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Q: Therapist Wants to Help Patient
I am a mental health therapist who has been working with a 52 yr old woman
for 3 years with a history of PTSD and, in the past, Major
Depression...She was recently hospitalized for suicidal ideation and severe
agitation, poor sleep, chronic loss of appetite.....She has been diagnosed with
Bipolar II Disorder, although she doesnt present with many of the symptoms...She
is not manic, never has been, nor is she impulsive with her behavior and she
does not overspend or have impulsive sexual encounters...In fact, she is rather
isolated, with high self discipline, very bright with a Master's degree and
careful with her behaviors...She has never made a suicide attempt, although has
had one previous hospitalization for suicidal ideation.....She had a bout with
alcohol abuse 7 years ago and has been sober for 6 years, never having any
relapse and very few urges to drink after becoming sober...I suspected she was
just medicating her depression.....Her previous meds were S! erzone, Effexor,
Remeron and Nueronten..... This combo did not help her reduce the depression, nor
did it help her sleep, other than the Remeron "knocking her out and doping her
up".. While in the hospital 2 months ago, her meds were changed to Lamictal,
Effexor, Nuerontin and Zyprexa ( Zyprexa given temporarily to stabilize her mood
with a calming effect)....Im wondering what you think of this med combo?...Will
the introduction of the antidepressant Effexor combined with the mood
stabilizers cause her to "rapid cycle"??, although I have never seen her "rapid
cycle" and am not totally convinced she is Bipolar II....To me, her symptoms
indicate Post Traumatic Stress Disorder, which she was diagnosed with 4 years
ago, having grown up with an abusive father who has PTSD himself as a WWII
veteran...In her worst periods, she comes across as very depressed,
hypervigilent, racing thoughts, poor sleep, irritable, suicidal in
thinking,...but never manic or impulsive in her behavior ! and never grandious
in her thinking....She also was very bothered because she could not sleep or
eat, not grandious that she didnt need the sleep or the food...She has had alot
of problems in the past with finding meds that will help her , along with
psychiatrists who wont listen to her or change her meds....Im sorry this letter
has been so long but I am frustrated and baffled as to how to help her with
this....Any info/education/advice would be appreciated.. ....Thanks
Dear Ms. S' --
Good on ya' for wondering about the accuracy of the diagnosis as a first
question, because obviously the treatment at this point (medications-wise) is
hinging on that, and if it's not on target, that could present an ongoing
problem. On the other hand, as you've gathered from experience, including
this woman's case in particular, differentiating PTSD and bipolar II is pretty
tricky sometimes. Continuing for a moment on this diagnostic question, you
may have read already my little e-treatise on Diagnosis in the
Bipolar
II section of my website; in it you'll have seen that anxiety can be a
bipolar symptom, although I grant you that is not at all specific (here's an
essay on that issue of
Anxiety
as a Bipolar Symptom with some more references). Similarly,
insomnia can be a bipolar symptom, also not at all specific. Difficulty
concentrating, often due to racing thoughts which you have noted, is also a
bipolar symptom without good specificity. Irritability, likewise.
Suicidality, even if it's phasic, not constant or clearly related only to
stressful situations, which is the more "rapid cycling" type pattern,
still lacks any specificity.
Despite that lack of specificity, though, in diagnosing
BPII we must look beyond grandiosity, impulsivity, or other more typical
"manic" symptoms. Other symptoms are now regarded by multiple
experts as sufficient. For example, I haven't finished polishing it
up on my site, including no answer key yet (soon), but here's a new
questionnaire for BPII, the
Bipolar
Spectrum Disorders Scale (BSDS) that its well known authors tout as more
sensitive in detecting subtle "bipolar spectrum" conditions which
don't look typically manic. Look at the kinds of symptoms they're looking
for therein; it's gone well beyond typical manic symptoms.
I wonder how your patient would score on the more
widely used
Mood
Disorders Questionnaire. Pies et al built the BSDS precisely because
they felt the MDQ was not sensitive enough -- so if your patient has a positive
MDQ, that's a positive on a relatively more conservative instrument.
(Here's a
downloadable
MDQ; or you can just send the patient to the above MDQ link on my site, so
she can read the
essay
about scoring afterward).
As for the medications issue, note that she started out
with 4 agents known to have the capacity to induce cycling (3 antidepressants
plus
Neurontin);
then went on to substitute for one antidepressant Lamictal, a mood stabilizer
with indeterminate efficacy for maintaining stability in the face of
antidepressants. They kept the Effexor and the Neurontin, and (probably
rather desperately, if this is really bipolar disorder) added Zyprexa, a solid
mood stabilizer and famous weight gain agent. So, yes, I'd be concerned
about the Effexor effects, but the trend is in the right direction (ie. toward
bona fide
mood
stabilizers, as she's certainly had a good go on multiple antidepressants,
including several simultaneously).
Even if she "only" has PTSD, it looks like it
might be time for a trial of Zyprexa alone (one of my colleagues with specific
interest and expertise in PTSD thinks Zyprexa is very effective for PTSD,
especially when it's looking somewhat BP-like), after slowly tapering away the
antidepressant types, last to go being the lamotrigine -- just my opinion based
on data here, mind you.
Good luck sorting all this out over time, and with your
collaboration (and your client's) collaboration with the psychiatrist.
Dr. Phelps
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