![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 28. This is the beginning of the thread.
Posted by Tomatheus on February 10, 2015, at 15:54:58
My question for anyone here who wants to respond is this: how would you describe the difference between the symptoms of clinical depression and the "negative" symptoms of schizophrenia or schizoaffective disorder (which are usually identified as affective flattening, poverty speech, and reduced goal-oriented behavior)?
Tomatheus
Posted by Chinaboy on February 12, 2015, at 6:04:37
In reply to Depression vs. 'negative' psychotic symptoms, posted by Tomatheus on February 10, 2015, at 15:54:58
> My question for anyone here who wants to respond is this: how would you describe the difference between the symptoms of clinical depression and the "negative" symptoms of schizophrenia or schizoaffective disorder (which are usually identified as affective flattening, poverty speech, and reduced goal-oriented behavior)?
>
Dear Tomatheus:Excuse my bad English! I've also been puzzled and even bothered by this question as well! Due to the
Chinese pdocs' inability to distinguish their differences, I had been wrongly diagnosed as a patient of bipolar depression (sometimes major depression) for almost 20 years!My answer to your question is that there is simply no answer! To solve it, you'll have to give an antidepressant vs. antipsychotic trail to see to which kind of medication you respond better.
I really really have a lot to say with regards to this question. But English is not my mother tongue and I'm also on a large dose of anti-psychotic, so I cannot give you a fairly detailed explanation for the time being. Let us keep contact through Email from now on and I'll try to help as much as possible. My Email address is wangguanzhuang167@163.com. Feel free to write to me and ask me questions!
Posted by Tomatheus on February 12, 2015, at 10:37:40
In reply to Re: Depression vs. 'negative' psychotic symptoms, posted by Chinaboy on February 12, 2015, at 6:04:37
Chinaboy,
Thank you for your reply. It seems that the difficulties that doctors have with distinguishing between depressive symptoms and "negative" psychotic symptoms know no boundaries, as doctors here in the U.S. seem to have similar difficulties with distinguishing between these symptoms as your doctors in China do. You're probably right that there aren't any clear-cut answers to my question and that it makes more sense to just try antidepressants and antipsychotics to see which medications will produce a better response. I know that in my case, antipsychotics generally worsen my problems with energy, concentration, and oversleeping to intolerable levels, although I've found a low dose of Abilify to be tolerable. I've tried most antidepressants, and although some of them relieved some of my symptoms in the short run, none seemed to be helpful in the long run. Some doctors have told me that I don't suffer from depression and that my problems with energy and concentration are "negative" symptoms that are related to my psychosis, while others have described my symptoms as being indicative of depression, so I don't really know what to believe in my case. Vitamin D3 was helping with some of my symptoms (problems with energy, concentration, and oversleeping) for a while, but now it's questionable as to whether it's helping. I suppose that my best bet might be just to give the vitamin D3 more time to work, since it did seem to do me some good for a while, and no other treatments that I've tried have produced long-term benefits.
I did read your recent post about the antipsychotics that you're taking, Chinaboy, and I think it's encouraging that your medication combo seems to be helping you. I hope that you'll continue to respond favorably to your treatment regimen.
Tomatheus
Posted by Chinaboy on February 13, 2015, at 0:39:29
In reply to Re: Depression vs. 'negative' psychotic symptoms » Chinaboy, posted by Tomatheus on February 12, 2015, at 10:37:40
> Chinaboy,
>
> I know that in my case, antipsychotics generally worsen my problems with energy, concentration, and oversleeping to intolerable levels, although I've found a low dose of Abilify to be tolerable. >
>
From my experience, low-to-medium dose of antipsychotics would improve rather than worsen those problems if they are truly negative symptoms. To know whether or not you have negative symptoms, we can do the guesswork based on the way in which a person manages his life. Take my life as an example, I'm 32， but unemployed, never know what it feels like to be loved or to love somebody, still rely on parents for a lot of things like a 5-year-old kid. There are many other typical negative symptoms manifested on me and my life fits typically into that of a withdrawn psycho. In your case, I don't feel you have negative symptoms just with energy and concentration problems only.>I've tried most antidepressants, and although some of them relieved some of my symptoms in the short run, none seemed to be helpful in the long run. >
>That is suggestive of a bipolar tendency??????So adding a small dose of Lamictal might help??????
>
Posted by Tomatheus on February 13, 2015, at 13:21:04
In reply to Re: Depression vs. 'negative' psychotic symptoms, posted by Chinaboy on February 13, 2015, at 0:39:29
Chinaboy,
See below for my responses to what you've written.
