Posted by Tomatheus on January 7, 2006, at 20:29:46
In reply to Re: Cycling...YOU ARE RIGHT!! PLEASE HELP!! » Tomatheus, posted by bigcat on January 6, 2006, at 23:59:56
Matt,
See below for my responses to various sections of your post...
> Yes this may be hypo or manic grandiosity, but there is an element of truth in it. I wrote an email this morning that outlined my political and moral views as I've never been able to express in more than some disassociated phrases, brewing for what seems like a lifetime of inablility to communicate whatsoever.
For what it's worth, I agree with you. Those who have never experienced the type of hypomania that you're describing - especially those within the psychiatric establishment - have a tendency to dismiss the productivity and creativity of hypomania as delusions in and of themselves. In other words, it is sometimes said that people only *believe* that they're more productive and creative while they're hypomanic, but in reality they actually aren't. Speaking as somebody who's (probably) experienced something similar to what you're experiencing (like you, I was getting cycling as a result of the inhibition of the reuptake of serotonin and norepinephrine on Paxil), I believe strongly that the benefits of your hypomanic state are real. I'm not saying that hypomania can't be dangerous if it becomes too intense, but I too possessed the capacity to express my thoughts much more clearly, efficiently, and insightfully than ever when I was hypomanic. I was actually able to follow through with the goals that I set, and my ability to write (like yours) was vastly improved. Even in retrospect, I think that there is no question that I accomplished more during the few hypomanic states that I experienced than I've ever been able to accomplish during the same length of time. So, I think it's clear that my ability to accomplish more (if nothing else) was a genuine enhancement in my ability, not just the product of a delusion. Now, *can* delusional thinking emerge as a result of being hypomanic? As you mentioned below, the answer is an obvious yes.
> I simply can't believe how my brain is working now. I see through every delusion in life. But alas, this is somewhwat delusional I understand. I'm even viewing the worst of times in a positive light.
And there you go. Considering that you're viewing the worst of times in a positive light, I would imagine that you're probably wondering to what extent you're seeing other things through a distorted lens. Of course, research has shown that depressives actually have the most realistic perceptions of the world around them, and that even euthymic (e.g., "normal") individuals think somewhat delusionally. So, in that sense, a little bit of slightly "delusional" thinking might not be such a bad thing. I guess it's just a matter of finding a good balance between feeling "good" and being able to perceive things realistically and accurately. Of course, that's a helluva lot easier said than done, especially for people like us.
> I'm a bipolar who only goes hypomanic (or a handful of times full-blown manic) when introducoing new, or high levels of an AD. Nardil and Marplan- initial hypomania (mania on the Marplan). Dexedrene (90mgs)- extremely manic for months. Grandiose delusions. A messianic delusion while on recreational drugs (VERY potent pot, like nothing I've ever inhaled, or even sniffed from a distance).
It seems that the two of us have some similarities in terms of our responsiveness to meds. As I've said, I experienced mood cycling in response to Paxil monotherapy, with hypomanic and depressive states each lasting three to four days and no euthymia in between. I also tried taking a low dose of fluoxetine (generic Prozac) when I was on my Wellbutrin/lithium combo, and I even experienced some low-grade cycling then. So, given my responses to both the Paxil and the fluoxetine, I've steered clear of SSRIs, SSNRIs, and TCAs since then.
Unlike you, I have never experienced any hypomania on an MAOI, but then again, I've never taken Marplan - only Nardil, Parnate, and moclobemide. I'm wondering if your initial hypomania on MAOIs (particularly on Nardil) might have had something to do with the way you started taking the meds. Did you just start taking 45 mg/day (or 60mg/day?) all at once, or did you gradually work your way up to a therapeutic dose 15mg at a time. On Nardil, I gradually worked my way up by taking 15mg/day for a week, then 30mg/day the next week, and then 45 mg/day the week after that. And as I said, I didn't experience any hypomania, but I wonder if I might have felt hypomanic if I had just gone straight to 45mg/day without gradually working my way through the lower doses.
> I do feel short of breathe, restless, and twithy now. Is the symptoim "akasthesia"(??).
I'm not quite sure about this one, but it's my guess that this symptom will probably fade away with the hypomania. I could be wrong, though. Maybe Ed or someone else here could be more helpful with this question.
> I appreciate your concern so deeply. I know it is out of care for my well-being that you regretfully, but strongly warned that I may be cycling.
Thanks. You hit the nail right on the head.
> Now that I know this, what should I do? Ed, I've backed the Effexor from 600 to 525, Lamictal kept at 225, Buspar at 20. That's my combo. Been taking thorazine and ambien for sleep since I ran out of my sure-bet sleep med, 400-800mgs Seroquel an hour before wanting sleep. I need some, the Mabien and Thorazine aren't helping, but Seroquel is too expensive. I'll "procure" samples anyway I can, and soon. What other suggestions besides possibly adding Lithiuim (?) and obviously backing off the Effexor significantly??
