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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by lpslpslpslpslpslps on June 5, 2010, at 20:12:04
Hi all,
I was hoping that if I described my particular matrix of symptoms and issues, someone else with a similar experience might be able to suggest ways I could improve my current treatment plan.
I am Bipolar Type II, and the presentation is anergic. I sleep sometimes 12 hours a day, and its almost impossible for me to motivate myself to do essential tasks. My apartment has at least 10 bags worth of trash scattered about. Very often I have to be somewhere, I'm 15-20 minutes late, because that's how long it takes to motivate myself to get going after the time I actually need to leave.
I am also severely ADHD, both inattentive and hyperactive. I frequently get hyperfocus, especially when I'm on my stimulant, but the hyperfocus is never directed toward something I really need to get done. I'm a phd student and I'm behind on my studies -- I have a few incompletes and I can't seem to focus for long enough to finish them. I take a psychostimulant, but I've become very tolerant to its effects and so it is much less helpful than it could be.
I'm also cripplingly sad right now -- my dear beloved cat died a month ago, I still weep every couple of days. He was five; his brother and litter-mate is still alive. Sometimes when I'm playing with my cat, I get so overwhelmed by some emotion that I can't do anything until the feeling starts to pass.
I am male, 28 years old, 150 pounds. My thyroid levels are normal, and though my resting heart rate and blood pressure are higher than they could be, they are within the normal range.
I currently take the following medications and supplements, in addition to weekly psychotherapy:
Morning:
Lamotrigine - 150 mg
Buspirone - 15 mg
Lisdexamphetamine - 70 mgFish oil - 2 grams of EPA/DHA
SAMe - 400 mg
Tyrosine - 6 grams
caffeine - 90 mgEvening:
Quetiapine - 100 mg
Mirtazapine - 30 mg
Buspirone - 15 mgFish oil - 2 grams of EPA/DHA
phosphatylserine - 100 mg
melatonin - 5 mg
L-Theanine - 200 mg
Multivitamin
Any and all advice would be much appreciated. One thing I was thinking about was adding something potentially energizing like Venlafaxine or Reboxetine or, alternatively, dropping the mirtazapine and taking Parnate, perhaps also lowering my stimulant dose. Also, I was thinking of dropping the buspar b/c I hate the multiple dosing, I sometimes forget in the morning, and of all my problems anxiety isn't really bothering me anymore. In fact, I almost wish I was a little more anxious so I wouldn't be so apathetic.Also, what about something like amisulpride or tianeptine?
My psychiatrist is great, always willing to work with me and accommodate suggestions about possible treatment options. He often seems less familiar with the current research about psych meds than I am (I subscribe to the abstracts in my rss feed of all the current biological psychiatry and psychopharmacology journals, and I usually read the full studies about medicines that I am currently taking (luckily have access through the university). Every medicine I'm currently taking is something I've proposed -- empowering, but also a little daunting if I screw up, since ceteris paribus I would prefer that everyone with imput to my treatment have some sort of expertise. I know a whole lot about the science of these medicines, but I'll clearly never be a physician or have that kind of expertise.
Posted by chujoe on June 5, 2010, at 20:42:13
In reply to Brainstorming alternate treatment options, posted by lpslpslpslpslpslps on June 5, 2010, at 20:12:04
Welcome to PB lpslps...
There are others here with much more expertise on psych meds than I, but I'd like to ask a perhaps impertinent question: Do you care about what you are studying in your PhD program? I'm an old academic, so I've seen a lot of this sort of struggle over they years, including my own. What you describe sounds like avoidance -- something depressed ADHDs like us are absolutely expert at. I don't know what you're studying, but unless it's pharmacology or biochemistry, it feels to me as if you are using a focus on your medications -- and on psych meds in general -- as a strategy for avoiding the work you are supposed to be doing.
I don't mean any of this as criticism -- it's just that I have been in a similar place. All I'm trying to do is suggest that there may be psychological issues as well as psychiatric ones at work -- at least that is what your description suggests to me.
Posted by lpslpslpslpslpslps on June 5, 2010, at 21:13:49
In reply to Re: Brainstorming alternate treatment options » lpslpslpslpslpslps, posted by chujoe on June 5, 2010, at 20:42:13
>Do you care about what you are studying in your PhD program?
