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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 3 of 3. This is the beginning of the thread.
Posted by cache-monkey on October 16, 2007, at 18:55:46
Hi all,
It's been a while since I've posted here. I had a very interesting experience with Ritalin today that's prompted me to question a few things. But before I get to that, I'll lay out my history. This is kind of long, so you can skip down to my explicit questions, which I've marked with triple asterisks (***).
Current DX: Anxiety and Bipolar, NOS. For most of my life I've been highly anxious; in recent years there has been a more pronounced physical component (restlessness). I also have borderline-like traits (scared of feeling trapped) due to some bad stuff that happened when I was young. Finally, there are seasonal fluctuations in mood that have been getting more noticable over the last 5 years or so: winter lows and summertime increases in energy and agitation. Oh, and I generally feel very removed from my underlying emotions.
The Bipolar DX was largely arrived at empirically due to increased anxiety/agitation in response to a number of antidepressants (see below). My current therapist doesn't see any evidence of it and my only hypomanic-like episodes have been due to benzo tapering. (I did have a summer of partying in my early 20s that could have been hypomania or could have been about breaking free from some emotionally repressive relationships from childhood.)
An annotated med history is at the end if you want to read it, but currently, I'm on 15 mg of Valium and 800 mg of magnesium daily. I also take 2.5 mg of Prozac every other day. Prozac has been very helpful in terms of my mood, but I've also found myself feeling wound up both physically (heart palps and restless legs). This has been particularly strong as I tapered from 17.5 to 15 on the valium over the last couple of weeks -- I had to reduce the Prozac to compensate.
Dopamine:
Today, I tried some Ritalin (~5mg) that a friend had given me as an experiment. I was expecting to get hyped up, especially since I hadn't taken any valium yet. Instead the _opposite_ happened. I felt amazingly calm and collected. I also felt like my physical jitteriness subsided quite a bit. I didn't feel like I needed the benzo at all until this feeling wore off about 4 hours later.*** My bipolar DX is questionable, but if it were true, would dopaminergics have the potential to be calming in the short-term but destabilizing over the long term? Or is it a what you see up-front is what you get?
*** Is my reaction to Ritalin indicative of anything? Possibly dopamine hypoactivity?
This would explain my extreme akathisia from very small doses of zyprexa and seroquel. It could also explain the initial akathisia from SSRI start-up and my difficulty with benzo tapering (high serotonin => transitorily low dopamine). Finally, increased dopamine is one of the common links between the smoking and the two treatments that have worked: Celexa+Wellbutrin and Tegretol+Klonopin. (The other common mechanisms are l-type calcium channel blockade and increases in GABA sensitivity due to allopregnanolone.)*** What does this mean for treatment?
I would be worried about Ritalin due to its potential for habit-formation. The other option would be Wellbutrin agumentation. Here I'm the problem is that I really don't react well to norepinephrine, which WB seems to have relatively more action on. Are there any other non-stim dopaminergics that I'm forgetting about?*** Could Ritalin or Wellbutrin worsen dopamine dysfunction in the long run?
Anyway, if you've read this far: thanks and I'd apreciate any ideas you might have. My pdoc is good, but I'm a really weird case.
Best,
cache-monkey
Meds and combos that have NOT worked:
> Wellbutrin alone - lift in mood, but increased agitation/anxiety (ag/anx) to the point of OCD-like behavior
> Serzone, Sezrone+BuSpar, Serzone+BuSpar+Xanax - no mood lift, increased ag/anx
> Cymbalta+Xanax - frank akathisia
> Lamictal+Xanax - increased anxiety and first/only panic attack
> Lithium+Klonopin - some lift in modd, but increased anxiety from Li+; had to d/c because of nephrogenic diabetes insipidus
> Depakote+Klonopin/Valium - horrible sleep, low mood and mental function, no real reduction in ag/anx and maybe it got worse
> Atypical neuroleptics+Klonopin - All gave akathisia at low doses (e.g. Zyprexa at 2.5 mg and Seroquel at anything above 25 mg)
> Lexapro+Klonopin - felt more tense
> Have also tried Trileptal, Keppra and Campral, all of which left me feeling down and had pain and/or itching as a side effect. Also, trying Lamictal again led to SJS-ish symptoms.What's worked?
> Celexa+Wellbutrin - felt very good ... limited anxiety, but I did have impulsivity in terms of binge-drinking and procrastinating (but no more than the "normals" I was going to school with); I was was actually in touch with my emotions and could act on them. D/c'ed because I felt like my depression was gone
> Benzos - help calm me, but leave me feeling blue and flat
> Tegretol+Klonopin - reacted similarly to Celexa+Wellbutrin, but with greater gains in anxiety both psychic and physical. Had to d/c due to SJS-like reaction
> Magnesium - a little calming
> Smoking - rarely fails to calm and lift mood
Posted by James_glasgow on October 17, 2007, at 1:10:22
In reply to Calmed by Ritalin: Questions about meds/DX, posted by cache-monkey on October 16, 2007, at 18:55:46
Hi
I would be interested to see what the reaction to your post is. I had a similar reaction with the stimulant phentermine used to reduce appetite, I became much calmer, whereas any SSRI combined with Zyprexa makes me hypomanic. My Pdoc find this very strange (the Zyprexa part).
I am pretty sure there is a biological reason for this. I recall reading about it sometime ago, and that it was an indicator of a distinct condition possibly neurological, however, I cannot recall what it was at the moment.
Good luck.
James
Posted by cumulative on October 17, 2007, at 1:19:07
In reply to Calmed by Ritalin: Questions about meds/DX, posted by cache-monkey on October 16, 2007, at 18:55:46
That's a long, well-organized post for someone who thinks he has dopamine hypoactivity. ;-) I couldn't say though.
IMO the idea of dopaminergic psychostimulants having a "paradoxical" effect on ADD/ADHDers is a myth, as the right (variable) dose of a dopaminergic will be calmative to pretty much everyone in the sense that they'll start doing work.
Some people here will warn about long-term use of psychostimulants. I don't think it's that negative of a proposition: these are very well-studied, safe (relative to aspirin) drugs that have helped numerous people immensely. The therapeutic effects (not euphoria) of dopaminergics usually take a very long time to develop tolerance if they do at all, because these effects also develop reverse tolerance or sensitization. I recommend looking at the addforums.com, there are some good experiences there and pretty much everything in the way of anecdote you would want to know regarding psychostimulants.
This is the end of the thread.
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