![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 11 to 35 of 42. Go back in thread:
Posted by Jack Smith on March 6, 2003, at 13:21:48
In reply to Re: Bowden: Lamictal question, posted by catmint on March 5, 2003, at 23:12:04
Do you think Lamictal monotherapy has any place for unipolar depression with associated anxiety?
JACK
Posted by elbee on March 7, 2003, at 9:06:50
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Dr. Bowden,
Thank you for your time with Babblers!
I was wondering what type of sucess rates to expect in treating BP1 with lamictal (in combo. therapy? Roughly how often does one expect lamictal to cause hypomania in BP1's? Are there solutions for patients when lamictal renders them unable to sleep?
Also, do you have any feedback on what drugs or personal strategies might be used to combat sleepyness/sluggishness in a.m. (or to increase mental altertness) when using bp meds such as depacote, lithium, seroquel (all taken at night)?
Hope this hasn't already been covered in prentation, but couldn't access.
Thanks & have a good week!
Posted by Ricky on March 8, 2003, at 11:13:42
In reply to Bowden: Lamictal for Unipolar Depression/Anxiety, posted by Jack Smith on March 6, 2003, at 13:21:48
I am the adult son of a bipolar mother. Since I was 18 I have been responsible in some way for her care. She is noncompliant with meds very often and I have taken her for inpatient and outpatient care many times. She is now 64 and she is getting worse. She lives in her own house and can be self sufficient when compliant. It is a great burden many times. I probably myself suffer from mild forms of this illness. I have never used any medication (though at times I am sure I needed it), but I have made some really dumb personal choices. Is it possible that my level of illness has been made more minor since I have had to be so exposed to my mothers illness. Or have I just learned more self control due to necessity. I have had the same job for 20 years. I have been promoted and commended many times but I am not a socially popular person. I have lived in the same house for 15 years. Is is possible that I forced corrective behavior on myself for so long that in some way I lessened the illness. Or have I simply adapted and deep inside I am as ill as my mother and some day I will end up in a psych ward like her. Sorry if this sounds harsh.
Posted by Eggy on March 8, 2003, at 22:05:37
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Dr. Bowden., I have been seing a psychiatrist and one of his fellow therapist for over a year(weekly)and I have been diagnosed Borderline personality,PTSD,DDNOS,OCD and Bi-polar. Although he still brings up that he is not sure if I am actually Bi-polar or not. I know he is participating in some type of Bi-polar study. So shouldn't he know by now what my diagnosis is? Or is there a fine line between Bi-polar and some of my other diagnosis? What are some of the guidelines. Not that I want to be Bi-Polar...I just don't want to think I am if I am not. The less the better when it comes to mental illness. Thank you so much. Sushmann
Posted by Dr. Bob on March 9, 2003, at 18:58:08
In reply to Bowden: Guest expert on bipolar disorders, posted by jaby on March 4, 2003, at 9:48:40
Dear Jaby,
In general ECT should only be considered for unequivocal bipolar I (full mania at some point) disorders. The II does not mean mild suffering or functional problems, however. It does mean mostly depression. Usually, some combination of a mood stabilizer (lithium, Depakote) needs to be combined with a drug that aids depression (Lamictal, Celexa, Parnate). Re the photic hypersensitivity, it may be unrelated to bipolar disorder. However, one of the fundamental features of having bipolar disorder is to be more sensitive than the non-bipolar person to various stimuli. This can be a good thing (more attention to aesthetic, pleasurable experiences) or a problematic thing (overreaction to stress, to light that interferes with sleep). It is possible that your visual sensitivity is some expression of that hypervigilance that goes with the disorder.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 9, 2003, at 19:01:57
In reply to Bowden: Bipolar II, posted by Jack Smith on March 4, 2003, at 12:09:49
Dear Jack,
I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 9, 2003, at 19:03:39
In reply to Bowden: BP II Sudden Breakthrough, posted by GreatDaneBoy on March 4, 2003, at 12:46:32
Dear GDB,
Actually there is an obvious trigger, although I cannot be for certain via email. Any antidepressant, including Prozac, can destabilize mood. This can happen even in the face of deriving some benefit from the antidepressant. My recommendation is to discuss this promptly with your psychiatrist, and seriously consider tapering off the Prozac. At the very least, you will learn whether the Prozac is a contributing factor.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 9, 2003, at 19:05:04
In reply to Bowden: lithium worsens cycling-reasons?, posted by Ritch on March 4, 2003, at 13:20:47
Dear Mitch,
Keep in mind that this was just one small study. However, it is consistent with what many patients and psychiatrists see with lithium. One clue is that in animals and humans, lithium, used at standard doses, drives down energy and activity to sub-normal levels. This is fine to the degree that the person is hyperactive, but not fine regarding maintaining normal range activity and energy. If this is the case, one first strategy if such occurred while taking lithium would be to try a somewhat lower dose.
