Q: "Turbulent Mood" Unexpectedly Triggered by Mood Stabilizers?
Dr. Phelps ,
thanks for your precious time and invaluable
I have Extremely unexpected responses from most of the
I am a Chinese (pardon my English), I have had
extremely unexpected responses from mood stabilizers.
When I first start a new drug or increase the dosage of
the same med, I would immediately feel rage, agnation, anxiety, uneasiness ( I
even smashed things), yes, very typical hypomanic symptoms. How could the
supposedly calming medications make me feel more hypomanic? ( I am certain that
I took no antidepressants along with them)
After that "hypomanic" period, my mind seems to be
foggy, i couldnot think clearly, couldnot speak fluently, feeling emotionless
all the time. Surprisingly, all the above unexpected responses from mood
stabilizers can be easily eased by sedative sleeping pills (benzodiazepines) But
they are addictive, I dare not use them othen.Does that mean I have anxiety
disorder instead of bipolar?? I have anther hypothesis. I have mild version of
mixed states. Is it possible that mood stabilizers have changed the course of
illness, making "mixed" become "clear-cut", so as to make me feel very typical
hypomania and depression, even more severe than before??? My Chinese physiatrist
diagnoses me as "mixed/ultra-rapid cycling bipolar disorder." I feel it is
rather a mild version. I sought physiatrist's help just to ease inner uneasiness
and restlessness (kinda like anxiety symptoms). At this stage, I doubt whether
the diagnosis is wrong, but I clearly had "up"s in 2000 and 2001.
So I want to know, do you see any patient experienced
"turbulent mood" unexpectedly triggered by mood stabilizers (like lithium
especially, after taking lithium 1000mg, the next day I mashed TV and computer)?
What is your idea regarding my case??
I am in China, don't know much about English
mental-health forum. I would be very grateful of you all. I am in a small city
of China, local doctors didn't listen to me.
(ps, i have mild hyperthyroidism as well)
Thanks!!! I am running out of hope now!! Life has almost come to an end.
Dear Kevin --
2 immediate thoughts, then on to your question.
1. Your English is working
very well, congratulations (just imagine me trying to say anything in Chinese,
that would be a disaster. I could not even say "good morning!") I have no
difficulty understanding your question.
2. On the other hand, your
distress is obvious. I wish I had a great answer that would lead you directly
to some new solutions. I am worried that I cannot provide such an answer. But
I hope that by telling you what I know about this, I might be of some small
use. In the United States, I would be encouraging you to contact your
psychiatrist and make sure that she/he knows how bad things are, that you feel
that life has almost come to an end. Sometimes, in our country, this motivates
the system to respond more quickly (not always). It sounds as though your
system of health care may not be very responsive. Unfortunately, there are
plenty of people in the United States who have had a similar experience, with
our healthcare system.
Now, on to your question.
Again I find myself reacting to one detail strongly and quickly: you mention
that you are "mildly hyperthyroid". Because the rest of your story is so
unusual, very unlike the typical experience that people have using things like
lithium, one immediately wants to look for some explanation as to why you are so
different. The thyroid abnormality is an obvious place to start. Indeed, this
is also logical because hyperthyroidism itself is associated with some of the
symptoms you describe, such as
anxiety and uneasiness
So, first I hope that this
hyperthyroidism is being investigated and that treating it has been considered,
perhaps even as a means of addressing some of your symptoms.
Secondly, you mention
something else which is very unusual and not typical of symptoms of bipolar
disorder. You describe: " After that "hypomanic"
period, my mind seems to be foggy, i couldnot think clearly, couldnot speak
fluently, feeling emotionless all the time."
If your "hypomanic" phase
described here goes on for several days, then the next phase could be
interpreted as a depression. Severe depression often follows hypomania (indeed,
that is the most common pattern). On the other hand, if your hypomanic phase
lasts only an hour or two (or less), then the next phase could be interpreted as
a recovery period following a form of seizure. Lithium can sometimes make
seizure disorders worse (here
is a reference; see the additional references at the bottom of the
article). So if lithium was somehow inducing an unusual form of seizure
activity, it could make some dramatic things happen, followed by a period of
confusion and a desire to sleep. Similarly, other medications used to treat
mania can also make seizure disorders worse, including nearly all of the
"antipsychotic" medications now often used as mood stabilizers (olanzapine/Zyprexa,
risperidone/Risperdal, quetiapine/Seroquel, and others;
here is a reference).
Third, you are correct.
it possible that mood stabilizers have changed the course of illness, making
"mixed" become "clear-cut", so as to make me feel very typical hypomania and
depression, even more severe than before???
) : sometimes when people are
in a mixed state, it seems as though mood stabilizer medications can suddenly
stop the intense combination of symptoms, yet leave people with one half of the
previous mixed experience. But in my patients, I've only seen this aware of the
remaining symptom is depression, not hypomania. For example, someone in a mixed
state is placed on a medication like divalproex/Depakote, and becomes
immediately very significantly depressed. It is as though the medication
removed the "top half" of the mixed experience, leaving only the "bottom half".
However, I don't think I have ever seen the reverse, which is something like
what you are describing: a medication taking away the bottom half of a mixed
state, leaving only the top half.
However, if that is truly what
is happening, then perhaps the solution that I have used for my patients who
experience a sudden depression coming out of a mixed state when placed on a mood
stabilizer might work for you. Although I am not certain about this, it looks
to me like this experience is more likely to occur when a powerful mood
stabilizer is added very quickly. If the mood stabilizers are added more
slowly, starting with very low doses and moving up gradually, over a period of
several weeks (instead of several days, as we usually would proceed), I have the
impression that this can prevent the entire problem. Instead, a medication that
otherwise might seem to have caused depression can turn out to be useful and
I've never seen anything like
this described in the psychiatric literature, but I assure you that I have
thought it before you raised the possibility in your letter. Unfortunately,
again you are very unusual: your version, if that is really what is happening,
is backwards from what I've seen in my patients.
I hope that one of those three
ideas proves to be useful. Good luck getting this figured out and handled in
your healthcare system. If you can do with your mood problems what you have
done with your English, I am confident that you will get this worked out.
Published June, 2009