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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by Solstice on March 1, 2012, at 18:21:58
Last night - Moon took her 10 mg Saphris - no lithium. This is her 4th day without lithium.
She seemed fine this morning. The school nurse called at 10:30. Moon was fine during 1st period, but when she got to 2nd period she felt disoriented, like she couldn't remember anything she'd done that week. She was anxious, couldn't participate in class, staring blankly. The teacher escorted her to the nurse. The teacher and nurse described her as slurring her words - and obtunded. Her blood pressure and pulse are erratic - have been fairly high off and on. It was 133/94 and 124p at 10am, but I just took it at 6pm and it was 102/69 70p.
I was able to get Moon in to see her psychiatrist early tomorrow morning.
After I got her home, she seemed a little better, except she has had a really bad headache since yesterday. She was relaxed though, and did not seem to have trouble talking. She asked if she was going to school tomorrow, and I told her probably not. She was upset, because she has two tests. But she said she wasn't prepared for them.
I am really struggling to figure out where her symptoms are coming from.
- bipolar hypomania
- bipolar depression
- a medication
- a combination of medications
- going off a medication
- anxiety over being so behind in school
- some viral thing (she feels nauseated - but is it because her head hurts?)The nurse told me that she is just not functioning... and her issues are becoming disruptive for the other students. They worry about her, and it has just turned into a real problem, which I really do understand.
Moon has been on 10mg Saphris now for 9 days, but it was combined with 900 mg Lithium until 4 days ago.
Any ideas?
Solstice
Posted by Solstice on March 1, 2012, at 18:28:57
In reply to Moon sent home from school today - sigh.., posted by Solstice on March 1, 2012, at 18:21:58
oh.. I forgot to say this:
I think anxiety might be playing a HUGE role in her symptoms. She is really behind, and because of the hypomanic episode, she can't really talk herself through to feel like she can cope. Her hypomanic distortions are catastrophizing her situation. Her school performance is far below ideal right now - but it's not the end of the world. The 'panic attacks' were emphasized by the teacher/nurse. So I'm thinking that she feels all this anxiety and gets no relief from it. She keeps trying to get caught up - but her bipolar and med issues get in the way - so she keeps feeling like a failure. Maybe that's why she seems more relaxed at home.
I just don't know what to do to help her. I'm thinking about keeping her out of school through spring break.. but if we don't figure out a way to address the academics, she'll be right back where she started.
Anyway.. what to you all know about anxiety?
Solstice
Posted by Twinleaf on March 1, 2012, at 19:37:28
In reply to Re: Moon sent home from school today - sigh.., posted by Solstice on March 1, 2012, at 18:28:57
There are a couple of things which really do seem like extreme anxiety: the fluctuation in vital signs, especially the very rapid pulse at school vs the normal one at home, and her normal behavior at home when she feels safe and relaxed. If her bipolar symptoms were as severe as they have been in recent months, she would not seem like herself at home, so that is one very encouraging development. I'm assuming that the extra-pyramidal symptoms have mostly cleared up?
It sounds that the most important issue right now (in addition to working out the best possible med combination) would be to help her be, and feel, successful, even if in small ways. Would it help to drop some classes and just concentrate on one or two, and planning on an additional year as you mentioned? I don't even know if that's possible in high school, but I do think you are right in suspecting that anxiety is making things very hard for her right now. Is she able to concentrate on homework when she is at home?
Posted by SLS on March 1, 2012, at 19:39:13
In reply to Moon sent home from school today - sigh.., posted by Solstice on March 1, 2012, at 18:21:58
> Any ideas?
For the last few days, I have been thinking about the potential for Depakote (valproate) to treat your daughter. Using a mood stabilizer is another avenue to investigate. It can definitely help with mania or mixed states. Klonopin might be something to consider for the anxiety. It, too, has mood stabilizing properties. However, if the mixed-state resolves, the anxiety might, too.Just a couple of ideas.