> In your case, I don't feel you have negative symptoms just with energy and concentration problems only.
I never said that energy and concentration problems are my only symptoms. They are the symptoms that I feel cause me the greatest deal of impairment at present, which is probably why I write about them here more than any of my other symptoms. But a lot of what you described in yourself fits me, especially since the onset of my "positive" psychotic symptoms eight years ago. I would say that having "poverty of speech," a "reduction in goal-oriented behavior," social withdrawal, and possibly "affective flattening" all apply to me. These symptoms are certainly problematic, but I guess I only give them so much thought in comparison to the difficulties that I have with getting out of bed when I want to, with having the vigor and vitality to put my thoughts into action, and with doing something as seemingly simple as reading a book (or sometimes even a medium-sized paragraph, depending on how bad my concentration is). I guess I don't question that I have "negative" symptoms, but whether the problems that I have with energy and concentration are part and parcel of my negative symptoms or part of something else (e.g., depression).
> That is suggestive of a bipolar tendency??????So adding a small dose of Lamictal might help??????
I've tried that. I can't remember how Lamictal affected my concentration (probably because I was in bed for much of the time), but the medication clearly worsened my energy.
Tomatheus
Posted by ed_uk2010 on February 13, 2015, at 16:03:53
In reply to Re: Depression vs. 'negative' psychotic symptoms » Chinaboy, posted by Tomatheus on February 13, 2015, at 13:21:04
>the difficulties that I have with getting out of bed when I want to...
Do you have anything to get out of bed for? Work, hobbies? Amotivation is common when there is little to get motivated about under the circumstances.
>whether the problems that I have with energy and concentration are part and parcel of my negative symptoms or part of something else (e.g., depression).
Would you say you mood is negative, or normal (you feel quite reasonable emotionally, most of the time, once out of bed)?
Flat affect implies you feel almost nothing eg. if a close family member died, you wouldn't feel bad, you would be emotionally blank. In depression, positive feelings are reduced but a lot of negativity is retained, and distress is still experienced when unpleasant personal events occur.
>Depression and mood disorders vs schizophrenia - type of negative symptoms.
Impairment of personal care is often much more severe in schizophrenia eg. loss of interest in washing, showering, brushing teeth etc. It is very common, for example, for a person with severe negative symptoms of schizophrenia to go for weeks without brushing their teeth. If questioned about this, there would (if a reply was received), be little sign that the person was bothered by this. This degree of deficit is rare in mood disorders except during the most severe depression. Negative sx in schizoaffective disorder are usually mild compared with schizophrenia, and overlap to a greater extent with depressive symptoms. In depression, a person may feel fatigued and less inclined to look after themselves, but would generally feel uncomfortable if they hadn't washed for days and say... had to go to see their pdoc. In the setting of severe psychotic negative symptoms, the appreciation and embarrassment about this situation would be lost - normal feelings are replaced by an indifferent blankness. In these severe situations, there is a difference, and the course of symptoms over time often follows a different course.
I'm not sure it's possible to tell the difference between mild negative sx of psychosis and depression in all cases because the problems overlap. It is possible to tell the difference in certain circumstances eg. when affect is totally flat in a pt with a history of psychosis, or when severe depressed mood is obviously present. When mild, it may not be useful to try and distinguish....
>poverty of speech, or writing (if alone, eg. writing on p-babble!)
Occurs in both. In depression, the remaining speech will often be negative. In negative sx predominant psychotic illness, speech is less likely to be negative, and much more likely to be vague, unusual in content and difficult to comprehend. In depression, speech may be slow or negative but is normally entirely understandable.
What counts as goal-directed behaviour?
Posting on here does, in my opinion. Your writing is exceptionally coherent, which can be the case in chronic depression, and when mild negative psychotic symptoms at present, but not in severe negative psychotic illness.
You replies will be helpful, but I do get the impression your symptoms represent:
1. Chronic depressive illness, somewhat resembling a bad case of dysthymia (this would be suggested by chronic low mood and loss of enjoyment while retaining some negative emotions towards yourself, your situation etc),
or 2. Moderate, post-psychotic, residual negative symptoms (this would be suggested by a loss of positive *and* negative feelings eg. not feeling any distress about something unpleasant which affects you personally... or by the persistence of some psychotic symptoms I'm not aware of).
