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Dr. Bob is Robert Hsiung, MD,
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Posted by Cairo on July 14, 2004, at 8:41:32
My teen daughter has dysthymia, anxiety, social phobia, ADHD and Fibromyalgia. All psychostims cause social withdrawal in her, Lexapro has helped mood and anxiety some and we'll be adding Seroquel in a couple of days to see if that helps. My question is whether Concerta helps or hurts. During the summer, she's been off Concerta due to the social withdrawal side effect, but the "I'm bored" factor is really becoming a problem (no friends to keep her busy and I have my own issues that make it difficult for me to constantly keep her amused).
Can psychostims worsen an already stressed young lady or is withholding it causing more problems? She developed depression on Strattera (thanks to one poster for his theory of why this might be so)? I'm confused as the to extent that ADHD is causing attentional and boredom problems or whether these are fueled by depression. We've received conflicting advice about the utility of salivary cortisol levels, one doctor telling us we don't need them, another telling us it might be useful to see if they are high or low (especially the 11pm). Any thoughts on this?
Would it make sense to hold off on the Concerta until we see what Seroquel can do for her? Or could the psychostims be making her condition worse if she has overstimulation of the stress system? Her short term memory has deteriorated lately, too.
Thanks for any input. I'm confused and tired and need some help. Everyone here has been great.
Cairo
Posted by linkadge on July 14, 2004, at 9:09:04
In reply to Should she be off psychostims and cortisol levels, posted by Cairo on July 14, 2004, at 8:41:32
Many parents try and give kids a break from stims during the suumer months.
I think that if an underlying emotional disorder is not currenty adressed, then it would be a good idea to stay away from stimulants for a little while. If there is an underlying emotional disorder than stimulants can mask it, or make it go away temporarily, but then return with a vengence.
Linkadge
Posted by Laree on July 15, 2004, at 3:07:25
In reply to Should she be off psychostims and cortisol levels, posted by Cairo on July 14, 2004, at 8:41:32
I too am a young lady with ADHD, anxiety & Fibromyalgia. I'm also on Lexapro right now. How long has your daughter been on it and what dosage? It sounds as if you still think she is depressed? It could be that it isn't working or isn't at a high enough dosage for her.
Has she really tried ALL (every) psychostim. out there? I have been on Ritalin & am currently on Adderall. When I don't take it (the Adderall) I feel very listless/bored. Can I ask why she is being rx'ed Seroquel?? I've been on it (for insomnia) before & it gave me terrible hangovers in the mornings. It's a very 'heavy' drug, at least for me, and I have heard others describe it this way. I don't know--that may make her even more listless.
As I understand it, Concerta is long-acting Ritalin. Ritalin made me feel incredibly anxious; it basically gave me panic attacks. Adderall has never had that effect on me. Is your daughter's anxiety made worse by the Concerta?
It also doesn't sound like she is socially active right now even though she's off of the Concerta. I'd give the Concerta a trial run--and if it doesn't work correctly I'd ask to get switched to a different med for ADHD.
Best,
L.> My teen daughter has dysthymia, anxiety, social phobia, ADHD and Fibromyalgia. All psychostims cause social withdrawal in her, Lexapro has helped mood and anxiety some and we'll be adding Seroquel in a couple of days to see if that helps. My question is whether Concerta helps or hurts. During the summer, she's been off Concerta due to the social withdrawal side effect, but the "I'm bored" factor is really becoming a problem (no friends to keep her busy and I have my own issues that make it difficult for me to constantly keep her amused).
>
> Can psychostims worsen an already stressed young lady or is withholding it causing more problems? She developed depression on Strattera (thanks to one poster for his theory of why this might be so)? I'm confused as the to extent that ADHD is causing attentional and boredom problems or whether these are fueled by depression. We've received conflicting advice about the utility of salivary cortisol levels, one doctor telling us we don't need them, another telling us it might be useful to see if they are high or low (especially the 11pm). Any thoughts on this?
>
> Would it make sense to hold off on the Concerta until we see what Seroquel can do for her? Or could the psychostims be making her condition worse if she has overstimulation of the stress system? Her short term memory has deteriorated lately, too.
>
> Thanks for any input. I'm confused and tired and need some help. Everyone here has been great.
>
> Cairo
Posted by greenwillow on July 15, 2004, at 16:17:17
In reply to Should she be off psychostims and cortisol levels, posted by Cairo on July 14, 2004, at 8:41:32
About cortisol, I think you should have it checked in your daughter. It can cause all sorts of goofy things to happen. I do not know about the saliva test, but they are presently (and have before) determining mine by 24-hour urine collection. Why not ask the doctor who talked to you about the saliva test? Or maybe the saliva test is the way to go, as I believe cortisol levels do change during the day.