I have a feeling that Ed and others here will be able to provide better suggestions than I'll be able to, especially considering that I know next to nothing about Buspar. But I'll throw in a few of my ideas just in case you might find one or two of them somewhat helpful.
First, I agree that you'll obviously need to significantly reduce your dose Effexor. Perhaps the combination of the Lamictal, the Buspar, and the Effexor dose reduction will be enough to reduce the intensity of your cycling.
With respect to lithium, I think it might be worth a try, but I will warn you that lithium doesn't have a reputation for being effective at controlling rapid cycling, whether the cycling is endogenous or medication-induced. As I mentioned earlier, I tried taking fluoxetine at a low dose when I was taking both lithium and Wellbutrin, and I still had some breakthrough cycling. So, even though lithium might be a viable option, keep in mind that it doesn't tend to be great for controlling bipolar-related cycling.
If you hadn't already tried both Nardil and Marplay, I would recommend going with an MAOI because they do have less of a tendency to induce rapid cycling in otherwise unipolar patients than other antidepressants. Obviously, some of what I'm saying comes from my own experience, but there is also some evidence in the scientific literature to support my claim. Clorgyline, an irreversible inhibitor of MAO-A that has been used only in research, has actually been found to be effective at treating endogenous rapid cycling (or in other words, cycling that's not med-induced) in some bipolar patients. But you've obviously already tried the MAOI route without immense success, so it seems that tweaking your combo is probably the most sensible thing to do at this time.
> The plan is to stay on the Effexor, Lamictal and Buspar, backing off the Effexor how much a day/week would you say? See how it goes, or make a drastic reduction and risk an atrocious withdrawal?? I know when I was moving the Effexor dose up and up every few days I was cycling awfully, but my ups were good, not perfect, and my downs were utter despair.
I feel hesitant to give my honest response to this question because I know that Effexor tends to produce extreme withdrawal reactions, and I really don't want to suggest that you do something that might lead to so much suffering. But I'm assuming that you wouldn't have asked the question that you did if you didn't want my honest response. So, here it goes, but please remember that my experience may not be the same as your experience, even though we seem to respond similarly to meds.
When I stopped taking Paxil, I basically did the unthinkable, even though I knew better. So, yeah, I stopped it cold turkey (although I can't remember why). Surprisingly, I experienced absolutely *no* withdrawal reactions. Knowing that it is highly unusual for a patient to stop taking Paxil cold turkey without experiencing any withdrawal, I put quite a bit of thought into the matter and eventually came up with a hypothesis. And my hypothesis is this: because I was constantly cycling, the levels of serotonin and norepinephrine in my brain were constantly changing. In other words, levels of the neurotransmitters were high when I felt hypomanic and low when I felt depressed. Considering that my hypomanic and depressive states only lasted three to four days, my brain never adapted to the increases (or decreases) in the levels of serotonin and norepinephrine. When most individuals take Paxil, the levels of serotonin and norepinephrine increase and remain that way indefinitely. Eventually, the brain adapts to these increases, possibly by downregulating neurotransmitter receptors, releasing fewer neurotransmitters, and/or producing fewer neurotransmitters. If Paxil is discontinued immediately in these patients, they experience withdrawal symptoms until the brain re-adapts itself to adjust to the way things were before the Paxil was taken. Once again, because my brain never adapted to any kind of long-term increase in the levels of serotonin and norepinephrine - there were only short term increases during my hypomanic periods - I never experienced withdrawal. Or at least that's how my hypothesis goes.
So, given my experience, I would not be surprised if you ended up experiencing absolutely no withdrawal symptoms from drastically reducing your dose of Effexor. Like Paxil, Effexor inhibits the reuptake of both serotonin and norepinephrine, but its inhibition of the norepinephrine transporter is stronger than that of Paxil. And of course, your response on Effexor seems to be similar to my response on Paxil. So, yeah, I wouldn't be surprised if drastically reducing your Effexor dose doesn't lead to any withdrawal reactions. But at the same time, considering how horrible withdrawal can be for some people, I don't think I can recommend in good conscience that you actually do risk the withdrawal symptoms. Of course, it's up to you. As I said in my previous post, you know how you respond to meds and changes in meds better than I possibly could, so I would recommend taking my experience into account and using your best judgment.
> Thomaseus- what MAOI is working for you? Nardil is beautiful for me for about a week, and then pisses out each time, even at 90mgs. Marplan rocketed me to the moon on the fourth trial, after three unsucessful attempts, and faded over a couple months into so-so, then nothing.