I think it's rather unusual for pronounced negative sx to occur in schizoaffective disorder in the absence of any recent depression or psychosis. Chronic fatigue may have many causes, on the other hand, both medical and psychiatric.
or 3. some mixture of the above, with more of the depression.Negative symptoms of psychosis normally involve at least some disorganisation of speech/writing and/or expression of odd/bizarre ideas. Neither is at all evident in your posts! Not even occasionally! Do you have any feelings of paranoia at all, or voices/hallucinations?
Impaired attention and fatigue are too non-specific to be helpful in diagnosis. Most forms of illness cause these symptoms!
Unfortunately, symptoms are often exacerbated by a person's circumstances. If you have been unable to work or go out much due to chronic ill-health, it's not surprising that increased amotivation has developed, whatever your condition.
Take care.
Posted by Tomatheus on February 13, 2015, at 17:47:24
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 13, 2015, at 16:03:53
Ed,
Thank you for taking the time to write everything that you did and for asking the questions that you asked. I made it through your post, which I would say means that something that I'm taking (probably the vitamin D3) is doing something at the moment for my concentration, although I will say that I didn't get through all of what you wrote on my first attempt. But anyway, your responses were very thoughtful, and I would say that your impressions as to what my symptoms represent seem to be basically on target. The more I think about my own symptoms, especially in light of what you and Chinaboy have written here on this thread, the more I lean toward the idea that I probably have some mixture of depressive and "negative" psychotic symptoms, with the depressive symptoms leading to the most impairment (especially when they're not responding at least reasonably well to treatment). I will say that over the course of the last few weeks that the severity of my problems with energy and concentration (which is how I prefer to describe my symptoms instead of using the "d" word that I think only describes how I'm feeling so well) has varied, after I went through a period of at least a month with mostly steady improvement, which I had attributed to the vitamin D3 that I've been taking. As I was telling Chinaboy, I think that I'm going to continue with my current treatment regimen for now, as I tend to think that the degree to which I'm going to be responsive to my current regimen is still evolving.
Now, on to your questions...
> Do you have anything to get out of bed for? Work, hobbies? Amotivation is common when there is little to get motivated about under the circumstances.
I'm not currently working. I think about volunteering a lot when I'm responsive to treatment and have on a few occasions decided that I'd volunteer by a certain point if my treatment response will continue up to that point. Unfortunately, it never does.
I don't have many hobbies, but reading is a big one for me, when I'm not struggling much with concentration. I probably spend most of my time reading when I'm able to do so, and I also have ambitions to write both fiction and nonfiction. So, I'm not without things that I want to do and without things that I am doing when my energy and concentration allow me to. I have things that I'm motivated to do, but I can't do them when my energy and concentration are as bad as they are when I'm not responsive to treatment. I know that saying what I just said isn't a popular thing to say, but I do think that there are enough posters on this board who can acknowledge that psychiatric illnesses and symptoms can sometime impair a person to the degree that they can't achieve many of the things they were once able to achieve. For me, when I'm not responsive to treatment, waking up at a time that most people would be happy with is one of those things. It doesn't matter how many alarms I set or how far away from my bed the alarm clocks are. I'll still just hit the "snooze" button and continue sleeping until my body decides it's time to wake up, regardless as to how many things I have to be motivated about. Do I *want* to keep pressing my alarm clock's "snooze" button in the mornings? Of course not, or I wouldn't have set the alarm in the first place.
> Would you say you mood is negative, or normal (you feel quite reasonable emotionally, most of the time, once out of bed)?
For the most part, I would say that my mood seems to be more or less than normal, which is why I said earlier that I dislike using the word "depression" to describe my problems with energy and concentration. Yes, I sometimes get discouraged, but that's *because* of the impairment that my symptoms cause, not the other way around. I think it's only natural for a person to feel like his life isn't amounting to much when he's not living up to what most would consider to be reasonable expectations due to functional impairment being experienced.
> What counts as goal-directed behaviour?
>
> Posting on here does, in my opinion. Your writing is exceptionally coherent, which can be the case in chronic depression, and when mild negative psychotic symptoms at present, but not in severe negative psychotic illness.Yes, I would agree with you that posting here counts as goal-directed behavior. If I had to evaluate myself, I would say that the quality of my written communications is superior to that of my verbal communications. Still, though, my ability to write here is sometimes impaired to at least a degree, even though that doesn't show itself when I'm responding at least somewhat favorably to treatment.
> Do you have any feelings of paranoia at all, or voices/hallucinations?