- Scott
Posted by Solstice on March 1, 2012, at 20:31:32
In reply to Re: Moon sent home from school today - sigh.., posted by Twinleaf on March 1, 2012, at 19:37:28
Thanks so much for responding, Twin..
> There are a couple of things which really do seem like extreme anxiety: the fluctuation in vital signs, especially the very rapid pulse at school vs the normal one at home, and her normal behavior at home when she feels safe and relaxed. If her bipolar symptoms were as severe as they have been in recent months, she would not seem like herself at home, so that is one very encouraging development. I'm assuming that the extra-pyramidal symptoms have mostly cleared up?
Those are some really good questions, but it's really hard to be sure. The tremors are pretty much gone. But this obtundedness.. her sense of having no memory of the last week.. staring and feeling 'blank'.. slurred speech.. some of that could be EPS.. but could also be anxiety, especially when anxiety really escalates. Intense anxiety can make you just 'check out,' and like you said, make your heart race, etc. And she has had some symptoms at home, but it is usually associated with pressure she feels about taking tests she's not ready for or doing homework she doesn't understand because she missed so much instruction.
>
> It sounds that the most important issue right now (in addition to working out the best possible med combination) would be to help her be, and feel, successful, even if in small ways. Would it help to drop some classes and just concentrate on one or two, and planning on an additional year as you mentioned? I don't even know if that's possible in high school, but I do think you are right in suspecting that anxiety is making things very hard for her right now. Is she able to concentrate on homework when she is at home?Lately, all the instruction Moon has missed has made homework difficult. Not so much for AP English, but more for Advanced Algebra and Pre-AP Chemistry.
I just really do think the anxiety is causing of the trouble, and it makes it difficult to know whether the new meds are working. Worst of all, is that I don't know how we're going to resolve what's behind the anxiety.
:-( Solstice
Posted by Solstice on March 1, 2012, at 20:36:34
In reply to Re: Moon sent home from school today - sigh.. » Solstice, posted by SLS on March 1, 2012, at 19:39:13
> > Any ideas?
>
>
> For the last few days, I have been thinking about the potential for Depakote (valproate) to treat your daughter. Using a mood stabilizer is another avenue to investigate. It can definitely help with mania or mixed states. Klonopin might be something to consider for the anxiety. It, too, has mood stabilizing properties. However, if the mixed-state resolves, the anxiety might, too.
>
> Just a couple of ideas.
>
Now.. she does take Lamictal. She's been at 300mg for about a week. I know they can be given together, but the Depakote affects Lamictal dosages. Do they work on different things?As for Klonopin, I don't know much about it, but this psychiatrist is pretty conservative about giving pediatrics meds that sedate. That said, I think we need *some*thing to maybe give PRN when she's really over the edge, because when that happens it can be pretty intense.. unmanageable. I very recently wished for tranquilizer darts :-)
How would Klonopin be used?
Solstice
Posted by papillon2 on March 1, 2012, at 20:36:39
In reply to Re: Moon sent home from school today - sigh.., posted by Solstice on March 1, 2012, at 18:28:57
> I just don't know what to do to help her. I'm thinking about keeping her out of school through spring break.. but if we don't figure out a way to address the academics, she'll be right back where she started.
>
> Anyway.. what to you all know about anxiety?
>
> SolsticeI'm sorry to hear that things have taken a turn for the worse. :-(
The difficulty with taking her out of school, is the need to balance the stress of going to school and not coping/learning well, with the stress about not going to school and falling even further behind. This is significant because your daughter places a premium on her education and academic abilities, so either way her self esteem and confidence is likely to take a battering.
I speak from personal experience, having only done half of my final year at school, with the other half spent in hospital. Thankfully I had completed enough of the school year for my teachers to alter the weightings of assessments, so a test counting for say 25% of my total marks was changed to 40%. Perhaps this would be an option for Moon if her previous marks have been good enough?