Posted by Sad Panda on July 15, 2004, at 19:28:58
In reply to Should she be off psychostims and cortisol levels, posted by Cairo on July 14, 2004, at 8:41:32
>the "I'm bored" factor is really becoming a problem (no friends to keep her busy and I have my own issues that make it difficult for me to constantly keep her amused).
>
>Isn't it normal for a kid to be saying "I'm bored" while on holdiays?
Cheers,
Panda.
Posted by Cairo on July 15, 2004, at 23:25:57
In reply to Re: Should she be off psychostims and cortisol levels » Cairo, posted by Sad Panda on July 15, 2004, at 19:28:58
Here's the psychostim rundown:
Ritalin - I think she's a fast metabolizer and gets too choppy an effect; Ritalin SR (older long acting form) - not very good for attention; Dexedrine - drug from hell,the daily come down was awful, make her aggressive; Adderall - flattened affect way too much, which was a problem with her anxiety and social phobia; Concerta >18mg - annihilates appetite; never tried pemoline - docs won't prescribe it.As for the summer "I'm bored" line, I saw an increase in this and attention, even during the school year when on Concerta. I wondered if we were getting psychostim poop out; maybe just due to an increase in anxiety and depression. We took her off Concerta this summer due to the social withdrawal causing real problems at school, such as school refusal and contributing to anxiety.
When I say boredom is a problem during the summer, I mean that in one morning we go to the movies, to the bookstore, she's been on the computer, done chores, etc. and she's still looking for a kick every 30 seconds. And her anxiety prevents her from calling friends and her fatigue prevents her from doing physical exercise. This is not the usual teenager's summer ennui.
I know boredom is partly due to her ADHD, but my question really pertains to what effect giving the stims will have on her dysthymia? Strattera induced melancholic depression (believe me it did and it abated as we weaned her off of it). As Strattera is an NERI, I'm concerned that increasing NE with psychostims will increase anxiety and too much of that will cause another episode of depression. The Chrousos article about dysregulation of the stress system and high CRH/NE causing major depression is what I'm talking about (actually I suspect she's got atypical symptoms, too; the article says you can have mixed types).
The consultant we just saw in Philadelphia at UPenn said to try Seroquel to augment the partial response she's getting to Lexapro for depression. What we're now facing with Lexapro is extreme fatigue. She's been on it for 5 months and the fatigue and short term memory seem worse, and it wasn't good to begin with. It breaks my heart to have her wake up tired in the morning, yawn all day, and avoid all activity except for the computer because she's too tired.
We just took her off Desyrel (for sleep as a sleep study showed she doesn't go into stage 3) because the doc said the Desyrel might be contributing to the memory issues (I'm thinking it's the Lex). Too soon to see if we see a change.
In my gut, I know she's a candidate for a cocktail of meds, but we simply haven't yet found a local doc to prescribe this. We're waiting for an appointment in August with a new local doc. Until then I just wanted to know if we could combat the inattention/boredom with Concerta or are we making things worse??? I'm totally confused.
Cairo
Posted by Sad Panda on July 16, 2004, at 0:13:06
In reply to Re: I'm bored, list of stims, Seroquel, posted by Cairo on July 15, 2004, at 23:25:57
> Here's the psychostim rundown:
> Ritalin - I think she's a fast metabolizer and gets too choppy an effect; Ritalin SR (older long acting form) - not very good for attention; Dexedrine - drug from hell,the daily come down was awful, make her aggressive; Adderall - flattened affect way too much, which was a problem with her anxiety and social phobia; Concerta >18mg - annihilates appetite; never tried pemoline - docs won't prescribe it.
>
> As for the summer "I'm bored" line, I saw an increase in this and attention, even during the school year when on Concerta. I wondered if we were getting psychostim poop out; maybe just due to an increase in anxiety and depression. We took her off Concerta this summer due to the social withdrawal causing real problems at school, such as school refusal and contributing to anxiety.
>
> When I say boredom is a problem during the summer, I mean that in one morning we go to the movies, to the bookstore, she's been on the computer, done chores, etc. and she's still looking for a kick every 30 seconds. And her anxiety prevents her from calling friends and her fatigue prevents her from doing physical exercise. This is not the usual teenager's summer ennui.