I hear sounds that others can't hear and also have thought-like voices that I usually describe as "pseudohallucinations," even with the Abilify that I take (which may not come as a surprise, given my low Abilify dose). I also experience ideas of reference and visual perceptual disturbances when I'm not taking an antipsychotic, but those are pretty close to being 100-percent under control with Abilify. I wouldn't say that I was delusional for the most part when I started taking antipsychotic medications, but in retrospect, I would say that I was highly delusional for at least several months and that those around me would have said (and did say) the same. I even believed that I was the second coming of Jesus Christ at one point, and it wasn't just a passing thought. I actually did very little posting here on Psycho-Babble during those months.
Tomatheus
Posted by ed_uk2010 on February 14, 2015, at 10:52:50
In reply to Re: Depression vs. 'negative' psychotic symptoms » ed_uk2010, posted by Tomatheus on February 13, 2015, at 17:47:24
Hi Tom,
>Thank you for taking the time to write everything
You're welcome.
>I lean toward the idea that I probably have some mixture of depressive and "negative" psychotic symptoms
This type of state seems common after recovery from the acute/florid features of psychotic, depressive, schizoaffective or bipolar episodes. It is often very much like depression with less psychological 'pain' and prominent lack of motivation and cognitive difficulties. Some pdocs use the term 'residual symptoms'. Since almost all medication studies are centred around treating acute episodes of illness, it's not at all clear how best to treat these symptoms.
>the vitamin D3
Do you know if your blood level of vitamin D is normal now? Have you been checked for thyroid dysfunction lately? Or any other 'routine blood tests'? eg. Complete blood count, glucose etc.
>I have things that I'm motivated to do, but I can't do them when my energy and concentration are as bad....
So, do you still feel able to enjoy things when you are able to concentrate? ...Or would you say your enjoyment of activities is reduced?
Does your mood/enjoyment correlate with the impaired concentration and fatigue, or do they seem disconnected?
>Do I *want* to keep pressing my alarm clock's "snooze" button in the mornings? Of course not, or I wouldn't have set the alarm in the first place.
I think this type of situation is very common indeed. You are not alone, for sure.
>have thought-like voices
Do you mean you sometimes hear your thoughts spoken aloud? It does appear that Abilify is doing a good job of keeping the most severe features of your illness under control.
What have you tried in terms of antidepressants? It sounds like you've had very little luck. Do you sleep and eat well?
>I even believed that I was the second coming of Jesus Christ at one point
So, was that part of a schizoaffective, manic episode? I'm guessing your diagnosis is schizoaffective disorder, bipolar type? - in partial remission.
Posted by ed_uk2010 on February 14, 2015, at 11:07:56
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 14, 2015, at 10:52:50
Hang on!
I just realised it might have been inappropriate of me to ask you to list the antidepressants you had tried. I assume you've tried a lot. I remember you did gain some benefit from MAOIs at one point.
Perhaps tell us... are there any major classes of AD you've not tried yet?
Posted by ed_uk2010 on February 14, 2015, at 11:23:40
In reply to Re: Depression vs. 'negative' psychotic symptoms » ed_uk2010, posted by Tomatheus on February 13, 2015, at 17:47:24
I don't recall you mentioning trying desipramine. I was thinking it could be useful because it can improve concentration and mood, and does not generally cause any amotivation and fatigue.
Given your previous manic-type episodes, I think you would need to be cautious with TCAs.... but it could be worth adding a little bit of desipramine to see how you do, while continuing Abilify of course.
Do you have any medical conditions which could make desipramine unsuitable?
Posted by Tomatheus on February 14, 2015, at 12:01:08
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 14, 2015, at 10:52:50
Ed,
Thank you again for writing and for asking more questions. My responses are below...
> Do you know if your blood level of vitamin D is normal now? Have you been checked for thyroid dysfunction lately? Or any other 'routine blood tests'? eg. Complete blood count, glucose etc.
I haven't had my vitamin D level checked since it came back low as part of the tests that were ordered when I went to an orthomolecular treatment center in February 2012. Certainly, getting it checked again would be a good idea.
I had thyroid tests, as well as Comp. Metabolic Panel and CBC tests done, when I was seen at the orthomolecular treatment center that I mentioned. Again, that I was in Feburary 2012. I haven't had such tests done since then. The only abnormal lab values that came back from those tests (other than the low vitamin D) were blood sugar being one point above the reference interval and white blood cells being elevated.
> So, do you still feel able to enjoy things when you are able to concentrate? ...Or would you say your enjoyment of activities is reduced?I would say that my enjoyment of activities is probably always reduced to a degree, but I'd say it's adequate when my energy and concentration aren't too bad.