Sort of, sometimes. To be honest, the field I am in was not my first choice or my second choice. As an undergraduate, I double majored in Philosophy and Classics. I wanted to do a PhD in philosophy, but I was rejected everywhere I applied despite almost perfect GRE scores, I suspect because my philosophy program was totally different from the analytical style so popular in the anglo-american world. Then, I wanted to do a PhD in pharmacology, and I scored in the 98% percentile on the gre biochem subject test... but because I had never taken a biochem course, I did not meet prerequisites and so was rejected (even if sensible in the general case, this particular decision-calculus on their part seems irrational to me). Likewise, I took a (free) MCAT prep course, and did extremely well on the practice exams, but I couldn't even apply to med school because I wasn't physically enrolled in an official biochem class, and I am completely unwilling to sit through a class that covers material that I already know. If I wanted to do something that regularly caused me to lose hours of my life, I'd take up smoking cigarettes. So my current field was not my first choice at all.
I am involved in intercollegiate policy debate, which is connected to communication departments generally, and I was a media message framing consultant for a year with Monsanto, so Communication seemed a good fit, and kind of a catch-all interdisciplinary discipline that tolerates a whole lot of subpar scholarship. That can be a good thing, but the shoddiness of our scholarship makes me anti-excited about the field.
Also, my focus is in qualitative and humanistic research methods -- principally I'm interested in argumentation theory, the rhetoric of science, and the rhetoric of religion -- but I used to teach statistics as an adjunct and I very much enjoy working on statistical data analyses, often coming on board other people's projects as the statistician. The trouble is that the subject matter of the kind of research questions and hypotheses that can be tested quantitatively, at least in my discipline, are all mind-crushingly boring to me. I get that it is important to figure out how to convince people to wear condoms or stop smoking, but I'd prefer if someone else thought about that stuff. I like grappling with high theoretical questions and intersections between rhetoric and the philosophy of communication. But that kind of work is really hard for me to do, while the quantitative stuff I can do in an instant-- the psychostimulant is still effective when I'm working on that kind of project. It is very straight forward, it doesn't require a lot of organizational planning, it doesn't involve revising an essay through multiple drafts, it doesn't require a whole lot of creativity, and the steps are all straightforward and easy to follow.
My choice of research methods also isolates me from my fellow doctoral students, because I can't really work in a research team, and quantitative social scientists hate and fear high theory, so I can't really have useful productive conversations about my work. Among the humanist phd students, only a couple really have the background knowledge to help me work through high theoretical problems, and they've got their own work to do.
I've co-authored a few things, including my first refereed publication -- an essay that I wrote entirely by myself, but a friend of mine (and a former student) helped me brainstorm, and read each draft. I listed him as second author b/c I would never have completed it without an external motivating force. In general, my work habits totally suck and I feel powerless to fix them.
So, in short, I'm not super excited about what I'm studying. I think you are right that that is probably a big part of the problem. But it also is something I cannot do a whole lot about at this point. I'm at the qualifying exam / candidacy stage, so if I didn't finish the dissertation it would be a pretty poor decision given how much time and energy I've already invested. Settling for a second masters degree at this point would mean the academic aspect of the last three years of my life was pointless.
I know it is sensible to pick a career that requires you to do things that come easy to you. And I can always shift gears later if I can find a quantitative research question that can hold my interest... but for the time being, I've got to make the most of my situation.
Being bipolar (and extremely depressed) and ADHD isn't helping things one bit.
lps
Posted by lpslpslpslpslpslps on June 5, 2010, at 21:25:43
In reply to Re: Brainstorming alternate treatment options, posted by lpslpslpslpslpslps on June 5, 2010, at 21:13:49
Also, given your insight about the psych med stuff being an avoidance strategy... should I stop trying to keep up with the field? I've almost finished reading Kaplan & Sadock's Comprehensive Textbook of Psychiatry, and the most pleasurable thing I do is acquire more knowledge about things I am fascinated with.
But, if there was a way I could redirect that motivation toward excelling academically and getting essays published, I'd take it in a heartbeat.
Aside from the avoidance thing, I do sometimes wonder if my fascination with the biological psych side of the bio-psycho-social matrix of explanations makes me unconsciously downplay the role of psychological factors, even ones that I am intellectually aware of... or if instead it is because clinical psychology and psychoanalysis are almost jokes scientifically, even if very interesting and often insightful. Often my doctor will point out possible psychological explanations for things I am dealing with, and they sound reasonable to me... but yet I can't stop thinking about neurobiological explanations, or I can't force myself to feel extremely compelled by psychological explanations, even ones that I think are reasonable. It often seems a little too 'spooky' or prescientific for me to take it as seriously as I want to.
