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Dr. Bob is Robert Hsiung, MD,
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Posted by fluffy on December 4, 2003, at 16:31:47
In reply to Lithium and hypothyroid question (at end of poat) » fluffy, posted by katia on December 4, 2003, at 15:55:45
Hey Katia--
Well even if you're not feeling tip-top, sounds like you are coming to terms with some stuff. It's tough to realize everything at once, like a big, undefined weight laying on top of you, and with a clinical name attached to it (Bipolar). It's been helping me a lot to go to a therapist who is well versed in the bipolar business. She really helps me work through relationship stuff, and shame of the diagnosis...and just coping with depression. Like she helps me to have a plan when I don't want to eat. Her suggestion: just keep some soup laying around, and don't feel overwhelmed. Just pop it on the stove, eat what you can, and don't beat yourself up for not having an appetite. (just common sense stuff that I'm not thinking about when I'm depressed).
So I got some discouraging news this afternoon. Turns out my sodium levels are low! The bad part about it is that they will continue to drop as long as I'm on Trileptal, and it can end up being very dangerous. It can end up with seizures, vomiting, coma, even DEATH!!! So unfortunately, I'm tapering off this week and getting my levels checked again. AGAIN, I'm part of the 3% of people with adverse side effects that don't seem to effect the majority of folks taking gold standard drugs. PPPPOOOOOOOPPPP!!! Back to the drawing board. aaarrghhgh. The good news is that at least I know that I don't have a mysterious illness with no cure.
As for the Lithium. I wouldn't be too scared. It can of course cause thyroid problems, but they can be remedied with supplements, as much of a pain as that is. Lots of people have ZERO problems. So just cross that bridge when you come to it. I would continue to take trileptal, even with the sodium problem, if there was some kind of supplement to fix it. But alas, the only way is to get rid of it. So at least, most Li problems are easy to fix. The thirst is annoying, but tolerable if you have a stable mood. And the weight gain...it's probably not nearly as bad as zyprexa or depakote in the chubs department. (those are my next options...new jeans, here I come!)
The alchohol thing is tough to deal with. I've had my share of dipping into it, but not really to remedy depression. Usually I drink if I'm hypomanic....PAAARRRTYYY! Then I feel mellowed out for a day or two, and then start again with another binge. It sure doesn't hurt to get some support if you feel it is becoming bigger than you, and damaging your mood stability. I'm struggling with my cigarette addiction right now. It's so, so hard to quit. I'm trying this week, though.
So glad to hear from you. Keep in touch, okay? I'll let you know what happens with this sodium BS.
hugs,
katy
Posted by katia on December 4, 2003, at 17:15:15
In reply to Re: Lithium and hypothyroid question (at end of po, posted by fluffy on December 4, 2003, at 16:31:47
Hi Katy,
I also have a weekly therapist - over a year now. it definitely is needed!!!
>
> So I got some discouraging news this afternoon. Turns out my sodium levels are low! The bad part about it is that they will continue to drop as long as I'm on Trileptal, and it can end up being very dangerous. It can end up with seizures, vomiting, coma, even DEATH!!!**Sorry to hear about that! You know, you'd probably do well on Depakote. I actually didn't gain any weight on it. It just caused extreme fatigue late in the afternoon. Probably something that wouldn't have lasted over time. If you do well on Trileptal, I've heard that you'd do well on Depakote.
> As for the Lithium. I wouldn't be too scared. It can of course cause thyroid problems, but they can be remedied with supplements, as much of a pain as that is. Lots of people have ZERO problems. So just cross that bridge when you come to it. I would continue to take trileptal, even with the sodium problem, if there was some kind of supplement to fix it. But alas, the only way is to get rid of it. So at least, most Li problems are easy to fix.
** yes, I know. but I don't want to take yet MORE pills. and I don't want to mess around with my thyroid. I don't want to permanently damage it for a temporary trial and error.
> The alchohol thing is tough to deal with. I've had my share of dipping into it, but not really to remedy depression. Usually I drink if I'm hypomanic....PAAARRRTYYY! Then I feel mellowed out for a day or two, and then start again with another binge.
