Posted by CareBear04 on February 2, 2008, at 22:42:46
In reply to Babbler VS Pdoc challange, posted by XR on January 28, 2008, at 12:48:50
This is fun! I wish I'd seen the post earlier.
Like a few other people, I was leaning toward cyclothymia or something in that spectrum. I guess a question in diagnosis and treatment is how much you're willing to diagnose separate co-morbid disorders and whether and when you should look for a simpler explanation that might account for a variety of the symptoms. My pdoc once said something to this effect in a funny adaptation of the old caution against looking for zebras when you hear hoofbeats. I forget his exact words, but it was something along the lines of "if you hear hoofbeats, you should expect to see a four-legged animal, not four one-legged animals."
The reason I tended to think something in the bipolar spectrum is that issues of mood, anxiety, attention, and self-esteem frequently present together, but they don't always rise to the criteria of the seperate diagnoses. From the little information you provided, I got the impression that an umbrella diagnosis that incorporates all your symptoms might be more appropriate than 3-4 distinct diagnoses. For one thing, you describe what sounds to be a pretty fuctional life. You're constantly tense and worried and you mention low self-esteem, but it sounds like others aren't so aware of it and you're able to keep up appearances. Re: the public speaking anxiety-- most people have this to some extent, so I'm not sure it's necessarily pathological. When you used meth, was it purely recretaional, or did it help you focus and improve your functioning? This might be relevant to your attention issues. In any case, an accurate assessment of ADHD needs to be made in the absence of confounding mood symptoms. Since you have chronic low mood and anxiety, these could account for lack of focus-- which you didn't mention specifically-- and also for the irritability.
Of course, a bipolar spectrum diagnosis does fall short in some areas. It doesn't sound like you have episodes of elevated mood, although most people with bipolar do spend much more time depressed than manic. Still, the mix of low mood and racing thoughts and anxiety are what I experience in mixed states. I also don't know about how you fit into the general timeframe for onset. The more severe forms of bipolar usually become apparent in adolescence, though maybe the "softer" bipolar categories emerge later?
Anyway, for treatment, I would probably focus first on the mood and anxiety. Like some other posters suggested, Effexor XR is approved to treat general anxiety disorder as well as depression. An SSRI might increase your anxiety and sleep problems, so I might try the other newer ADs first. I might add low-lose lithium to your AD; even if you're not bipolar, it can augment the effect of an AD, and if you do respond well to it, it can even you out generally, helping with anxiety, sleep, and irritability. Ideally, I would give this regimen a few weeks to see if it works at all, but your anxiety is probably very uncomfortable, so I would prescribe a long-acting benzo like Klonopin or even Xanax XR. I'd also give you a script for some prn propranolol for public-speaking anxiety. The only potential problem with benzos and Adderall is the breakthrough anxiety as the benzos wear off and the energy crash and extreme irritability when Adderall stops working. And as you grow tolerant to them, you usually need higher doses to get the same effect.
Of course, this is all good and well for me to say, but my own med regimen is no good example of restraint in prescribing though no one is really to blame.
Anyway, just my thoughts. thanks for the challenge!
cb
poster:CareBear04
thread:809355
URL: http://www.dr-bob.org/babble/20080124/msgs/810394.html