Another idea is homeschooling. Moon could get her work from her current school, do it in her own time rather than having to stick with the school timetable, and send it back for marking. Perhaps she could get a tutor to help where needed.
To me, the cognitive slowing smacks of depression and/or a response to medication. But you're right, anxiety can also cause one to shut down. So what do I know about anxiety? Well, when you first posted about Moon's outbursts and irrational arguments, the first thing I thought about was that she might be incredibly anxious. Anxiety is at the root of a lot of anger even for people without a mental illness.
I personally become angry when my level of anxiety is ridiculously high and something happens that pushes me over the edge. I know others who do the same. Sometimes I will insist upon a particular thing being correct or incorrect, when I know it really isn't. I'll continue with my argument because the truth is too scary for me to openly acknowledge. I'm not saying this is necessarily the case for Moon, but it's a possibility.
Then there is displaced anger: Moon may be angry/anxious at one thing, but show anger towards another. And she has a lot about which to be rightfully angry in my opinion, her illness and its treatment for starters. But anyway, I have gone completely off topic...
I wish you all the best with tomorrow's appointment. If the removal of Lithium was partly to blame, Moon might be able to tolerate Lithium at a lower dose without any adverse effects. Side effects with Lithium are largely dose dependent. It would have to be combined with other medication, however.
Posted by Phillipa on March 1, 2012, at 20:53:16
In reply to Re: Moon sent home from school today - sigh.., posted by papillon2 on March 1, 2012, at 20:36:39
I didn't know Moon was in advanced classes also. That really is very stressful. I'm sure her intelligence is more than capable of the advanced classes but can her both physical and mental conditions or better yet should they be on the extreme? I was also in advanced high school and my Mom died and I asked to be put into classes for average. My anxiety was too high. I can remember walking the halls in a fog that is the way stress effects me at times or feel like my head will explode. I'd also thought of the home schooling. I sure don't want to take a thing away from Moon I just feel she could be under too much pressure from herself and is she a people pleaser. I also get to the point of exploding and do when so frustrated at not knowing what's wrong. Fear is powerful I keep using myself as an example only as I trying to step into her shoes as I'm fearing death terribly and Moon is fearing "what's wrong with me & not wanting to fail? If I'm wrong I'm wrong. As for anxiety I'm probably the Queen of it. For instant relief if haven't been on them xanax. And a person will only take the amount to relieve the horrible stress not keep escalating the dose. These are just my thoughts. And sincerly good luck tomorrow. Phillipa
Posted by papillon2 on March 1, 2012, at 21:00:27
In reply to Re: Moon sent home from school today - sigh.. » SLS, posted by Solstice on March 1, 2012, at 20:36:34
Twinleaf's post has made me remember that I also dropped both advanced and extension maths, so I was better able to focus on other subjects. In any case, I could no longer follow anything in my maths classes.
In Australia we have a system called Pathways, in which students can split their schooling over two years. Half their subjects are done in one year, the other half in the next. If you have something similar in the US, a lighter load might significantly lower her stress level, which should in turn have a positive effect on her schooling and boost her self-esteem.
Moon might see such a plan as a failure. The emphasis should be on how it is a reasonable and fair accomodation for any student with a serious illness, and how would help her succeed at the level she wants and would otherwise be capable of reaching.
Posted by Solstice on March 1, 2012, at 21:17:43
In reply to Re: Moon sent home from school today - sigh.., posted by papillon2 on March 1, 2012, at 20:36:39
Thanks Papi.. you had so many good things to say.. very helpful>
> The difficulty with taking her out of school, is the need to balance the stress of going to school and not coping/learning well, with the stress about not going to school and falling even further behind. This is significant because your daughter places a premium on her education and academic abilities, so either way her self esteem and confidence is likely to take a battering.I know.. it is such a dilemma. I'm just so worried that keeping her in that pressure cooker right now is going to threaten her ability to recover.. and could cause her mental health to get worse.. impacting her future.