**I'm both. When depressed - drink. When hypo - DRINK!!!
I'm sorry to hear you have to come off of Tril. But I think you'd do well on Depakote. From what I remember of you, you need to gain weight anyway. And I didn't gain weight on it.
good luck to you.
hugs back -
katia
Posted by BarbaraCat on December 5, 2003, at 16:05:37
In reply to Re: Lithium and hypothyroid question (at end of po » fluffy, posted by katia on December 4, 2003, at 17:15:15
Hello Girlfriends,
Sorry I haven't been around lately. We got DSL and our Outlook email got screwed. But really, the real reason is that I've been down so very low that this might be the clincher. I don't mean anything might happen to me, but this is about as desparate as I've been without being depressed about it. It sounds weird but true. Oh, fooey, I am depressed about it. Very, very, very, but it's not the hopeless kind. It's the 'for a good reason' kind.My rather irresponsible but kind husband went to a freind's wedding in Calif and I pursuaded him to to please go and leave me alone. My Mom's death anniversary is tomorrow, but mainly I'm being flooded with PTSD like memories and 'being there' experiences of severe abuse by my father. It's so absolutely horrific and wailing and shuddering and I'm here alone eating canned soup that I'm tossing in the trash afterwards and I give a flying f*ck about sorting them out into environmentally proper piles. But you know? It's OK. It feels real, like this is not bio-chemically induced (although I'm sure that the intensity is a result of something not working). I'm mourning and reliving and remembering awful awful experiences that I could only view at a distance before. I'm writing in my journal alot and sleeping when I can. I'm letting this pain well up and inviting in disowned parts of myself that I was ashamed of and hated. Please keep me in your prayers, dear friends. This is hard stuff but like I said, I'm not morbidly depressed and I know I'll survive it. It's been long due and I finally feel I'm strong enough to take how very difficult it's turned out to be. I'm exhausted from it. So if you don't hear from me it's because it's all I can do to stumble over to the computer and get my fingers working. Bless you all. I hope to get back to the Girl's Club real soon. Love, Barbara
Posted by katia on December 6, 2003, at 0:20:58
In reply to Hi from Barbara » katia, posted by BarbaraCat on December 5, 2003, at 16:05:37
Dearest Barb,
I'm sorry to hear you're having such a hard time. And I'm glad you reached out to us. I was really wondering what happened to you. you know the Indians (from India) say that grief brings you right up front and closer to "God"; whatever that is for you. Sometimes it is a very hard, but a healing thing to be present for - cleansing. I hope this is how it turns out for you and you come out of it refreshed and new in a way. The holidays AND this time of the year are so hard as it is for me, that I can't imagine a double whammy with the first year anniversary of your mother's death. Hope your hubby comes back soon to comfort you. Hope you have some friends near by as well. At least you have your little teegers - all nine of them?I was also wondering how you're doing with the no drinking. For me it lasted five weeks, then I fell. I've half assed re-committed myself, even went to a Life Ring meeting tonight; but I don't feel the committment like before especially come x-mas.
I'm thinking about you Barbara -
Many blessings to you.
Katia
Posted by fluffy on December 6, 2003, at 12:07:21
In reply to Re: Hi from Barbara » BarbaraCat, posted by katia on December 6, 2003, at 0:20:58
Hi miss Barb-cat.....
I also wondered where you were. but alas, we all need a babble break. whether we are in grief, or just off living our lives happily, not thinking about drug combos and such.
i hope that when people don't turn up again on the babble boards, it's because they have found what they needed, moved on to just living their lives. but I know that it is sometimes that they only have enough energy to take care of themselves. (which is ultimately the most important thing). supporting others requires strength...gather your strength slowly again. i can really identify with the dragging your body to the computer, and only being able to eat soup. sometimes it takes more energy to put into words the unpleasantness you are feeling, than to just FEEL it. rest assured that you are not alone. sometimes i forget that when i'm hurting, even if i know it.
although you are having a tough time, I know you'll pull through, and this is what you can do right now. I'm not quite as elegant in my wording as katia, but i also care about you very much...your presence has healed me in many ways. I offer you a big, big hug. please know you are in my thoughts. I'm so sorry you are hurting. please take care, and reach out if you need us (and have enough energy).
lovins,
katy
Posted by katia on December 6, 2003, at 15:36:23
In reply to Re: Hi from Barbara, posted by fluffy on December 6, 2003, at 12:07:21
**Hi Katy,
"not quite as elegant". That's not true! You write very well and expressively! and thank you for the compliment.I upped the Lam. to 175mg yesterday and what do you know - I felt a slight rise in my mood! It too shall pass and I"ll up it to 200mg and hope that it stays there! If not, add Lithium. I guess that's indicative of the fact that it does work, it just poops out and it's indicative of the fact that if it works, then I'm probably bipolar. (I know the other factors point to BP too). I'm still just trying to believe it. Belief happens on all sorts of levels. One thing I've noticed since either being on Lamictal or with the season change (I think I'm a SAD victim); that I haven't been elevated at all in the past month or so - just grades of depression.