> Does your mood/enjoyment correlate with the impaired concentration and fatigue, or do they seem disconnected?
Yes, I would say that my enjoyment of activities does correlate with my energy and concentration.
> Do you mean you sometimes hear your thoughts spoken aloud?
No, at least not most of the time. They tend to respond to my thoughts and sometimes seem to try to predict things to come. They don't usually repeat my own thoughts. But I don't *hear* them with my ears. They're sort of like whispers, but even more subtle. I guess I can't think of a better way to describe them other than to say that they're thought like.
> What have you tried in terms of antidepressants? It sounds like you've had very little luck. Do you sleep and eat well?
I've tried most of the SSRIs, Cymbalta, Anafranil, Wellbutrin, Remeron, tianeptine, and all of the MAOIs. I might be leaving some out. I'm avoiding taking more SNRIs and TCAs because Cymbalta and Anafranil left me feeling quite agitated and irritable. I also don't think that agomelatine, which I haven't tried, would be a good choice for me, given the difficulties that I have with waking up and the fact that taking melatonin seems to worsen my energy quite a bit.
I would say that my diet is ok, but not great. What I eat is pretty balanced, and I stay away from pure "junk" food more often than not, although I would guess that I probably consume more refined carbohydrates than most health experts would recommend.
My sleep seems ok when I'm responding to treatment. When I'm not, I sleep a bit too much -- usually 10 hours, sometimes more.
> >I even believed that I was the second coming of Jesus Christ at one point
>
> So, was that part of a schizoaffective, manic episode? I'm guessing your diagnosis is schizoaffective disorder, bipolar type? - in partial remission.Well, my current psychiatrist has never discussed his diagnosis with me. The doctors who I would say spent the most time observing me and questioning me during my fourth hospitalization diagnosed me with schizophrenia. Without much doubt, a case can be made that I went through a manic episode during the first few months of my psychosis, as there was clearly some grandiosity. And that would undoubtedly leave me with either a schizoaffective-bipolar or bipolar diagnosis. So, different doctors have told me different things (or in the case of my current psychiatrist, nothing) as far as diagnosis is concerned. I think that I clearly have some depressive symptoms and some psychotic symptoms to contend with at present and that my psychosis quite possibly involved some mania initially. What it all amounts to diagnosis-wise, I'm not 100-percent sure.
Tomatheus
Posted by Tomatheus on February 14, 2015, at 13:04:28
In reply to Re: Depression vs. 'negative' psychotic symptoms » ed_uk2010, posted by Tomatheus on February 14, 2015, at 12:01:08
I just realized that I was a year off in stating the date of my appointment at the orthomolecular treatment center that I mentioned. I went there in February 2013, not February 2012.
Tomatheus
Posted by ed_uk2010 on February 14, 2015, at 18:09:54
In reply to Re: Depression vs. 'negative' psychotic symptoms » ed_uk2010, posted by Tomatheus on February 14, 2015, at 12:01:08
Hi Tom,
>I haven't had my vitamin D level checked since it came back low as part of the tests that were ordered when I went to an orthomolecular treatment center in February 2013.
So, have you been supplementing for around 2 years? If so, I would expect your level to be adequate. It wouldn't hurt to have it re-checked though, plus some routine bloods eg. CBC with differential. It's generally recommended that people on antipsychotics should have monitoring of fasting glucose and lipids too.
>I had thyroid tests, as well as Comp. Metabolic Panel and CBC tests done, when I was seen at the orthomolecular treatment center that I mentioned.
I read your post about it below :)
>blood sugar being one point above the reference interval and white blood cells being elevated....
Mild elevation of glucose is very common in the general population, and extremely common in those on APs. I don't think it's of immediate concern, but it should be rechecked at intervals due to the frequency of type II diabetes.
>I would say that my enjoyment of activities is probably always reduced to a degree, but I'd say it's adequate when my energy and concentration aren't too bad.
> Yes, I would say that my enjoyment of activities does correlate with my energy and concentration.I think this is very typical of chronic depressive states.
The fact that you set your alarm with the intention of getting up and then struggle is more typical of depression than a negative psychotic state - in which case it's unlikely an alarm would be set at all! I know you don't suffer from markedly low mood at the moment, but I think this is typical of your partly-treated illness.
>They tend to respond to my thoughts and sometimes seem to try to predict things to come. They don't usually repeat my own thoughts.
I expect if you weren't on Abilify you'd suffer the typical 'voices commenting' symptom of schizophrenia/schizoaffective.
>Diagnosis.