Posted by violette on June 6, 2010, at 1:02:30
In reply to Re: Brainstorming alternate treatment options, posted by lpslpslpslpslpslps on June 5, 2010, at 21:25:43
Intellectualization is a prominent defense mechanism used to avoid unpleasant or traumatic emotions from surfacing. By the way, this has been my primary defense strategy to avoid painful emotions for many years. Unfortunately, its a lot of wear and tear on your brain to repress emotions; and depending on your primary defenses and childhood attachment situation, this coping strategy leads to depression and anxiety.
Understanding theory is not analagous to the ability to apply it-whether it's evidence based or more qualitative--no matter how intelligent the interpretor. You never know if you will be one of the "outliers"--and neither do PDocs who seem to structure their treatment based on antecdotal experience (at least the experienced ones do). There are meds shown to be more effective for OCD or PTSD, for example, and clinical alogrithms based upon empirical evidence are never absolute (or even close, imo). Additionally, most studies are based on "DSM criteria"-yet, I've never met a therapist or psychiatrist who actually uses the DSM criteria for treatment; instead, its used for billing. That doesn't give much credibility to empirical evidence, imo.
Psychology is a very fragmented discipline. Emotions, the unconscious, and other non-tangibles are difficult to quantify. Psychotherapy is, and should remain an art, imo. After being in psychodynamic therapy myself, I could care less what any evidence shows. I've had one insight after another-all those "aha" moments provoke change and symptom improvement. I don't expect this to be the case for everyone...
Many of those with strong defense mechanisms, say-intellectualization, can benefit from psychodynamic therapy, which is about "feeling". It's amazing to experience processing those painful emotions after years of repression. Insight after insight enters your awareness, and you slowly, but securely, process the emotions. It has been amazing for me, and although it is a slow process, it has proved more effective than medications. I have actually felt chemical endorphins in my mind after sessions.
However, I believe some people are better off left in denial. Sudden awareness of repressed emotions of the strongly defended can do harm. But if you have good ego strength, and it sounds as if you do, feeling as opposed to rationalizing and intellectualizing may be a more appropriate strategy.
When my emotions surfaced, it was clear to me that medications were not the ultimate answer. I have degrees in both the arts and sciences, and have come to the conclusion I do not give a f*ck what the evidence reveals. I am finding my truth-and its through the application of art by my psychtherpist, not science. It manifests with the help of an experienced, honest, and empathetic therapist who understands, interprets, listens...and promotes insights throughout the week. I feel physical relief of tension, whether it be grief or anger, after sessions.
Think about what you are doing....and what your motivations are. I've been there--for way too long. It has wasted my time, not to mention my life quality.
Posted by chujoe on June 6, 2010, at 10:16:20
In reply to Re: Brainstorming alternate treatment options, posted by lpslpslpslpslpslps on June 5, 2010, at 21:25:43
Maybe you should start with the idea of brain plasticity -- the known scientific fact that feeling states and thought process change the physical brain. After that, it becomes easier to see treatment as flowing both directions, from the psychological to the physical and from the physical to the psychological.
Posted by bleauberry on June 6, 2010, at 15:02:27
In reply to Brainstorming alternate treatment options, posted by lpslpslpslpslpslps on June 5, 2010, at 20:12:04
Just some opinions here. Nothing qualified or scientific. Just what my eyes have seen over the years observing others.
Most of your meds would have anti-motivation as predictable outcome. So no surprise there. Between the potent antihistamine going on, the dopamine blockade, the sedation, and the nervous system inhibitory actions, I don't see how motivation stands a chance.
But, hard to do, when you feel least motivated is when you have to muster strength and force it. The brain can learn but it takes repetition. Not a cure, but a coping mechanism, a strength builder, a symptom reducer, and way of screaming at the enemy "I'm the boss here, not you!" Hopefully someday you'll have pills to fix things. But until then, you have to fight back. People often say they just can't do it. I've been there. I can relate to that. But it isn't true. It is a deceptive enemy. It really is literally a matter of placing one foot in front of the other. Unless your legs are paralyzed, there is nothing in the world stopping you from taking the trash out except your own decisions.
Tyrosine. There is no way to know how much is being converted to dopamine. Maybe very little. The body has genetic commands. Feedback loops. If it is helpful, cool. If not, why take it. Too much dopamine can cause the symptoms you feel also.
SAMe is not a bad idea but that is a very low dose compared to what they use in clinical studies.
Some people react the opposite to stimulants. More focus yes, but less motivation, more blah. It depends on the sensitivity of the dopamine receptors for that particular person. People who were never bipolar can be destabilized by longterm stimulant usage. I mean, that's what happens to street addicts. Whether it is from a dealer on the street or a doctor, it is still the same drug with the same longterm outcome. Personally I see one of the versions of ritalin being a much better choice, and avoid anything generic.