It's just interesting to actually monitor my behavior and moods for the first time in years. From the looks of thing so far, I rapid cycle or just go from elevated to mixed for the summer and spring. ANYWAY! I won't bore you more!I'm here, so reach out if you need to.
hugs-
katia
Posted by BarbaraCat on December 11, 2003, at 14:09:25
In reply to Re: Hi from Barbara, posted by fluffy on December 6, 2003, at 12:07:21
Hi All,
A catchup of sorts. Still coasting here on the rim of chaos but getting used to it. Forget who said it, but it goes something like 'the wisdom of peace is simply learning to tolerate uncertainty' and ain't it the truth. If only we could be certain that another intense stress is really some kind of breakthrough or even a breakdown and not just the same old recycled shit in a new package. But we must trust that there will be an answer, right? Ah, grasshoppah, such wise words of calm and loving spirit. Now this is how I REALLY feel:With all the crummy suffering cropping up everywhere in my life, just learned 2 days ago that our beloved oldest (not that old, just 13) cat has chronic renal failure and it's just a matter of time. I don't know how long, of course, and it may be years, but it will mean giving him very frequent IV's and watching him slowly decline as his little kidneys inevitably fail. There has to be a point where a decision must be made to pull the plug, but oh, I'll miss my little fuzzy buddy. I was just thinking the other day as we were head butting and purring together 'this little guy loves and trusts me more than any being on this planet' and then the thought 'oh no, now I've done it. As soon as I let myself love too much or get too happy the fan turns on and the brown stuff flies'. So, yeah, I know that's what life is all about and 'tis better to have loved and lost and all that stinkin' pukey crap but I'm just tired of the pain. Physical, emotional. I'm sure I'm even bumming you all out but if you can't come here to kvetch then where the hell can you? But here's a little gem. We were at some friends (now ex-friends) the other night and I was into some major pain. It was to the day the one year anniversary of my Mom's death, I've been going through the flooding PTSD processing and although haven't gone into the disturbing details with anyone, I'm not at my best or perkiest these days. I made the sorry ass mistake of over-indulging (yes Katia, I've fallen a few times. Sometimes feeling awful is just too much and there's a little bottle of elixer guaranteed to help just around the corner. I KNOW you can relate!) and starting letting on how miserable I was feeling and talking about death and loss and STUFF YOU THINK YOU CAN TALK TO FRIENDS ABOUT, DAMMIT!! Long story short, I was accused of bringing evil, demonic, dark and negative energy into their house and had done so on many occasions in the past. Now, I can get as dark and despondent as the best of them and my mixed states depressions can be mighty scary, but sheesh, this was nothing! This was simple pain and needing compassion asking some deep questions, and yes, babbling on stupidly in my inebriated state, but hey, folks, this was plain mean and I don't get this life. You don't do this to someone who'se hurting and mourning. Yes, I believe they have issues with death and questions of afterlife and yada yada but I'm seriously questioning wanting to ever give my heart, trust, need to anything ever again.
Are we learning anything here from all this pain? Are we wearning ourselves down cause we don't know how to stop immersing ourselves in the pain? I thought these were my friends and only now I learn they've got this Gandalf/Balrog fantasy complex and guess who got to be the Balrog. Oh, if only I knew how to do that little trick like combust into flames at that moment! Or snuck some split pea soup into my mouth and spewed it all over the room! Ah! Now THAT would have been worth it!