I don't believe that a 'precise' diagnosis is always possible or worthwhile. Indeed, psychiatric diagnosis is not precise by its very nature.
Your hallucination-like experiences seem much more typical of psychosis than bipolar disorder, but your history of pronounced mood symptoms suggests the schizoaffective diagnosis is a better fit than schizophrenia. Naturally, only so much can be said over the internet, and I'm not a doctor, but that's my impression.
How old were you at the onset of depression? And how old at the onset of psychosis/manic? Was any of the psychosis potentially drug-induced? Any family history of mental health problems?
>I've tried most of the SSRIs, Cymbalta, Anafranil, Wellbutrin, Remeron, tianeptine, and all of the MAOIs. I might be leaving some out. I'm avoiding taking more SNRIs and TCAs because Cymbalta and Anafranil left me feeling quite agitated and irritable.
Apart from the MAOIs, did you experience any benefit from any of them? And apart from Cymbalta/Anafranil, did you experience any major side effects?
This is entirely speculative, but I was wondering whether your intolerance of dual re-uptake inhibitors might not automatically equal intolerance of selective NE antidepressants eg. desipramine. I think you would need to be very cautious and initiate with the minimum possible dosage if you were to attempt this strategy. Still, it might be something to consider under close monitoring. It's possible that the dual re-uptake effect led to mood instability which a more selective drug might not necessarily produce. Even so, there is undoubtedly a risk of side effects as you're already well aware.
>I also don't think that agomelatine, which I haven't tried, would be a good choice for me, given the difficulties that I have with waking up and the fact that taking melatonin seems to worsen my energy quite a bit.
I doubt it would be a good choice either. Melatonin receptor agonism is certainly the major effect of agomelatine. In fact, I'm unconvinced that its much weaker affinity for the 5-HT2c receptor is of any clinical relevance. It might be nothing more than a synthetic for of melatonin. A sort of expensive melatonin with liver risks! It would be interesting to see plain melatonin studied more for depression. I doubt we'll see this happen due to financial issues.
>I probably consume more refined carbohydrates than most health experts would recommend.
Me too. Too much salt and saturated fat too! Still, I don't get the impression that your diet is likely to be a major contributor to your fatigue.
Take care.
Posted by ed_uk2010 on February 14, 2015, at 18:30:37
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 14, 2015, at 18:09:54
I forgot to mention...
What's your experience of fish oil supplements? No other supplement has been examined as much in psychotic disorders. It does seem necessary to take a substantial dose over a prolonged period of time, however.
Posted by Tomatheus on February 14, 2015, at 21:52:11
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 14, 2015, at 18:09:54
Ed,
Thank you for responding to so much of what I've written. Your responses all seem to make a lot of sense, and I appreciate the fact that you've taken so much time to write.
Now, to your questions...
> So, have you been supplementing for around 2 years?I haven't been supplementing that whole time. I was initially wary of taking vitamin D3 because I had noticed what seemed to be a worsening of my psychotic symptoms when I tried taking it previously when I wasn't taking any antipsychotics. So, I've been taking vitamin D3 (which doesn't worsen my psychosis when taken with Abilify) consistently now for a little more than a year, although I've only been at my current dose of 3,600 IU for what I'd guess to be three to four months.
> How old were you at the onset of depression? And how old at the onset of psychosis/manic? Was any of the psychosis potentially drug-induced? Any family history of mental health problems?
I was 20 when my depressive symptoms first surfaced and 27 when the psychosis and likely mania emerged. Other than having a cousin who has Asperger's syndrome (which I think is now just classified as "autism spectrum disorder" in the new DSM), I don't have any family history of problems related to mental health.
As far as the extent to which my psychosis might drug-induced is concerned, I was taking tranylcypromine with SAM-e (which I don't recommend anyone trying, as the combo is contraindicated) at the time the symptoms emerged. About a month before my psychosis began, I took aminoguanidine alongside the tranylcypromine and SAM-e that I was taking and had a bad reaction to it. My cognition seemed to be horribly affected on the day I took aminoguanidine, and in the days that passed after that, I didn't feel as though my cognition had completely recovered. Perhaps it still hasn't completely recovered, and taking aminoguanidine with tranylcypromine and SAM-e might have played a part in bringing on my psychosis? Curiously, I've come across some animal studies showing that aminoguanidine and other inducible nitric oxide synthase inhibitors can exacerbate Toxoplasma gondii infections. Now, that doesn't necessarily prove that an existing latent T. gondii infection + inducible nitric oxide synthase inhibition = psychosis due to activated infection, but I would hypothesize that that might represent one possibility in my case. That's not to say that there aren't other possible explanations for my psychosis.
