Dear Dr. Phelps,

Thank you for this site and your insight, they are both very informative and helpful. I have been recently diagnosed ith Bipolar type 2 or pehaps 3 disorder. This diagnosis was made at a residential treatment facility that I admitted myself to. Initially I voluntarily admitted myself to the facility for treatment of what I felt was a panic disorder. I have suffered from panic attacks for ~ 30 years. My panic comes in cycles of 5-7 years. I can not determine a causative factor, nor can I determine what causes the symptoms to disappear. My father and his mother have had similar symptomology. Prior to my admission, I had multiple unsuccessful trials with SSRI's. They actually made my sypmtoms worse. Additionally I went ~ 8 months with only 15-20 hours of sleep. I was essentially agoraphobic or house bound. At the treatment facility, I was placed on 900 mg of trileptal, 150 mg of zoloft, and 1.25 mg of zyprexa. I am equivocal with respect to the efficacy of the treatment. While the phobic symptoms have dissapated some (~75%)and I have been able to return to work, physically I feel horrible. I have no physical or mental energy, my short term memory is shot, I am jittery, and sexually impotent. My doctor says this is the trade off I have to live with. I am sleeping 6-8 hours a day continuously which is nice. Can you please provide some direction on how to manage both type 2 and co-morbid panic ? Your direction would be most appreciated. God Bless and thank you.


Dear Ken --
There are so many medication approaches to consider, I am not satisfied with the "live with it" you received from your doctor, whom we might ask if she/he would be willing to "live with it", e.g. just the sexual dysfunction alone, without searching for some alternative.

First off comes the issue of diagnosis. You had clear anxiety symptoms, but ended up with a bipolar diagnosis. We could wonder if that is correct, and go back to considering treatment targeting the anxiety alone. For example, there is a cognitive-behavioral therapy that has better long-term results than medications, for panic disorder.

However, if you do indeed have bipolar disorder (e.g. in addition to the panic and agoraphobia), then we could look at the routine approach to bipolar medications. Antidepressants should not be in there unless you have depression, and even then that's controversial. If the Zoloft is in there to treat your panic disorder, and if it was actually working (a big if, in my view, especially if it was in there before the Trileptal and Zyprexa), then it could be replaced by the cognitive-behavioral approach above. This is worth considering as in many people antidepressants can cause the jitteriness, certainly the impotence where it's the prime candidate offender, and maybe (in my view) indirectly the memory issues as well. However, this must be worked out with your doctor (here are some thoughts on talking with doctors, generally); Do Not stop the Zoloft on your own, this must be tapered carefully if that's the decision.

 
Published November, 2003