>
> I know boredom is partly due to her ADHD, but my question really pertains to what effect giving the stims will have on her dysthymia? Strattera induced melancholic depression (believe me it did and it abated as we weaned her off of it). As Strattera is an NERI, I'm concerned that increasing NE with psychostims will increase anxiety and too much of that will cause another episode of depression. The Chrousos article about dysregulation of the stress system and high CRH/NE causing major depression is what I'm talking about (actually I suspect she's got atypical symptoms, too; the article says you can have mixed types).
>
> The consultant we just saw in Philadelphia at UPenn said to try Seroquel to augment the partial response she's getting to Lexapro for depression. What we're now facing with Lexapro is extreme fatigue. She's been on it for 5 months and the fatigue and short term memory seem worse, and it wasn't good to begin with. It breaks my heart to have her wake up tired in the morning, yawn all day, and avoid all activity except for the computer because she's too tired.
>
> We just took her off Desyrel (for sleep as a sleep study showed she doesn't go into stage 3) because the doc said the Desyrel might be contributing to the memory issues (I'm thinking it's the Lex). Too soon to see if we see a change.
>
> In my gut, I know she's a candidate for a cocktail of meds, but we simply haven't yet found a local doc to prescribe this. We're waiting for an appointment in August with a new local doc. Until then I just wanted to know if we could combat the inattention/boredom with Concerta or are we making things worse??? I'm totally confused.
>
> Cairo
>
>Have you tried or your doctors suggested a stimulating TCA? I would try Nortriptyline as it combines stimulate effect with the anxiolytic &sleep qualities of Desyrel. I wouldn't be in any hurry to try Seroquel, I tend to think AP's are for psychotics & maybe bipolar people.
Cheers,
Panda.
Posted by Cairo on July 16, 2004, at 8:31:18
In reply to Re: I'm bored, list of stims, Seroquel » Cairo, posted by Sad Panda on July 16, 2004, at 0:13:06
> Have you tried or your doctors suggested a stimulating TCA? I would try Nortriptyline as it combines stimulate effect with the anxiolytic &sleep qualities of Desyrel. I wouldn't be in any hurry to try Seroquel, I tend to think AP's are for psychotics & maybe bipolar people.
>
> Cheers,
> Panda.Tried imipramine quite awhile ago and she developed tachycardia. No other TCAs tried. The doc we saw at UPenn is a researcher in bipolar and said while she doesn't think there's BP, because of a family history of schizophrenia, we need to watch very carefully to see if the social phobia and depression symptoms are early signs, though she really doesn't think this is the case because there is a strong desire to have friends and she has one friend whom she does get along with (though she doesn't live close so there's not much opportunity for getthing them together). The schizophrenia seems to be in males only with females having more depressive symptoms. In my last post I mentioned that she looks like she has some atypical depression symptoms and I know that there is some overlap between atypical depression and Bipolar II symptoms. Maybe that's the rationale to the use of an atypical antipsychotic here.
I know of one several young teens put on Risperdal who do great on low dose, evening out their moods, making them more talkative. The doc hopes we get some antianxiety effect from Seroquel. BTW, I used a short course of Risperdal for a Fibromyalgia flare a couple of times, which knocked the muscle aches and nervousness right out. A quarter to one half tablet worked wonders, while increasing it made symptoms worse. The atypical antipsychotics have myriad effects, apparantly.
I don't really question a trial of Seroquel, especially at low dose, but I still haven't had my concerns answered about psychostims worsening an overaroused CRH/NE system. She always seem like fight or flight with low level irritability, too much sight and sound (like at the mall) making her nervous, difficulty falling asleep, and even an noticeable increase in hypermobility of joints (we ruled out Fragile X, Ehlers-Danlos, Marfans) which could be a sign of chronic fight or flight. The doc said to just keep her off Concerta this summer, unless there is a situation that we feel she needs it and lets see what the Seroquel will do. I agree, but if we need Concerta for attention when school starts, are we adding kindling to the fire?
Any thoughts about this psychostim thing?
www.neurotransmitter.net/Gold.pdf
Thanks!
Cairo
Posted by Sad Panda on July 16, 2004, at 11:05:46
In reply to Re: I'm bored, list of stims, Seroquel, posted by Cairo on July 16, 2004, at 8:31:18
> > Have you tried or your doctors suggested a stimulating TCA? I would try Nortriptyline as it combines stimulate effect with the anxiolytic &sleep qualities of Desyrel. I wouldn't be in any hurry to try Seroquel, I tend to think AP's are for psychotics & maybe bipolar people.