Charles L. Bowden, M.D.
Posted by Ilene on March 9, 2003, at 21:07:09
In reply to From Dr. Bowden: Bipolar II, posted by Dr. Bob on March 9, 2003, at 19:01:57
> Dear Jack,
>
> I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
>
> Charles L. Bowden, M.D.
This is interesting. I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.I've been at 200 mg. Lamictal for about 2 or 2 1/2 weeks now, and for about a week I've had more energy and less suicidal ideation, etc. I'm beginning to think I'm responding to it (at last! something)
So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away? Especially when a person isn't sure how "normal" feels, and has a hard time recalling how things felt in the past?
I read about mental illness in the family, even if it's not BP, as one indicator of BP. One more relative with a disorder would be the swing vote in my self-diagnosis. But it can be so hard to determine! E.g., my mother suffered from migraines and I wonder if she also had a mood disorder...not many people liked her. (I know there's some correlation between migraine and mood disorders.) Even so, I don't recall any psychiatrist asking me about the mental status of my relatives. And when you don't like your mother it doesn't mean she is loonytoons!
How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
Sorry to ramble on so.
--I.
Posted by cybercafe on March 10, 2003, at 0:36:39
In reply to For Dr. Bowden: More Q's on BP II » Dr. Bob, posted by Ilene on March 9, 2003, at 21:07:09
> > Dear Jack,
> >
> > I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
> >
> > Charles L. Bowden, M.D.
>
>
> This is interesting. I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
>
> I've been at 200 mg. Lamictal for about 2 or 2 1/2 weeks now, and for about a week I've had more energy and less suicidal ideation, etc. I'm beginning to think I'm responding to it (at last! something)
>
> So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away? Especially when a person isn't sure how "normal" feels, and has a hard time recalling how things felt in the past?
>
> I read about mental illness in the family, even if it's not BP, as one indicator of BP. One more relative with a disorder would be the swing vote in my self-diagnosis. But it can be so hard to determine! E.g., my mother suffered from migraines and I wonder if she also had a mood disorder...not many people liked her. (I know there's some correlation between migraine and mood disorders.) Even so, I don't recall any psychiatrist asking me about the mental status of my relatives. And when you don't like your mother it doesn't mean she is loonytoons!
>
> How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
>
> Sorry to ramble on so.
>
> --I.
>could you try the DSM or Kaplan and Saddock?
Posted by SLS on March 10, 2003, at 7:21:16
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
Dear Dr. Bowden,
I have been suffering from an unremitting severe anergic depression for over 25 years (since age 17). However, several antidepressants have induced psychotic manic mixed states that have twice required hospitalization. In addition, for two years I exhibited a remarkable 11-day ultra-rapid cycle that did not deviate by as much as 24 hours: 8 days depression / 3 days euthymia (not hypomanic).