I'll be OK, I am OK. I'm just really pissed that someone who is a very good person, that would be myself, who really wants more than anything to just do my best and get a tad bit of enjoyment and happiness on the way keeps getting kicked in the gut. So you can see why I'm not on here more. Maybe I should be so I don't dump all this on you at once. Maybe that's the whole problem. Maybe I should get out more so I don't get life dumped on me all at once every time I step out the door. So, that's me, how about you? Oh, I upped Lam to 200mg during this time, am tolerating the insane itchies, would rather swallow a bucket of tobacco chaw juice than an ounce of booze, am in therapy, and am about to call my pdoc to take away this dread but he can't of course. It's good practice to learn to tolerate the discomfort. Hah, my negative 'evil and demonic' mind sneers, 'preparing for what? The neurotoxic warfare about to arrive?' But that's horsecrap. All of us here at least know that's already happened. LovE, Barbara
Posted by Dr. Bob on December 11, 2003, at 18:24:22
In reply to Re: Hi from Barbara, posted by BarbaraCat on December 11, 2003, at 14:09:25
> A catchup of sorts...
I'd like to redirect follow-ups not about medication to, well, let's say Psycho-Babble Substance Use. Here's a link:
http://www.dr-bob.org/babble/subs/20031208/msgs/288885.html
Thanks,
Bob
Posted by katia on December 11, 2003, at 18:55:32
In reply to Re: Hello gals... » katia, posted by BarbaraCat on November 6, 2003, at 19:54:33
Hey Barb,
Just want you to know to follow that redirect because I replied to you.
katia
Posted by Sharon12345 on December 13, 2003, at 20:14:31
In reply to Re: Hello gals... » BarbaraCat, posted by katia on December 11, 2003, at 18:55:32
I just joined this board and I must thank you all so much for posting the mails on the itching syndrome. I have been on 100 mg Lamictal (for the second time) since September. I was temporarily back on Lithium and now I am back on a cocktail. I feel great mood-wise, however I have been itching like mad all over my body for several weeks now. Even though this never happened when I was on Lamictal before, I told my pdoc about it to see if there could be some relation to it. He says not to worry about it unless I start to blister around my face. I decided to check the web for a forum such as this. Thank you SO much. I now know the answer I was looking for and I know that I am not going to put up with this for the rest of my life!
Sharon
Posted by lizbeth on December 23, 2003, at 11:17:34
In reply to lamictal update and questions, posted by linnette on November 13, 2003, at 17:31:24
Hi there,
Just started Lamictal 2 weeks ago, as part of my bipolar II cocktail. The previous 900 mg Lithobid and 20 mg prozac combo was not helping my bipolar depression. Just went up to 50 mg of Lamictal today. Had to stop prozac right away--too much AD effect between the two. The Lamictal does seem to be helping.
Interestingly, I found I had to move the Lithobid up to 1200 mg because prozac had been boosting it's effect when at the 900 dose.
My issue is that lately, no matter how little coffee and/or caffeine I have in the morning, I get very agitated within a short period of time. My psychopharmacologist simplified it as such: unlike stimulants like Adderall, which create dopamine in the system (and are bad news for non-ADD bipolars, IMHO and experience), caffeine simply raises the ceiling on the amount of dopamine that's possibly available. Lamictal's effect on glutamate indirectly raises dopamine and norepinephrine (sp) and perhaps this increased dopamine gets magnified by caffeine?
Yikes. Anyone else had similar reactions? I know one of you (Fluffy?) mentioned it.
Take care and happy holidays!
Lizbeth
Posted by katia on December 23, 2003, at 13:43:24
In reply to Coffee and Lamictal agitating combo for bipolars?, posted by lizbeth on December 23, 2003, at 11:17:34
hi Lizbeth,
yes, I've noticed this - but ONLY when I'm buzzing on Lam. does the coffee increase it. It's a breathless euphoric high. But my Lam. is no longer giving me brief moments of hypomania...so I don't get high on coffee either..also, VERY good to know that Lamictal effects the dopamine and norepinephrine. It's easy to know that with ADs, but with MSs, it's hard to know what's being affected and how....How about Lithium?
katia
Posted by bruce_w6 on January 15, 2004, at 23:41:31
In reply to Lamictal side effects, posted by seamus o'noolan on June 30, 2003, at 17:37:40
Can someone tell me if Lamictal works?
Posted by Dalilah on January 16, 2004, at 0:45:17
In reply to Re: Lamictal side effects, posted by bruce_w6 on January 15, 2004, at 23:41:31
> Can someone tell me if Lamictal works?