> >
> > Cheers,
> > Panda.
>
> Tried imipramine quite awhile ago and she developed tachycardia. No other TCAs tried. The doc we saw at UPenn is a researcher in bipolar and said while she doesn't think there's BP, because of a family history of schizophrenia, we need to watch very carefully to see if the social phobia and depression symptoms are early signs, though she really doesn't think this is the case because there is a strong desire to have friends and she has one friend whom she does get along with (though she doesn't live close so there's not much opportunity for getthing them together). The schizophrenia seems to be in males only with females having more depressive symptoms. In my last post I mentioned that she looks like she has some atypical depression symptoms and I know that there is some overlap between atypical depression and Bipolar II symptoms. Maybe that's the rationale to the use of an atypical antipsychotic here.
>
> I know of one several young teens put on Risperdal who do great on low dose, evening out their moods, making them more talkative. The doc hopes we get some antianxiety effect from Seroquel. BTW, I used a short course of Risperdal for a Fibromyalgia flare a couple of times, which knocked the muscle aches and nervousness right out. A quarter to one half tablet worked wonders, while increasing it made symptoms worse. The atypical antipsychotics have myriad effects, apparantly.
>
> I don't really question a trial of Seroquel, especially at low dose, but I still haven't had my concerns answered about psychostims worsening an overaroused CRH/NE system. She always seem like fight or flight with low level irritability, too much sight and sound (like at the mall) making her nervous, difficulty falling asleep, and even an noticeable increase in hypermobility of joints (we ruled out Fragile X, Ehlers-Danlos, Marfans) which could be a sign of chronic fight or flight. The doc said to just keep her off Concerta this summer, unless there is a situation that we feel she needs it and lets see what the Seroquel will do. I agree, but if we need Concerta for attention when school starts, are we adding kindling to the fire?
>
> Any thoughts about this psychostim thing?
>
> www.neurotransmitter.net/Gold.pdf
>
> Thanks!
>
> Cairo
>
>Some atypicals hit a bunch of receptors like the original AP's did (& TCA's), but what actual makes them atypical is they cause TD & EPS a lot less often than the older AP's. At low doses I think Risperdal is probably the choice of the atypical AP's for anxiety as it is most potent as a 5-HT2A antagonist. Seroquel starts as a H1 & A1 antagonist which causes it's sedation & most of it's side effects.
For psychostims I don't know what to suggest. Most of the ADD stimulant takers on this board seemed to be rotating their stims around to try & avoid tolerance & the ADD users with social phobias seem to favour stimulant + benzo.
Can you tell us what her atypical symptoms are?
Cheers,
Panda.
Posted by Cairo on July 16, 2004, at 15:07:56
In reply to Re: I'm bored, list of stims, Seroquel, posted by Sad Panda on July 16, 2004, at 11:05:46
> Can you tell us what her atypical symptoms are?
>
> Cheers,
> Panda.While she has difficulty falling asleep, her sleep quality is poor; she is fatigued and yawny all day. Except for the one obvious major depressive episode on Strattera, she looks more dysthymic with irritability. She doesn't look sad and can be roused to having lots of fun (assuming there's nothing to trigger the anxiety and social phobia). In comfortable situations, with people she knows, she's funny and very enjoyable.
She has what looks like thyroid-like symptoms (her TSH and T3, T4 are fine): constantly cold, more hair falling out, tired, dry skin, acne (could be teen hormones raging), brittle nails, out of breath upon exercise, muscle aches and trigger points, delayed/erratic menses. Her ferritin level was low normal; anemia can be secondary to thyroid problems. She gets plenty of red meat, so iron source is good. She poops out more in the afternoons, and just wants to sit. I'm wondering if the thyroid-like symptoms are due to HPA axis hypofunctioning.
We just got back from a "forced" walk - she goes about 5 minutes, then refuses to walk more due to fatigue.
Thank you for your interest.
Cairo
Posted by Cairo on July 16, 2004, at 15:10:40
In reply to Re: I'm bored, list of stims, Seroquel, posted by Sad Panda on July 16, 2004, at 11:05:46
The psychiatrist said that the sedating effects of the Seroquel might be better for her because of her sleep issues and we can get her off the Desyrel because it might be causing memory problems.
Cairo
Posted by greenwillow on July 16, 2004, at 19:30:07
In reply to Re: I'm bored, list of stims, Seroquel, posted by Cairo on July 16, 2004, at 15:07:56
Have they tested Parathyroid (PTH) and 24 hour urine calcium excretion levels yet? Cortisol should be checked.