My questions:
1. If the only instances of mania are associated with medication, is this necessarily a presentation of bipolar illness?
2. Is there to be a DSM V classification to describe this?
3. What treatment strategies are best pursued to treat this sort of thing?
Thank you.
- Scott
Posted by Ilene on March 10, 2003, at 10:26:16
In reply to Bowden - Unipolar with drug-induced mania or BP?, posted by SLS on March 10, 2003, at 7:21:16
> Dear Dr. Bowden,
>
> I have been suffering from an unremitting severe anergic depression for over 25 years (since age 17). However, several antidepressants have induced psychotic manic mixed states that have twice required hospitalization. In addition, for two years I exhibited a remarkable 11-day ultra-rapid cycle that did not deviate by as much as 24 hours: 8 days depression / 3 days euthymia (not hypomanic).
>
> My questions:
>
> 1. If the only instances of mania are associated with medication, is this necessarily a presentation of bipolar illness?
>
> 2. Is there to be a DSM V classification to describe this?
>
> 3. What treatment strategies are best pursued to treat this sort of thing?
>
>
> Thank you.
>
>
> - Scott
>
>
Try a search for "bipolar III" using Google. Use the quotation marks! Bipolar III is one term for medication-induced mania. So IMHO you are bipolar. If I were you I'd never take another AD!I haven't found the DSM-!V descriptions very helpful either. This might interest you. It explains the logic behind DSM IV:
The DSM-IV Classification and Psychopharmacology
http://www.acnp.org/g4/GN401000082/Default.htmThis is a concise overview of treatments for BP written by an undergraduate(!) at the University of Colorado. I couldn't find a date, but it seems to be fairly current. It is both informative and relatively jargon-free. and has links to other sites:
http://dubinserver.colorado.edu/prj/ane/1.html
--I.
Posted by Ilene on March 10, 2003, at 21:26:52
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
> >
> > I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
> >
> >
> > So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
> >
> >
> > How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?> > --I.
> >
>
> could you try the DSM or Kaplan and Saddock?DSM is not helpful. It doesn't describe all of the variations of BPII, according to some authors. Kaplan and Saddock? I'd either have to leave the house or spend some serious money. I'm not ready to do either.
--I.
Posted by Jonathan on March 10, 2003, at 21:58:56
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
... or do only unipolar depressives respond? or (making the question more general) What percentage response to Li augmentation (LiAug) of an antidepressant (AD) would you expect in populations of patients reliably diagnosed (a) unipolar and (b) 'soft' bipolar with depressive episodes so much more frequent than (hypo)manic that prophylaxis of the latter is not an issue?
If the percentage responses for these two populations are significantly different, then (non-)response to LiAug would be an aid to a notoriously difficult diagnosis. According to "Bartos", any patients now diagnosed as predominantly-depressed soft bipolar have a history of years of inappropriate treatment, when they were misdiagnosed as unipolar because the first hypomanic episode needed for bipolar diagnosis either had not yet occurred or had not been recognised as such by their doctor.
According to my psychiatrist, LiAug is tried only as a last resort on patients for whom all available classes of AD have failed (i.e. on a group for whom success rate of any AD without LiAug = 0%). Despite this selection of patients who are least likely to respond to anything, he claims an astoundingly high success rate of 57%. (I'm in the UK: the US figure may be different for various reasons including your higher diagnosis rate of BP2.)
Until recently I assumed that most of these LiAug responders, although (mis-)diagnosed as unipolar, are really undiagnosed BP2, BP3 or cyclothymics whose first hypomanic episode either has not yet occurred or was not identified as such. Such patients are likely to have a much higher frequency of depressive than of (hypo)manic episodes (otherwise the episode enabling a bipolar diagnosis would already have occurred), so antidepressant-induced cycling will probably present as a depressive episode soon after starting any antidepressant. Lithium augmentation would appear to succeed for this group by suppressing AD-induced cycling.