It works for me. But I need to take 300mg and I also need my lithium. I hope it works for you. What it's done is relieve some of that never ending die please depression. And for me the antidepressants did NOT work. They made mania come on or mainly just didn't do a damn thing.
It's been the ONE thing to relieve my killer depression. Also, it must have some mood stabilizing qualities, but I'm convinced I need my lithium as well. And as stated on this site before, the Lam and the Lith combo might be just the right thing (for me.)
Dalilah
Posted by Kristylynn on January 16, 2004, at 7:08:10
In reply to Re: Lamictal side effects, posted by Dalilah on January 16, 2004, at 0:45:17
I have been on Lamictal for a little over a month along with wellbutrin xl 300mg. I am taking 75 mg of the lamictal. In the past few days I have experienced severe mood swings , depression, crying . Not really wanting to associate with anyone which is kinda hard for me since I am a waitress. Is this normal..? I keep reading that lithium and lamictal work well together.... Should I ask my doctor to try this..? I just want to stop feeling like I do right now. Someone please respond ...Thanks
Posted by metalflipflop on January 16, 2004, at 9:29:06
In reply to Re: Lamictal side effects, posted by bruce_w6 on January 15, 2004, at 23:41:31
i'd say that lamictal works too. i am currently taking 300mg--i felt good things at lower doses, but then they would taper off. i like how it's subtle in lifting my mood and i can still think clearly. i also like how i don't feel blunted at all, no emotional numbing (felt that some on ssri's). and now that i'm not titrating up so much, i don't feel anxious on it. i still take 100mg of zoloft with it (down from 150) b/c i don't quite trust it to take care of horrible depression alone. i think the synergy is nice. at any rate, i feel better than i have in over a year!
good luck!
liz
Posted by katia on January 16, 2004, at 15:14:18
In reply to Re: Lamictal side effects » bruce_w6, posted by metalflipflop on January 16, 2004, at 9:29:06
Are you bipolar?
Posted by katia on January 16, 2004, at 15:15:36
In reply to Re: Lamictal side effects, posted by Dalilah on January 16, 2004, at 0:45:17
Hi Dalilah,
We talked before right??
Did you not get the cognitive side effects from Lithium? (like trapped in a stupor)? Aren't you bipolar II?
Katia
Posted by katia on January 16, 2004, at 15:23:36
In reply to Re: Lamictal side effects, posted by Kristylynn on January 16, 2004, at 7:08:10
Hi,
I wait tables too and IT IS HARD when going through this - and it's just HARD!
Wellbutrin and Lamictal are both activating meds. I've heard that they both can cause irritability. It may be that having both is too much.
I was on Lam. at 200mg for a couple months and it helped with the depression some, but the irritability was intense still. I'd snap at customers and people at work and so forth and still experiencing dreadful mixed states. So then I added the Lithium at450mg and then 900mg. At 900, I got the dreaded Lam. rash and had to come off of it. and the cognitive side effects of Lithium were too much for me - I was a shuffling drooling idiot. So I've backed down to 225mg of Lithium which isn't anything really. I'm still somewhat unclear in my head, but I can function. but I can't sleep to save my life. And my irritability is back. Lithium worked for quelling irritability and settling my *rse down. But the s/e were too much and lam. caused me the rash. It might've worked. I've heard it's a good combo - but if I were you (and I'd talk to my pdoc) (btw-are you bipolar?). i'd have one activating med and one that is not so.
hope that helps.
Katia
Posted by bruce_w6 on January 16, 2004, at 15:43:32
In reply to Re: Lamictal side effects » metalflipflop, posted by katia on January 16, 2004, at 15:14:18
We think so. Lexapro and other ssri's dont help. Mostly Depression.
Posted by metalflipflop on January 16, 2004, at 18:42:21
In reply to Re: Lamictal side effects » metalflipflop, posted by katia on January 16, 2004, at 15:14:18
what i KNOW that i have is severe, recurrent depression since i was 15. it has alternated with periods of intense irritability, still dysphoric in mood actually, but not severe enough to be called a mixed state. bipolar runs in my family, zoloft made me hypomanic enough to run to the ER in fear of what it was, so my doc says i have a bipolar "feel." i definitely do not qualify for bipolar II even, maybe this new idea of "bipolar III" which i have heard people on here talk about. i went to lamictal b/c ssri's made me anxious and somehow didn't lift the depression, even at high doses. the mood stabilizer also prevents (hopefully) the recurring depression that ssri's didn't.
the mind is confusing.
