Posted by Elizabeth on August 12, 2001, at 4:35:53
In reply to Recurrent unipolar vs bipolar...a way of life, posted by alexamum on August 10, 2001, at 18:54:59
Here's my take on the issue of "soft" bipolar disorders (a seemingly ever-expanding category)....
In addition to classic depression and manic-depression, there seems to be another category of mood disorder, the core symptom of which is what I will call "mood dysregulation" (a term sometimes used in the literature). This symptom is often attributed to anxiety and/or personality disorders. It may be identified as extreme interpersonal sensitivity (social phobia, atypical depression) or excessive mood reactivity (usually diagnosed as emotionally unstable [cluster B] personality disorder). The mood dysregulation syndrome also resemble posttraumatic stress, except that the reactions occur frequently and are far out of proportion to the "traumatic" events. Sometimes there is a personal history of severe childhood trauma, which probably contributes to the syndrome in many people, perhaps sensitising them to emotional pain later in life, contributing to the development of dissociative symptoms, etc. There also may be temperamental (congenital) aspects: some people seem to be sensitive, easily hurt, "thin-skinned," by nature.
The group of people who I'm attempting to identify are very susceptible to emotional pain and tend to have extreme reactions even to relatively minor hurts or losses. The mood dysregulation results in behavioural manifestations that can resemble symptoms of depression, mania, and/or anxiety disorders.
The course appears to be episodic; mood dysregulation episodes are much briefer than major depressive, manic, or hypomanic episodes, lasting hours or at most days rather than weeks, months, or years. Some examples of mood dysregulation episodes:
-extreme, but short-lived, depression following interpersonal rejection or loss (e.g., feeling suicidal after the breakup of a romantic relationship)
-anxiety attacks in response to fear or threat of loss, rejection, or abandonment
-emotional "crises" or "breakdowns," often involving self-injury or impulsive suicide attempts
-impulsive aggression and intense anger, often directed at selfMood dysregulation and emotional hypersensitivity also have profound effects on a person's outlook:
- a sense of desperation and chronic suicidality
- feelings of bleakness, emptiness or boredom when not in a state of "crisis"
- thrill seeking, risk taking, and/or self-destructive behaviour (perhaps in an effort to recreate emotional crises)
- extreme concern about how the person is viewed or judged by others, resulting in body dysmorphia, eating disorders, various types of social anxiety, etc.
- drug abuse (especially, alcoholism) in attempts to self-medicate; addiction may occur very rapidly perhaps due to impulsivity and frequent excess in the use of drugsMedications that seem to be helpful for people with this type of mood disorder include:
- Anticonvulsants: valproate (Depakote) and carbamazepine (Tegretol) are the best-studied ones, but lamotrigine (Lamictal), topiramate (Topamax), and gabapentin (Neurontin) may also be effective in smoothing out the mood swings.
- Antipsychotics: can be helpful, as you've discovered, in relieving rage, obsessive suicidal ideation, and other intense and dysphoric feelings. Because of their better safety profile, the newer "atypical" antipsychotics are the ones usually used; these include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). They are usually used in smaller doses than would be prescribed for psychotic disorders. They can be used acutely/"as-needed," to help the person out of episodic emotional "crises," or on a fixed schedule, to prevent such episodes from occurring. Because these drugs can take a couple of hours to work, the latter may be more practical unless the episodes are infrequent or are mostly controlled by other medication.
- Psychostimulants: in some cases, mood dysregulation may arise from what is currently called "attention deficit disorder;" stimulant drugs can help them to focus and slow down (or perhaps, allow them to keep up with their racing thoughts and feelings) so that they can experience moderate emotions and not only extreme ones, and so that they are able to think fully before acting, rather than acting on impulse.
- Serotonin reuptake inhibitors: the selective SRIs (Prozac, etc.) and the nonselective ones (e.g., Effexor) can be helpful in smoothing out moods and alleviating hypersensitivity and decreasing mood-reactivity.
- Monoamine oxidase inhibitors: may combine the benefits of SSRIs and stimulants.
- Opioid antagonists (naltrexone (ReVia)): seems to be particularly helpful for people who experience dissociation. I'm not too clear about this, but my guess is that naltrexone eliminates the "rush" that some people experience from "dangerous" behaviours such as self-injury. It also decreases opioid and alcohol cravings.Because of the wide range of medications that can be helpful to people with this problem, I think that it would be interesting to study the relationship between clinical features and drug response (antidepressant, stimulant, mood stabiliser, antipsychotic) in individuals with this type of syndrome (which I think should be classified as a mood or anxiety disorder).
OK, so now that I've written a dissertation < g >, back to your question! I think you're on the right track toward achieving long-term stability. I'm pretty sure you will find that at least some of the stuff I've written about applies to you. If the Risperdal is working and you're tolerating it okay, stay with it -- "antipsychotic" drugs (dopamine antagonists) can be effective in nonpsychotic disorders and may even have antidepressant effects in some people (just as "antidepressants" can be used for panic disorder, social anxiety, and even nonpsychiatric disorders such as neuropathic pain and allergies). Has Risperdal helped with any other symptoms besides rages?
Some of the other medications I mentioned might be worth looking into as well. It might be a good idea to take a look at the anticonvulsants, since your response to antidepressants has been lukewarm; on the other hand, you might want to try some other antidepressants since Effexor did help for a while. See what your doctor says. Stimulants and naltrexone are more experimental, so those should probably be low on your list of things to try.
One thing worth noting is that tricyclic antidepressants rarely work for emotion dysregulation; MAOIs, SSRIs, and Effexor have good track records, and Remeron, BuSpar (in high doses and/or in combination with SSRIs or other ADs), and Wellbutrin might be worth looking at too.
I know a few people who would fit into the category I've described. One is a young woman diagnosed with bipolar II disorder, borderline personality disorder, and temporal lobe epilepsy who has an extensive history of self-injury and multiple suicide attempts (she has several large, prominent scars as well as many smaller ones). She now takes Tegretol, Zyprexa, and Zoloft. Another woman, who has been diagnosed with unipolar depression and borderline personality, was abused as a child, used to dissociate and cut herself, and has an extensive drug abuse history (mainly alcohol and methamphetamine), takes Wellbutrin, naltrexone, and lithium (lithium can also be used as a mood stabiliser, although I think the anticonvulsants have a better record for this type of mood swings). She was the person who first brought naltrexone to my attention as a potential treatment for this condition, actually. A third woman, diagnosed bipolar I and borderline personality, has a history of self-injury (cutting and burning) and has had a hard time achieving stability despite being very intelligent (IMO). She is now getting herself together. She takes Moban (an older antipsychotic), Topamax, Zyprexa (as-needed), Wellbutrin, and Prozac. These are just some examples -- there are a lot of people who are overcoming this very painful condition.
I think that psychosocial therapy is warranted, if you can afford it. Are you seeing a psychotherapist of some sort, and if so, what is his or her school of thought (psychoanalytic, cognitive-behavioural, etc.)? This isn't really the primary topic of this board, but I thought I should mention it because I think it's important for people who've been mentally ill for most of their lives. (I have too, BTW, although the emotion dysregulation syndrome I described is not among my problems.)
Be well. I hope this lengthy discourse has helped answer some of your questions.
-elizabeth
poster:Elizabeth
thread:74539
URL: http://www.dr-bob.org/babble/20010809/msgs/74736.html