> >I've tried most of the SSRIs, Cymbalta, Anafranil, Wellbutrin, Remeron, tianeptine, and all of the MAOIs. I might be leaving some out. I'm avoiding taking more SNRIs and TCAs because Cymbalta and Anafranil left me feeling quite agitated and irritable.
>
> Apart from the MAOIs, did you experience any benefit from any of them? And apart from Cymbalta/Anafranil, did you experience any major side effects?I noticed very weak benefits from Wellbutrin, and taking Wellbutrin with lithium carbonate seemed to produce further partial benefits. I took that mix of medications for about two years for my depressive symptoms before the onset of my psychosis. I recall noticing some kind of positive response to tianeptine on the first day I took it and possibly the second day as well, but nothing noticeable that was positive after that. Some of my SSRI trials seemed to lead to a cyclical response, with a pattern of worse depression symptoms alternating with euthymia or perhaps hypomania. However, with Zoloft and Lexapro, I just seemed to notice a worsening of depressive symptoms. I didn't stay on either medication, especially the Lexapro, for long, though.
As far as major side effects were concerned, those from Remeron were awful. I experienced extreme rage and aggression following ingestion of a single dose of mirtazapine and did not take any more of the stuff.
> This is entirely speculative, but I was wondering whether your intolerance of dual re-uptake inhibitors might not automatically equal intolerance of selective NE antidepressants eg. desipramine. I think you would need to be very cautious and initiate with the minimum possible dosage if you were to attempt this strategy. Still, it might be something to consider under close monitoring. It's possible that the dual re-uptake effect led to mood instability which a more selective drug might not necessarily produce. Even so, there is undoubtedly a risk of side effects as you're already well aware.
You could be right that I might respond more favorably to a medication that's more selective in its inhibition of norepinephrine, such as desipramine. I'm kind of wary of taking norepinephrine-boosting medications mainly because I suspect that it might be the NRI actions of Anafranil and Cymbalta that led to the agitation and irritability that I experienced on those medications, but desipramine might be something to consider, especially if the response that I currently seem to be noticing to my vitamin D3 completely fades.
And from your other post:
> What's your experience of fish oil supplements?I've responded differently to fish oil during different stages of my illness. Prior to the onset of my psychosis, I never seemed to notice positive benefits or any real side effects from it. At one point following the onset of my psychosis, I tried taking a high-EPA version of fish oil and noticed a slight worsening of ideas of reference. I've also taken DHA on and off at various points since the onset of my psychosis, noticing a boost in both energy and agitation/irritability during my first few days taking it.
Well, that's all for now. Thank you again for writing and for asking the questions that you've asked. You've certainly delved deeper into my case than some psychiatrists I've seen, including my current one.
Anyway, take care,
Tomatheus
Posted by Christ_empowered on February 14, 2015, at 22:25:21
In reply to Re: Depression vs. 'negative' psychotic symptoms » ed_uk2010, posted by Tomatheus on February 14, 2015, at 21:52:11
Schizophrenia and schizoaffective are poorly defined. If you talk to God, you're praying. If God talks to you, you're schizophrenic. That kinda thing.
I like Orthomolecular because Hoffer and others spoke of "the schizophrenias," with the understanding that there are multiple types of schizophrenia. Under the old school OM diagnostic criteria, a lot of people with "psychotic depression," "personality disorders," and "bipolar I" would, in fact, be schizophrenic.
Negative symptoms are sometimes drug induced. I think its good that Tomatheus has been able to keep his Abilify dose low because nothing zombifies quite like high dose neuroleptics. Also, lack of stimulation, institutionalization, basically..the life of a low status, unemployed, possibly under-employed "mental patient" can lead to "negative symptoms." Its sort of like how shrinks like to pathologize feminine angst, the ill effects of poverty, racism, etc.
Anyway, the research--and much of the research in psychiatry is of very poor quality--seems to show that some people w/ a schizophrenia diagnosis benefit from ADs. Wellbutrin, Remeron, even Tofranil. Others...don't. Old school shrinks would give Ritalin, sometimes even low dose amphetamines. I seem to recall reading that Vyvanse was recently studied for this indication.
Personally, I think I fit into a moody sort of schizophrenia, at least under Hoffer's OM protocol, and wellbutrin has made a huge difference for me. I also take a hardcore OM protocol and live in a supportive environment (my people take good care of me, lol), so I'm protected from the ill effects of being unemployed and low status.