=) liz
Posted by Flipsactown on January 16, 2004, at 20:33:04
In reply to Re: Lamictal side effects, posted by Dalilah on January 16, 2004, at 0:45:17
I can relate with Dalilah. I am currently on 400mg lamictal, 100mg prozac, 90mg remeron and just recently 600mg lithium. Although I have only been on lithium for 6 days, I have already felt it's AD effect. My depression is not returning as much in the late afternoon/evening as before the lithium was added. Eventually, I would like to be on lamictal and lithium only as this combo seems to work the best in relieving my unipolar depression and from my research online will probably be effective on bipolar depression.
Flipsactown
> > Can someone tell me if Lamictal works?
>
> It works for me. But I need to take 300mg and I also need my lithium. I hope it works for you. What it's done is relieve some of that never ending die please depression. And for me the antidepressants did NOT work. They made mania come on or mainly just didn't do a damn thing.
>
> It's been the ONE thing to relieve my killer depression. Also, it must have some mood stabilizing qualities, but I'm convinced I need my lithium as well. And as stated on this site before, the Lam and the Lith combo might be just the right thing (for me.)
>
> Dalilah
>
>
Posted by jtevers on January 20, 2004, at 17:09:34
In reply to Re: Lamictal side effects » Dalilah, posted by Flipsactown on January 16, 2004, at 20:33:04
hello all...
i have been taking seroquel ( an antipsychotic ) and neurontin / gabapentin ( a mood stabilizer ) for several years since a diagnosis of bipolar in 2000.i have consequently gained 60 lbs. in two divided increments of 30 each over two winters due to my med. regimen. ... this weight gain has not responded to diet or exercise and so i am investigating a switch.
a doctor has advised, in case the neurontin is to blame, that i should switch to lamictal / lamotrigine ... she demands that it is weight neutral , but i have read (here) differently.
does anyone who has remained on a trial of lamictal have any insight about its propensity to cause weight gain?
Posted by Dalilah on January 20, 2004, at 20:36:34
In reply to Re: Lamictal side effects, weight gain?, posted by jtevers on January 20, 2004, at 17:09:34
Hello,
I can honestly say that since Lamictal has began working (300mg) and therefore keeping me active, not in bed all day, I have lost weight! Really. I took off all the pounds put on at the hospital and then some.However, I know that seroquel can be a nasty weight gainer. I take only a small amount (50mg) for sleep and the mild psychosis. My sister takes a lot of seroquel and she's gained a lot, most to be blamed on depakote.
I do think that when you put the weight on it's hard to lose it. But hey, this is one success in the weight department.
-Dalilah
> hello all...
>
> i have been taking seroquel ( an antipsychotic ) and neurontin / gabapentin ( a mood stabilizer ) for several years since a diagnosis of bipolar in 2000.
>
> i have consequently gained 60 lbs. in two divided increments of 30 each over two winters due to my med. regimen. ... this weight gain has not responded to diet or exercise and so i am investigating a switch.
>
> a doctor has advised, in case the neurontin is to blame, that i should switch to lamictal / lamotrigine ... she demands that it is weight neutral , but i have read (here) differently.
>
> does anyone who has remained on a trial of lamictal have any insight about its propensity to cause weight gain?
Posted by jtevers on January 21, 2004, at 18:10:31
In reply to Re: Lamictal side effects, weight gain?, posted by Dalilah on January 20, 2004, at 20:36:34
> Hello,
> I can honestly say that since Lamictal has began working (300mg) and therefore keeping me active, not in bed all day, I have lost weight! Really. I took off all the pounds put on at the hospital and then some.
>
> However, I know that seroquel can be a nasty weight gainer. I take only a small amount (50mg) for sleep and the mild psychosis. My sister takes a lot of seroquel and she's gained a lot, most to be blamed on depakote.
>
dalilah,thanx a lot for the insight, i have read many a success story about lamictal and believe i will probably give it a try... although, i am increasingly nervous about weight gain, anxiety and insomnia sometimes caused by its usage.
at this point i have nothing to lose (except 60lbs.) and this trial holds a lot of promise ... because i take both a GABA drug and seroquel (famously sedative) i could use the "activating" effect of lamictal.
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