Speaking of which, if any of your meds are generic, then you have no idea whether that particular med is right for you or not. The difference between brand and generic can be night and day. We see that a lot. My pharmacists see it a lot. One of my doctors will not even prescribe generics because he has seen them confound his attempts to get people well too often.
I doubt buspar is helpful in any way. I don't see a purpose for mirtazapine, seroquel. and just a tad bit suspect of lamictal. I have a hard time figuring out how you got there, but then, I don't know your history or your doctor. There are certainly much better ways to go for your cluster of symptoms.
Posted by desolationrower on June 7, 2010, at 10:16:32
In reply to Brainstorming alternate treatment options, posted by lpslpslpslpslpslps on June 5, 2010, at 20:12:04
well i would drop the quetiapine and increase the mirtazapine
i have a lot fo the same symptoms, i found nortryptaline and nicotine the most helpful, though parnate was by far teh best for getting out of depression, bupropion was pretty helpful as well for adhd
-d/r
Posted by lpslpslpslpslpslps on June 7, 2010, at 18:51:43
In reply to Re: Brainstorming alternate treatment options, posted by desolationrower on June 7, 2010, at 10:16:32
> well i would drop the quetiapine and increase the mirtazapine
>The weird thing about the quetiapine is that when I started taking it at 25 mg per day, it pulled me out of a long (1 year) dark depression in a matter of 2 days. But I'm as depressed as ever now, with weeping fits every few days and fantasies about death (I'm not at all suicidal, but sometimes I do imagine dying in an accident as a form of relief).
It occured to me this weekend that maybe I'm not really Bipolar II. My doctor has suggested this in the past, noting that it may not be that important to have a perfect diagnosis, but that he suspected that I wasn't a 'true bipolar.' I am ADHD and I was a compulsive gambler, and both of those things 'look' like bipolar disorder, but I've never had a hypomanic episode that lasted more than a couple hours except when I was gambling. If what I have is unipolar depression, it most closely matches the description for atypical depression: hypersomnia including sleep paralysis, it temporarily responds to positive events (mood reactivity), and I've had a problem with interpersonal rejection since I was a child, and it is often the precipitating thing that starts a depressed episode. I don't have an overeating problem, but I do take a stimulant (and even so I've gained 10 pounds in the last 6 months).
For anyone with relevant experience, does it sound like I'm on the right track? In either event, I'm happy to continue to take the Lamotrigine, since it is (very mildly) stimulating and it (very slightly) slows down the motion of my thoughts from one subject to another.
I've read that atypical depression responds much better to an MAOI like nardil or parnate than it does to a drug like mirtazapine or imipramine. But, I can't take any medicine that makes it impossible to take amphetamine. Does anyone have any experience adding or switching to an MAOI while concurrently taking a psychostimulant?
I'm going to talk to my doc this week's appointment to see what he thinks about increasing my vyvanse dose, dropping the buspar, and then either replacing mirtazapine with parnate or adding something like effexor or cymbalta or desipramine to the mirtazapine.
My doctor has said yes to every medicine request I've had over the years, with the exception of mirapex-- after reading the PDR entry, he (quite sensibly, I think) pointed out that the narcolepsy side effect, though rare, could very easily make my problems worse, and on top of that he had never heard of using mirapex as a psych med. Reasonable. I'm hoping he will either agree with my ideas or offer a counterproposal... all I know with certainty is that I'm taking a whole lot of drugs and they aren't working at all to solve the problems they are intended to solve.
Posted by lpslpslpslpslpslps on June 7, 2010, at 19:19:23
In reply to Re: Brainstorming alternate treatment options » lpslpslpslpslpslps, posted by violette on June 6, 2010, at 1:02:30
> Many of those with strong defense mechanisms, say-intellectualization, can benefit from psychodynamic therapy, which is about "feeling".
Can you tell me more about psychodynamic therapy? I've asked my psychiatrist about different types of therapy in the past, but he tends to do his own thing. He basically just asks me to talk about what is going on in my life, and he periodically asks follow-up questions, or makes suggestions about possible connections between things I have said, and if I ask him to suggest a course of action he will give me a little guidance.
After med school and residency this guy spent several years training at a psychoanalytic institute, so I trust that his approach to psychotherapy is based on some expertise, but I don't know if he really 'takes requests' when it comes to forms of psychotherapy.