However, a few months ago I read your review paper, Clinical correlates of therapeutic response in bipolar disorder, J. Affective Disorders 67 (2001) 257-265, in which you say "Elated mania is quite responsive to lithium, but such patients are likely to suffer from worse depressive symptomatology during subsequent maintenance treatment with lithium." (Section 6, last paragraph, p. 260, col. 1); Slide 16 of your recent Grand Rounds presentation confirms the same phenomenon using a different experimental source. Combined with the well-known observation that Li on its own is an effective antidepressant for unipolar patients (e.g. Souza FG & Goodwin GM (1991) Lithium treatment and prophylaxis in unipolar depression: a meta-analysis. Br. J. Psychiatry 158: 666-675) this difference in the effects of Li on unipolar and bipolar patients suggests that, *if* the differential response is maintained in the presence of an AD, then only unipolar depressives would be expected to respond to LiAug, while bipolar depression would respond better to the AD alone than with lithium: the opposite of the previous paragraph's apparently plausible conclusion!
No doubt the truth is somewhere between these two simplistic and extreme views. Perhaps someone has performed a retrospective study in which patients' (non-)response to LiAug a number of years ago is matched with their present diagnosis as bipolar or unipolar, the latter being assumed to correct any misdiagnosis at the time of treatment? A couple of percentage response figures to plug into Bayes's Theorem would be ideal!
Dr Bowden, I am looking forward very much to hearing your views on this question, not least because of their possible implications for my own diagnosis. I recently started lithium augmentation of a tricyclic NRI, lofepramine, after four years trying various ADs without or with only ephemeral success. My current diagnosis is atypical depression, which according to Benazzi (Prevalence of bipolar II disorder in atypical depression, Eur. Arch. Psychiatry Clin. Neurosci. (1999) 249: 62-65) implies prior probabilities of about 2/3 bipolar and 1/3 unipolar.
Thanks for reading this, and for a fascinating and informative presentation.
Jonathan.
Posted by Jonathan on March 10, 2003, at 22:00:25
In reply to Do only bipolars respond to Li augmentation of AD? » Dr. Bob, posted by Jonathan on March 10, 2003, at 21:58:56
Posted by cybercafe on March 10, 2003, at 22:08:13
In reply to Re: For Dr. Bowden: More Q's on BP II » cybercafe, posted by Ilene on March 10, 2003, at 21:26:52
> > >
> > > I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
> > >
> > >
> > > So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
> > >
> > >
> > > How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
>
> > > --I.
> > >
> >
> > could you try the DSM or Kaplan and Saddock?
>
> DSM is not helpful. It doesn't describe all of the variations of BPII, according to some authors. Kaplan and Saddock? I'd either have to leave the house or spend some serious money. I'm not ready to do either.
>
> --I.
>If the DSM isn't used as the standard source for definitions of psychiatric disorders, then what is?
Posted by Ilene on March 10, 2003, at 23:06:51
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 22:08:13
> If the DSM isn't used as the standard source for definitions of psychiatric disorders, then what is?The DSM is not the written in stone. It gets revised from time to time. This one is DSM IV. The other principal "dictionary", if you will, is "The International Statistical Classification of Diseases and Related Health Problems, tenth revision" published by the World Health Organization. Not that it matters.
Here is an analogy: If you ever took biology you probably learned about taxonomy (or systematics). Kingdom, phylum, class, order, family, genus, species. Very orderly, right? It is in school, but it's not out in the "real world". First of all, how do you determine the boundaries of the group of individuals called X? What are the criteria for being an X? Is there more than one subtype of X? Is each subtype actually a species? Is X actually a genus?
Taxonomists wrangle about this stuff. There are two kinds of taxonomists: lumpers and splitters. The names are self-explanatory.
The questions about bipolar vs. unipolar, or bipolar II vs. bipolar III, etc. are similar. What is bipolar? How many subtypes of bipolar are there? and so on.
If you are really curious, here is an article about the reasoning behind the latest revision of the DSM (DSM IV):
http://www.acnp.org/g4/GN401000082/Default.htm--I.
