderal) + (Cytomel and/or Synthroid) + ((Lithium or Depakote) and/or (Lamictal or Neurontin))
2. ((Effexor or (Parnate or Nardil)) + (desipramine or Sinequan) + (Ritalin or Adderal) + (Cytomel and/or Synthroid) + ((Lithium or Depakote) and/or (Lamictal or Neurontin))
3. Effexor + Provigil + Ritalin + Cytomel + mood stabilizer(s)
I'm looking into combining Provigil with an MAO-inhibitor.
I didn't mention Tegretol because it has a tendency to produce more cognitive side effects than Depakote, but you may want to put it on your list if Depakote is a no-go.
Sometimes I feel as if I'm trying to cover my ass by mentioning every drug in the pharmacopoeia. Sorry. I hope you still find some direction here.
- Scott
poster:SLS
thread:33078
URL: http://www.dr-bob.org/babble/20000508/msgs/33078.html