He's always been supportive of my interest in psychiatry and psychopharmacology. He loans me issues of the academic journals he subscribes to, he gave me his old PDR, and he's loaned me a couple textbooks that's he's used when teaching at the UCLA med school. And if I come in for our weekly session and I ask him a bunch of questions about treating schizophrenic patients or about his experience running a psych hospital (which he did when he was younger), he's happy to talk to me about that for the whole time. It's like having weekly one-on-one access to an expert in a field I am intensely curious about, in addition to having a caring doctor that I like.
In short, I really like this doctor. He doesn't talk down to me, he doesn't tell me things that he knows I already know (and he has a good sense for what I do know and what I don't know). A few times, he has told me that a pharmaceutical rep has recently given him samples of a new drug, and he wants to know what I've seen about that drug in the literature. Of course, I suspect he does this in order to facilitate transference-- heck, I don't know how much I would trust him if he really made it a practice of consulting non-expert mentally ill patients about medication-- but in any event I like it b/c I feel like he's one of the only people in my life that takes me completely seriously. In three years, I've never gotten the "how cute, the patient thinks he knows something about psychiatry" condescension that I expect I would get elsewhere. He's the only person in my life I haven't had to prove myself to.
But, I have no idea if the form of psychotherapy he offers is optimal, b/c I've got no basis for comparison. I do notice two things though: 1) I generally feel better after our appointments than I did before the appointment, even if he hasn't said hardly anything, and 2) often when I am by myself, I start talking to myself mentally as if I were talking to him -- several hours a week of this, in fact, and it feels as effective as the actual therapy. And I never did anything like that before, so who knows.
Posted by Leo33 on June 7, 2010, at 19:57:22
In reply to Re: Brainstorming alternate treatment options, posted by lpslpslpslpslpslps on June 5, 2010, at 21:13:49
LPS, not to diminish your symptoms, but you have plenty of motivation and intelligence to write responses like that, you could be in a lot worse of a place than studying for your PHD.
I believe I see in your response an uncertainty of which direction you want to take, which is always daunting.
I have a couple questions for curiosity:
Have you ever been hospitalized?
Have you ever not been able to complete things on a prolonged basis, such as failing out of school or being fired from jobs?
What would you consider to be healthy or what you would be if complete remission were achieved?
take no offense, just wondering.
Posted by lpslpslpslpslpslps on June 7, 2010, at 20:10:42
In reply to Re: Brainstorming alternate treatment options, posted by Leo33 on June 7, 2010, at 19:57:22
> LPS, not to diminish your symptoms, but you have plenty of motivation and intelligence to write responses like that, you could be in a lot worse of a place than studying for your PHD.
>Yeah, I find this suspicious myself. But I feel so badly all the time that it is much easier to motivate myself to think about feeling better. Much harder to do things like get showered and dressed, eat regular meals, pay bills, read the mail, take out trash, etc. Right now, there is no part of the floor in my apartment I can touch. And cleaning just feels hopeless, like it would take a thousand years.
> Have you ever been hospitalized?
>Yes, for panic attacks that I convinced myself were more than panic attacks, but never over night. However, I have had to go away and stay with family for a week or two to get back on a regular schedule and out of crisis, which I imagine is similar but less serious than being hospitalized.
> Have you ever not been able to complete things on a prolonged basis, such as failing out of school or being fired from jobs?
>Yes. I took an incomplete on every seminar I took in the last two semesters. I am trying to catch up now, and I can focus for extended periods of time, but the problem is that I can't stay on a single task more than 5-7 minutes. So I can write out a really nice email or paragraph, but then I won't be back to that project for two hours.
> What would you consider to be healthy or what you would be if complete remission were achieved?
>What do you mean? I'd like to be able to go through every day without spontaneously weeping. I'd like to be able to work on the same project for an hour straight without taking a break or switching projects. If I could get those two things, my life wouldn't be perfect, but I wouldn't feel disabled.
Posted by Dr. Bob on June 11, 2010, at 13:57:50
In reply to Re: Brainstorming alternate treatment options » violette, posted by lpslpslpslpslpslps on June 7, 2010, at 19:19:23
> Can you tell me more about psychodynamic therapy?
Sorry to interrupt, but I'd like to redirect follow-ups regarding psychodynamic therapy to Psycho-Babble Psychology. I hope this discussion continues there. Here's a link:
http://www.dr-bob.org/babble/psycho/20100529/msgs/950715.html
That'll be considered a new thread, so if you'd like to be notified by email of follow-ups to it, you'll need to request that there. Thanks,
Bob
This is the end of the thread.
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