Posted by SLS on March 11, 2003, at 6:36:01
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
> I always thought I had atypical unipolar depression. A few months ago I found some articles on the Internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.> So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
Hi.Over the last few years, the concept of the existence of a "bipolar spectrum" had been gaining acceptance. Some psychiatrists use the term "soft bipolar" to describe presentations that exhibit bipolarity, but do not qualify as bipolar I, bipolar II, or cyclothymia according to the DSM IV diagnostic manual. One of the biggest proponents of these concepts is Hagop Akiskal, MD. I would recommend doing a Google search using the keywords "Akiskal" and "bipolar" to find out more about this.
Regarding the misdiagnosis of atypical depression for bipolar II, there are some researchers who believe all presentations of atypical depression are actually bipolar depression. I don't believe this is true, as *true* mood reactivity seems to be exclusive to unipolar depression. Bipolar depression most often resembles atypical unipolar depression, as anergia and reverse vegetative symptoms predominate. I would say that mood reactivity would be useful in coming to a differential diagnosis. Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder. This is in contrast to atypical depression, where the sufferer reports a temporary lifting of all aspects of depression in reaction to environmental stimuli.
- Scott
Posted by Ritch on March 11, 2003, at 9:32:48
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by SLS on March 11, 2003, at 6:36:01
>
> > I always thought I had atypical unipolar depression. A few months ago I found some articles on the Internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
>
> > So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
>
>
> Hi.
>
> Over the last few years, the concept of the existence of a "bipolar spectrum" had been gaining acceptance. Some psychiatrists use the term "soft bipolar" to describe presentations that exhibit bipolarity, but do not qualify as bipolar I, bipolar II, or cyclothymia according to the DSM IV diagnostic manual. One of the biggest proponents of these concepts is Hagop Akiskal, MD. I would recommend doing a Google search using the keywords "Akiskal" and "bipolar" to find out more about this.
>
> Regarding the misdiagnosis of atypical depression for bipolar II, there are some researchers who believe all presentations of atypical depression are actually bipolar depression. I don't believe this is true, as *true* mood reactivity seems to be exclusive to unipolar depression. Bipolar depression most often resembles atypical unipolar depression, as anergia and reverse vegetative symptoms predominate. I would say that mood reactivity would be useful in coming to a differential diagnosis. Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder. This is in contrast to atypical depression, where the sufferer reports a temporary lifting of all aspects of depression in reaction to environmental stimuli.
>
>
> - Scott
>
>Scott, whenever I have my bipolar seasonal depressions (which are very atypical depressive in nature) good/bad news events can change my mood very markedly. In the case of good news making me feel better during a depression it is primarily the *duration* of the positive reaction that is stymied and short-lived. Sometimes it can last a few days, but more often the temporary positive response is just a few hours. I can feel quite good in contrast to how I was previously feeling. It feels kind of like a rubber band that "snaps" me back into my default mood for the time (when it fades).
Posted by SLS on March 11, 2003, at 10:41:58
In reply to Re: For Dr. Bowden: More Q's on BP II » SLS, posted by Ritch on March 11, 2003, at 9:32:48
> > Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder.
> Scott, whenever I have my bipolar seasonal depressions (which are very atypical depressive in nature) good/bad news events can change my mood very markedly. In the case of good news making me feel better during a depression it is primarily the *duration* of the positive reaction that is stymied and short-lived. Sometimes it can last a few days, but more often the temporary positive response is just a few hours. I can feel quite good in contrast to how I was previously feeling. It feels kind of like a rubber band that "snaps" me back into my default mood for the time (when it fades).
Hi Mitch.What features or events of your illness demonstrate bipolarity? Can you describe the magnitude and duration of your manic episodes? Have these been in association with medication changes of any kind? Are you definitely SAD? If so, I wonder if it is valid to classify your depression as bipolar proper.
