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Q: BP, BPD, Thyroid - Trying to Sort It Out
Dear Dr. Phelps,
My daughter since age 12 has beeen diagnosed with Hypothyriodism. Over the years
her Endocrinologist progressed her Levoxyl to 100mmg. She felt pretty good at
this dosage. She is now 20 and over this past year her local Dr. lowered her
dosage to 75mmg. After about a month of being on the lowered dose she started
having mood swings, poor concentration, muscel cramps, irritability, depression,
ect... During this time she enlisted in the Service, when she got to Boot Camp
the Service Dr. confinscated her Levoxyl, do to a mixup with the Dr's she never
got her perscription. After nearly 4 weeks without her meds she got very
depressed and went to talk to the Service Pschologist. She was administered a
test and it was determined that she has Boderline Personnality Disorder. She was
dismissed and when she got home we got her back on the Levoxyl, and had her TSH
level checked, it was very high. 9 days after being home we got her into see the
local Psychologist, again she was given a test, this time it was determined that
she has a mild form of Bipolar II Disorder. She was perscribed Paxil 12mg. After
2 months of being back on her thyrioid med. and 6 weeks on the Paxil we did
another TSH test and it showed that she was now Hyperthyroid. She has since
stoped taking the Paxil and we are trying to get her TSH on an even keel. Did
the Paxil interact with her Levoxyl? I am wondering why the Service Psych. and
the local Psych. hvae two different diagnosis? How accurate are these tests
since there has never been a history of Borderline Personnallity Disorder or
Bipolar II. It sounds like she was given the same test both times, with the
local test being a little more indepth. Can Hypo and Hyperthyroidism cause these
same symptoms and is there any material out there that can confirm
this? Also has there been much studies done on a defective thyroid and it's
effect on the emotional and mental psyche? Sorry for any inconvenience of my
long history explination.
Dear Jeanne --
As you obviously understand, this is a very complicated set of interactions of
time and several medications (not to mention diagnoses). Let's see if we
can tease out something without guessing too much.
First of all, the diagnosis if "borderline
personality disorder" is worth questioning under almost any circumstances,
in my view, as long as the questioning is done in a way that doesn't make your
daughter's situation worse, which is not a trivial concern. Here's an
essay about the relationship, diagnostically, of
"borderline"
and bipolar. As you'll see, my emphasis there is that the label should
not interfere with the focus on treatment options.
Second: what happened to her thyroid status
during this mess, and why was she "hyperthyroid" on a dose that seemed
to have been managing things well before it was stopped? Well, first we
could wonder if there was a TSH done fairly near the time it was (so oddly)
stopped. Perhaps she was "hyperthyroid" even before she got to
boot camp, i.e. by the test anyway, though not by symptoms (which can certainly
happen), and it just wasn't detected then because the 100 mcg dose had been
working fine for a long time prior to that.
But, that's probably not the answer. I'll bet
it's way more complicated than that, but here the guessing starts. I think
there's some sort of relationship of the two disorders, thyroid and bipolar
disorder, and that the symptoms which emerged (called by the military
"borderline personality disorder") while she was off thyroid were
directly related to being off thyroid (no way to prove that, no point, in my
view, in chasing after the military to blame them, because this relationship is
too speculative). However, I would also speculate that once they emerged,
they represented the emergence of something closer to bipolar II (as
"hypothyroidism" should not lead to such diagnostic speculations if
that's really what was going on; those two are not thought to be related in
terms of how they show up). That emergence could, causatively, have
had something to do with the thyroid shift, is my guess, and let me emphasize
that this is a guess based on how often I hear about thyroid disturbances
somehow appearing near the onset of bipolar symptoms.
Third: why "hyperthyroid" on the previously
effective dose of thyroid? Again, guessing: I think that the
relationship of bipolar and thyroid is "two-way", i.e. that bipolar
disorder can affect thyroid production too. Fairly often I see a TSH down
around 0.2 in someone where it had been closer to 1.0, during a mildly
hypomanic-symptom phase. The relationship is remarkably fuzzy
though: it's not directly related enough to say the
"hyperthyroidism" (note this is by lab test, a too-low TSH, not by symptoms
of hyperthyroidism) caused the bipolar symptoms, but rather just that I
occasionally seem to see these things showing up at the same time in someone who
does not have formally recognized underlying thyroid problems.
Fourth: did the Paxil interact with levoxyl? Not
likely; there is no such recognized interaction I'm aware of. Rather, I
would guess that Paxil interacted with an underlying mood condition that
was emerging then (as above, perhaps in some relation to the
thyroid condition; and I would guess there's a family history of mood
problems?), namely this bipolar -like thing, and that in that fashion the Paxil might
have contributed to the "hyperthyroid" thing via it's well-known
capacity to adversely affect bipolar disorder (as all antidepressants
may). Now this one is really speculating, trying to draw some
connection between Paxil and what happened. It's certainly possible that
Paxil was an "innocent bystander".
Lastly, about diagnosing bipolar disorder: there
is no test. Any testing the psychologists may have done, e.g. the MMPI or
some such, has not been connected to the diagnostic process (psychologists and
psychiatrists, with the latter responsible for the official naming system, the
DSM, sort of live in two different worlds, by a rather odd political
history). There is no blood test for bipolar, for example. There is
only the "Mood Disorders Questionnaire", which is supposed to be a
"quick and dirty" test that can be used instead of a long
diagnostic interview. In my view the only "test" for bipolar is
to make sure the patient understands in some detail the nature of
bipolar
II, as described on my website for example, and then see if she comes back
in from reading it and goes "that's me!" In that case, it's
almost certain the MDQ would be strongly positive as well (the best way to try
that test, which you can complete about her as well, is to take the link in this
paragraph and read up about BPII, then use the links you'll find there to take
the MDQ; it comes at the end of the section about Diagnosis. This allows
you to read about how to score it and how to interpret that score).
Thanks for your interesting questions. I hope
things get smoother from here.
Dr. Phelps
Published July, 2003
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