> She has what looks like thyroid-like symptoms (her TSH and T3, T4 are fine): constantly cold, more hair falling out, tired, dry skin, acne (could be teen hormones raging), brittle nails, out of breath upon exercise, muscle aches and trigger points, delayed/erratic menses. Her ferritin level was low normal; anemia can be secondary to thyroid problems. She gets plenty of red meat, so iron source is good. She poops out more in the afternoons, and just wants to sit. I'm wondering if the thyroid-like symptoms are due to HPA axis hypofunctioning.
>
> We just got back from a "forced" walk - she goes about 5 minutes, then refuses to walk more due to fatigue.
>
> Thank you for your interest.
>
> Cairo
>>
Posted by Sad Panda on July 17, 2004, at 10:54:34
In reply to Re: I'm bored, list of stims, Seroquel, posted by Cairo on July 16, 2004, at 15:07:56
> > Can you tell us what her atypical symptoms are?
> >
> > Cheers,
> > Panda.
>
> While she has difficulty falling asleep, her sleep quality is poor; she is fatigued and yawny all day. Except for the one obvious major depressive episode on Strattera, she looks more dysthymic with irritability. She doesn't look sad and can be roused to having lots of fun (assuming there's nothing to trigger the anxiety and social phobia). In comfortable situations, with people she knows, she's funny and very enjoyable.
>
> She has what looks like thyroid-like symptoms (her TSH and T3, T4 are fine): constantly cold, more hair falling out, tired, dry skin, acne (could be teen hormones raging), brittle nails, out of breath upon exercise, muscle aches and trigger points, delayed/erratic menses. Her ferritin level was low normal; anemia can be secondary to thyroid problems. She gets plenty of red meat, so iron source is good. She poops out more in the afternoons, and just wants to sit. I'm wondering if the thyroid-like symptoms are due to HPA axis hypofunctioning.
>
> We just got back from a "forced" walk - she goes about 5 minutes, then refuses to walk more due to fatigue.
>
> Thank you for your interest.
>
> Cairo
>
>Has she been to an endocrinologist? Adding thyroxine is one of the few things that doesn't seem to have a downside. Does she sleep poorly on Trazodone?
Cheers,
Panda.
Posted by Cairo on July 19, 2004, at 21:29:29
In reply to Re: I'm bored, list of stims, Seroquel » Cairo, posted by Sad Panda on July 17, 2004, at 10:54:34
> Has she been to an endocrinologist? Adding thyroxine is one of the few things that doesn't seem to have a downside. Does she sleep poorly on Trazodone?
>
> Cheers,
> Panda.Not officially, but both her Rheumatologist and my endocrinologist have said that since her TSH, T3 and T4 are normal (TSH under 2), then giving T3 or T4 would not be wise because of negative feedback to the thyroid. It was the Rheumatologist who suggested that HPA axis hypofunction might be responsible for her delayed menses and there is another problem in the loop, perhaps elevated cortisol or CRH hypersecretion.
I know of someone who started on T3 and felt great for a short while, but later crashed and her thyroid shut down. I think using T3 would only be treating something "downstream" anyway.
I'm really not sure if her sleep is restful on the Trazodone. She has usually slept through the night even before taking Traz, but I don't think the quality is there and she definitely has a sleep phase shift. We'd need to repeat the sleep study to see what Trazodone is doing. And AD can cause/aggravate sleep apnea, so it's a catch 22. I think I read that only Xyrem can induce stage 3 sleep. I don't anything about it, but I'd want to eliminate other stressors before I would consider that anyway.
I wonder if they would consider a TCA; she was much younger when they tried imipramine and the dose may have been too high (tachycardia) given the sensitivity that some fibromyalgia patients have to meds.
One thing is for sure, Lexapro is only partially effective at 20mg. Her mood and sociability are somewhat better, but she still looks depressed, her appetite is not picking up and the SP hasn't been helped much.
She is a puzzle, but we love her.
Cairo
Posted by Sad Panda on July 19, 2004, at 23:43:40
In reply to Re: I'm bored, list of stims, Seroquel » Sad Panda, posted by Cairo on July 19, 2004, at 21:29:29
Remeron is another to keep in mind for improving sleep. Remeron, Trazodone, the sedating TCA's & the majority of antipsychotics are all 5-HT2A receptor blockers & this is the mechanism for improved sleep quality. Primarily it increases stage IV sleep & also provides good relief from anxiety.
Cheers,
Panda.
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