For two years, I was an ultra rapid cycler. As I mentioned above, my cycle was of 8 days of depression followed by 3 days of euthymia. On "switch" day, my mood would change completely within an hour, many times 30 minutes. I know what it feels like to experience a true lifting of depression within a short period of time. At no time do my temporary reactive states of arousal in response to good stuff feel anything like remission, either in quality or magnitude. It is possible that my depression is unusual in this respect.
- Scott
Posted by jrbecker on March 11, 2003, at 11:32:42
In reply to Re: For Dr. Bowden: More Q's on BP II » Ritch, posted by SLS on March 11, 2003, at 10:41:58
In regards to the unipolar-bipolar spectrum, this slide show presentation on soft bipolarity by Akiskal might be helpful.
http://www.wpic.pitt.edu/stanley/2ndbipconf/ppt/W404_13/sld001.htm
I have also stuggled with a possible dx of soft bipolarity. A grandparent of mine was bipolar, so it seems highly suspect. Beyond just my core atypical symptoms, they have also included irritability/agitation as well as tension and restlessness. However, I have never experienced a classic hypomanic state as described by the literature. Yet many believe that "grumpiness" can be a manifestation of hypomania as well.
Some researchers have begun to suggest other categories called "agitated depression" or "anxiety/aggression-driven depression" fitting somewhere in between bipolar II and atypical depression.Despite my suspicions, all the docs I have ever consulted with still believe I suffer from a fairly 'typical' version of atypical depression. For the most part, I tend to agree. However, it seems evident that -- as susggested by the literature -- many forms of atypical depression seem closer to the bipolar spectrum than pure unipolarity.
Posted by Ilene on March 11, 2003, at 13:10:51
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by SLS on March 11, 2003, at 6:36:01
> Hi.
>
> Over the last few years, the concept of the existence of a "bipolar spectrum" had been gaining acceptance. Some psychiatrists use the term "soft bipolar" to describe presentations that exhibit bipolarity, but do not qualify as bipolar I, bipolar II, or cyclothymia according to the DSM IV diagnostic manual. One of the biggest proponents of these concepts is Hagop Akiskal, MD. I would recommend doing a Google search using the keywords "Akiskal" and "bipolar" to find out more about this.
>
I already did; Akiskal was a primary source of information. Interesting name. I wonder what ethnic group he comes from.The notion of "soft" bipolarity contributes to the notion that BPII and its relatives are somehow lesser disorders compared to BPI, don't you think?
> Regarding the misdiagnosis of atypical depression for bipolar II, there are some researchers who believe all presentations of atypical depression are actually bipolar depression. I don't believe this is true, as *true* mood reactivity seems to be exclusive to unipolar depression. Bipolar depression most often resembles atypical unipolar depression, as anergia and reverse vegetative symptoms predominate. I would say that mood reactivity would be useful in coming to a differential diagnosis. Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder. This is in contrast to atypical depression, where the sufferer reports a temporary lifting of all aspects of depression in reaction to environmental stimuli.
>
>
> - Scott
>
>
Mood reactivity = lifting of *all* aspects of depression? How long is "temporary"?Dementia?
--I.
Posted by Ritch on March 11, 2003, at 13:40:18
In reply to Re: For Dr. Bowden: More Q's on BP II » Ritch, posted by SLS on March 11, 2003, at 10:41:58
> > > Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder.
>
> > Scott, whenever I have my bipolar seasonal depressions (which are very atypical depressive in nature) good/bad news events can change my mood very markedly. In the case of good news making me feel better during a depression it is primarily the *duration* of the positive reaction that is stymied and short-lived. Sometimes it can last a few days, but more often the temporary positive response is just a few hours. I can feel quite good in contrast to how I was previously feeling. It feels kind of like a rubber band that "snaps" me back into my default mood for the time (when it fades).
>
>
> Hi Mitch.