Actually, I wouldn't say that any of the MAOIs have actually "worked" - not if "working" means working well. What they have done is produced some kind of antidepressant response in me without causing me to cycle or become hypomanic in any way. I know that's not saying much, but I firmly believe that the right antidepressant (possibly, but not necessarily, in combination with a mood stabilizer) is what will get me to a state of remission if I ever get there. Even though I'm technically bipolar, the course of my illness is really best described as an ongoing state of unipolar depression - unless I'm taking an antidepressant that inhibits the reuptake of serotonin and/or norepinephrine. Mood stabilizers have been of little help to me and have sometimes made me worse. What I really need is a medication that produces that antidepressant effect that I need but doesn't go too far. So far, the MAOIs have been the only meds that have produced this effect in me, even though the effect can never seem to last.
Right now, I am taking Nardil. Like you, I have had some success on it, but I have found that this success is usually short-lived. Basically, I also get an antidepressant response each time I raise the dose, but I would say that my responses are just partial responses - in other words, pretty good, but not quite "beautiful." I'm actually considering bouncing back and forth between one dose and another (probably between 60mg and 75mg) as a sort of short-term plan until my pdoc and I can agree on a decent long-term plan. In other words, I would go from 60mg to 75mg, stay at 75mg for about two weeks to get that startup antidepressant response, and then go back down to 60mg for another two weeks, and then repeat that process again. I know it's extremely unorthodox, but I might just do it if I can get my pdoc to be ok with it because it will at least enable me to get a partial response, which I think is the best thing that I can hope for at the moment. The next best option I have (in my opinion) is to try Parnate again. When I took Parnate for the first time, I didn't give it much of a chance because the daytime sedation put me to sleep every afternoon (caffeine or no caffeine), and I ended up sleeping through some university classes that I was taking as a result. So, I had to stop it. I might just try it again if I become so fed up with the Nardil that I decide to join the "poopout club," but I'm really not crazy about the idea of taking a med that will make me have to schedule everything around an afternoon nap. So, I'm kind of in limbo right now, but I'm staying on Nardil for the time being.
What I really hope to be able to take at some point (assuming that it ever becomes available again) is the "old" Nardil that Pfizer manufactured for consumption here in the United States until the fall of 2003. Although some patients noticed no difference between the old and the new Nardil formulations, others were drastically affected by the change - sometimes to the point that they lost their jobs as a consequence of the "new" Nardil's inability to control their symptoms of depression and/or anxiety. A group of patients who were wonderfully responsive to the "old" Nardil (but not the "new" Nardil) has since come together to form a committee, which has been taking action to try to bring the "old" Nardil back to the American market. Additionally, I have developed a working hypothesis of my own concerning patient responsiveness (or lack thereof) to the "new" Nardil, and I've been digging up mounds of research material in hopes eventually finding enough evidence to provide strong support for my hypothesis. It is my prediction that the "old" Nardil will eventually become available once again in the United States, and possibly elsewhere. How long it will take for that to happen (assuming that my prediction will come to pass) is another matter, but I think it will happen at some point. I have reason to believe that the "old" Nardil might provide me with the relief I'm looking for, and I intend to do everything in my power to help make the "old" formulation available once again not only so I can try it, but also so the hundreds (or perhaps thousands?) of patients who were uniquely responsive to the "old" Nardil could once again find the peace of mind that they enjoyed for years (and even decades, in some cases) until it was suddenly just taken away from them.
Considering that you took Marplan relatively recently, I'm guessing that you're in the U.K. Am I correct? I was just wondering so I could get an idea as to what version of Nardil you were taking. But honestly, based on what I've read about the different Nardil formulations being manufactured for consumption in different countries, it seems that the Nardil being made in the U.K. and elsewhere in the world is basically comparable to the "new" Pfizer Nardil in terms of its efficacy and tolerability. So, I doubt that you've ever taken anything comparable to the "old" Pfizer Nardil. And I know that there's no way to guarantee that the "old" Nardil will become available again - and it would certainly be a long shot to say that something equivalent to the "old" Pfizer Nardil will one day become available outside the U.S. - but, if by some chance the "old" Pfizer Nardil or something equivalent to it ever becomes available to you, I would strongly recommend trying it.
But in the meantime, I would recommend focusing on the here and now, which of course means trying to find a way to tweak your current cocktail until you can get a halfway decent response, or possibly something even better. As much as I think that both of us might be responsive to the "old" Pfizer Nardil, I'm sure that you realize there might be a way to achieve remission through some other means. I wish I could have provided you with some better suggestions as to which of these "other means" would be the best, but hopefully you'll find this post to be of some help.
Tomatheus
poster:Tomatheus
thread:595776
URL: http://www.dr-bob.org/babble/20051231/msgs/596338.html