>
> I speak from personal experience, having only done half of my final year at school, with the other half spent in hospital. Thankfully I had completed enough of the school year for my teachers to alter the weightings of assessments, so a test counting for say 25% of my total marks was changed to 40%. Perhaps this would be an option for Moon if her previous marks have been good enough?Her difficulties have been going on pretty much since the beginning of the year. But.. this is an interesting approach! She has no trouble with AP English.. it's like breathing for her. As I think back about it, she was doing real well with Advanced Algebra and AP Chemistry too. Her counselor did say that one option would be to let her take her classes through the online thing they have that some kids will use to take classes during the summer - accelerate graduation - etc. I'm somewhat worried about that because her social life is central to her functioning well. Being isolated from her friends would be a problem, I think. Of course, maybe she could be at school for electives, and take the other courses online, which would allow accommodation for times when she is not functioning.. but I don't know what the rules are (whether she could do both). And of course, another option is for her to just delay graduation. But that, of course, creates other issues.
>
> Another idea is homeschooling. Moon could get her work from her current school, do it in her own time rather than having to stick with the school timetable, and send it back for marking. Perhaps she could get a tutor to help where needed.Taking classes online would be similar to homeschooling.. but again, being isolated from her classmates would be pretty detrimental.
>
> To me, the cognitive slowing smacks of depression and/or a response to medication. But you're right, anxiety can also cause one to shut down. So what do I know about anxiety? Well, when you first posted about Moon's outbursts and irrational arguments, the first thing I thought about was that she might be incredibly anxious. Anxiety is at the root of a lot of anger even for people without a mental illness.
>
> I personally become angry when my level of anxiety is ridiculously high and something happens that pushes me over the edge. I know others who do the same. Sometimes I will insist upon a particular thing being correct or incorrect, when I know it really isn't. I'll continue with my argument because the truth is too scary for me to openly acknowledge. I'm not saying this is necessarily the case for Moon, but it's a possibility.
>
> Then there is displaced anger: Moon may be angry/anxious at one thing, but show anger towards another. And she has a lot about which to be rightfully angry in my opinion, her illness and its treatment for starters. But anyway, I have gone completely off topic...Papi - thank you SO much for your amazing descriptions of this. This is incredibly helpful.
>
> I wish you all the best with tomorrow's appointment. If the removal of Lithium was partly to blame, Moon might be able to tolerate Lithium at a lower dose without any adverse effects. Side effects with Lithium are largely dose dependent. It would have to be combined with other medication, however.Yeah.. I don't know how the lithium factors in right now. It's probably not completely out of her system yet, so if it's playing a role, it's hard to know whether it's because it's not out of her system, or because she needs a little more than what's left. I'm going to talk to her psychiatrist about whether we should try 300mg, but Moon hated the lithium the entire time. I think she had hand tremors even on 300mg, and she did not feel the lithium made any difference.. but she may have been so irritated with the side effects that she was unwilling to give it a chance.
Anyway, thank you so much for all your great input.
Solstice
Posted by Solstice on March 1, 2012, at 21:33:22
In reply to Re: Moon sent home from school today - sigh.., posted by Phillipa on March 1, 2012, at 20:53:16
> I didn't know Moon was in advanced classes also. That really is very stressful. I'm sure her intelligence is more than capable of the advanced classes but can her both physical and mental conditions or better yet should they be on the extreme? I was also in advanced high school and my Mom died and I asked to be put into classes for average.
Her counselor and I have been trying to get her to move into regular classes (except AP English). I think she's a little more open to it. In her bipolar distortions, she somehow thinks that moving out of the advanced classes is *because* she's not smart enough. We keep telling her that it has nothing to do with her intelligence; that it's just that she has an illness she didn't ask for that is interfering with her ability to perform, and she needs to move so she can have a chance to heal and that when she heals, she can go right back on to do it however she likes. I've had trouble getting her to see that she might do long-term damage if she doesn't look after her mental health and have respect for the limitations her illness imposes. The grandiosity of her hypomania causes her to take on WAY more than is humanly possible, and she has really got to understand that she can't do that to herself. But.. when in an episode, there's no reasoning with her.