>
> What features or events of your illness demonstrate bipolarity? Can you describe the magnitude and duration of your manic episodes? Have these been in association with medication changes of any kind? Are you definitely SAD? If so, I wonder if it is valid to classify your depression as bipolar proper.
>
> For two years, I was an ultra rapid cycler. As I mentioned above, my cycle was of 8 days of depression followed by 3 days of euthymia. On "switch" day, my mood would change completely within an hour, many times 30 minutes. I know what it feels like to experience a true lifting of depression within a short period of time. At no time do my temporary reactive states of arousal in response to good stuff feel anything like remission, either in quality or magnitude. It is possible that my depression is unusual in this respect.
>
>
> - Scott
>
>
>Scott, I have three "sets" of cycles that are more or less remarkable during the course of the year. Everything is very predictable and seasonal. The first "macro" cycle is recurrent seasonal major depressions (if it weren't for these I would just be cyclothymic). There are two of these every year. One starts in mid-November and lasts through January. The second starts in mid-June and lasts through early September. Throughout this entire time I have approx. 20 day cycles. During the major depressions I might not experience any highs at all, just waxing and waning of the depression as I course through these 20 day cycles. When I am out of these two MDE's the rest of the year the highs start becoming really obvious. Without AD's I would see about half of that time (10 days) feeling depressed, and the remaining ten days about equally divided between feeling generally high or euthymic. My highs are the peakiest in April and May and October. I've had them without antidepressants triggering them, but without an AD I am so miserable during the depressive parts.... SSRI's are the worst for making me hypomanic, but they work well for anxiety so I keep the dose WAY down. The third set of "cycling" is morning/evening. I generally always feel pretty good in the mornings/midday, and then in the evenings my mood tends to worsen. I've had an anticycling response to stimulants, but they make me too anxious.
Posted by Ilene on March 11, 2003, at 13:53:56
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by jrbecker on March 11, 2003, at 11:32:42
The real issue is how the diagnosis (unipolar/bipolar, BPII, "soft" bipolar, etc.) affects treatment. Once a disorder proves itself to be refractory, treatment algorithms break down to trial and error.
So--if there were evidence-based and unequivocal diagnostic criteria that a psychiatrist could use as soon as a patient walks in the door, effective treatment could start earlier.
And--perhaps the variations in response to medications are because the disorders derive from different origins. If this is so, then maybe someone can figure out which drugs work for which patients.
This is a little obscure, but it might prove a good example. A friend of mine has a genetic heart arrhythmia called Long QT Syndrome or LQTS. (Q and T are points on an electrocardiograph.) One kind is associated with deafness, another not. So there were thought to be 2 kinds.
As the genome was unraveled, several point mutations were discovered that cause identical (or nearly so) LQTS symptoms. One affects calcium channels, another potassium; I know there are 5 or 6 specific mutations, but I don't remember if they all have to do with the same set of proteins.
Current treatments are blunt instruments: pacemakers, implanted defibrillators, beta-blockers, a few other things. (The defibrillator is like ect for the heart; a true current treatment.) You can see that if new medications are developed to treat LQTS, they may not be one size fits all, even though the disorders all *look* the same.
Okay, I'm not going to keep rambling off on tangents. This has gotten theoretical enough.
--I.
Posted by jrbecker on March 11, 2003, at 14:13:25
In reply to Re: For Dr. Bowden: More Q's on BP II » jrbecker, posted by Ilene on March 11, 2003, at 13:53:56
Agreed. The specific diagnosis doesn't seem to be relevant outside of the realm of considering treatment options. In my case, the adjunct of a mood stabilizers or anticonvulsants were tried and not found not to be effective. Of course, this dosen't negate the possibility of latent bipolarity, but at least it helps to dampen past suspicions.
In the end, this discussion seems to be about the need for physicians to be more cautious in their diagnostic criteria and remain more fluid in how they perceive the depressive spectrum. As a result, more refined treatment modalities can hopefully evolve.
JRB
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.