> My anxiety was too high. I can remember walking the halls in a fog that is the way stress effects me at times or feel like my head will explode. I'd also thought of the home schooling. I sure don't want to take a thing away from Moon I just feel she could be under too much pressure from herself and is she a people pleaser.
You're right on point. Moon's self-expectations are incredibly unreasonable.
I also get to the point of exploding and do when so frustrated at not knowing what's wrong. Fear is powerful I keep using myself as an example only as I trying to step into her shoes as I'm fearing death terribly and Moon is fearing "what's wrong with me & not wanting to fail? If I'm wrong I'm wrong. As for anxiety I'm probably the Queen of it. For instant relief if haven't been on them xanax. And a person will only take the amount to relieve the horrible stress not keep escalating the dose. These are just my thoughts. And sincerly good luck tomorrow. Phillipa
Thanks Phillipa, your descriptions really are very helpful
Solstice
Posted by Twinleaf on March 1, 2012, at 23:45:56
In reply to Re: Moon sent home from school today - sigh.. » papillon2, posted by Solstice on March 1, 2012, at 21:17:43
Practically speaking, once you take the regular classes rather than the APs, your credits for college come from those, don't they? She is clearly so bright, and remembering my son's experience, the APs make such a difference with college admissions. Could she take one or two AP courses online with a tutor helping, and some courses at school, perhaps AP English and one other?
As to the medications, there have been several additions in a short period of time. Maybe it would be good to keep everything the same for a few weeks, and then, if changes are needed, to add or subtract just one at a time. You are a very sensitive, medically astute observer, which is an absolutely wonderful help in such a complex situation.
Posted by SLS on March 1, 2012, at 23:56:44
In reply to Re: Moon sent home from school today - sigh.. » SLS, posted by Solstice on March 1, 2012, at 20:36:34
> > > Any ideas?
> > For the last few days, I have been thinking about the potential for Depakote (valproate) to treat your daughter. Using a mood stabilizer is another avenue to investigate. It can definitely help with mania or mixed states. Klonopin might be something to consider for the anxiety. It, too, has mood stabilizing properties. However, if the mixed-state resolves, the anxiety might, too.
> >
> > Just a couple of ideas.> Now.. she does take Lamictal. She's been at 300mg for about a week.
Oh, gosh. In some people, Lamictal at 300 mg can put them in a brain-fog and impairs memory and cognition. This drug should be suspect whenever these impairments emerge. 200 mg is usually okay. Lamictal, even at high dosages, is NOT a potent drug for treating acute hypomania or mania. It makes sense to take it to help ease depression.
When adding Depakote, you must reduce the dosage of Lamictal by half. Both drugs work to inhibit sodium channels. However, Depakote seems to work more robustly to enhance GABA activity, which can be calming. I once took both drugs without adverse effects.
For anxiety, Klonopin has a long half life for a BZD, and might provide anxiolysis all day long. If a shorter-acting drug is required, Ativan would be my first choice. Xanax can produce behavioral disinhibition and make things worse.
> I very recently wished for tranquilizer darts :-)
For you or your daughter? Maybe both?
:-)
- Scott
Posted by Jeroen on March 7, 2012, at 11:21:19
In reply to Moon sent home from school today - sigh.., posted by Solstice on March 1, 2012, at 18:21:58
Hi there,
i took risperidone and fell asleep and was zombie in class, people taught i had cancer, no it was just the medication,
i'm sorry to say but your daughter needs to find a stable treatment where she can focus and feel good, not everything, but just ok i guess where she can function
it wasnt funny going trough all this by myself
in school
This is the end of the thread.
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