I dunno...I think there's a lot that goes into psychotic disorders that never gets studied because, well, psychiatry isn't always about helping people, now is it?
Posted by Tomatheus on February 14, 2015, at 23:05:17
In reply to Re: Depression vs. 'negative' psychotic symptoms, posted by Christ_empowered on February 14, 2015, at 22:25:21
Christ_empowered,
I think that you made some good observations in your post here, as you usually do. I definitely agree with you that schizophrenia and schizoaffective disorder seem to be poorly defined, and I do think that a lot of overlap exists between schizophrenia, schizoaffective disorder, and bipolar I disorder with psychotic features. Another thing that I find odd is that the descriptions of the "negative" symptoms all seem to be from the perspective of those who observe patients with psychotic disorders instead of from the perspectives of the patients themselves. With other disorders, such as the mood disorders, the symptoms listed describe how the patients feel, but with symptom descriptions like "reduction in goal-oriented behavior," "affective flattening," "poverty of speech," and even "social withdrawal," we don't so much (at least in my opinion) get a good idea as to what "negative" symptoms feel like. Maybe part of the reason for this is that "negative" symptoms may involve a lack of feeling, but I think it would be nice if the descriptions of the "negative" symptoms would be more from the perspective of the patients themselves than they currently are.
And I agree with you that high-dose antipsychotics are best to be avoided, if that's possible. With the problems that I have with energy and concentration, much more than my low dose of 5 mg of Abilify becomes intolerable to me. I do contend with more psychotic symptoms than I did when I tried higher doses of Abilify, but I would say that my symptoms are basically under control, as those around me wouldn't describe me as delusional, and I don't take what the "pseudohallucinations" tell me too seriously (it seems like they often try to deceive me, which makes me take them even less seriously).
Thanks for your post,
Tomatheus
Posted by ed_uk2010 on February 15, 2015, at 13:09:26
In reply to Re: Depression vs. 'negative' psychotic symptoms » ed_uk2010, posted by Tomatheus on February 14, 2015, at 21:52:11
Hi Tom,
>I was initially wary of taking vitamin D3 because I had noticed what seemed to be a worsening of my psychotic symptoms when I tried taking it previously when I wasn't taking any antipsychotics.
Do you think it was related? Side effects seem possible if you were taking doses which were grossly in excess of normal physiological requirements over a prolonged period of time, but that doesn't appear to be the case. The body can manufacture thousands of units of D3 per day when adequate areas of skin are exposed to the summer sun... or at other times of year near the equator.
>So, I've been taking vitamin D3 (which doesn't worsen my psychosis when taken with Abilify) consistently now for a little more than a year, although I've only been at my current dose of 3,600 IU for what I'd guess to be three to four months.
Although it's impossible to be certain without a blood test, your regimen is consistent with what is likely to be an adequate replacement dose for the treatment of proven deficiency. Do you know how severe your deficiency was?
Recently, several D3 products have been officially approved in the UK. Doctors can prescribe these medicines to treat deficiency. Prior to this, unlicensed vitamin supplements were prescribed, and such products are still widely purchased of course. (None of the popular over-the-counter vitamin D products are approved/licensed medicines, they are exempt as food supplements).
The approved capsules have the following official dosage recommendations for treating biochemically proven deficiency states in adults:
3200 units daily for up to 12 weeks, followed by a maintenance dose, if appropriate.
2 x 20 000 unit capsules (total 40 000 units) WEEKLY for 7 weeks, followed by a maintenance dose...... (This is equivalent to taking around 5000-6000 units per day for 7 weeks).
The suggested maintenance dose depends on the product, but for all products is between 800 units and 2000 units per day. I suppose a few people may require more than 2000 units/day for maintenance after full correction, but presumably not many.
There is a tendency to prescribe 800 units per day for people who are not deficient, but where it's important to protect against deficiency eg. in osteoporosis. Higher maintenance doses eg. 1600 units to 2000 units per day are more likely to be chosen for those with recent severe deficiency which has been corrected.
I believe the vitamin D council suggests 5000 units/day on a long term basis. This seems a lot for routine use. I find it difficult to imagine that most people would require so much for maintenance treatment. For sure, you can use high doses to treat deficiency, including huge 'one off' doses, but once the blood level is normal, smaller amounts should normally keep it that way. D3 appears to be well absorbed orally, especially when taken with something fatty. Very high oral doses may sometimes be needed in those with disorders causing fat malabsorption eg. cystic fibrosis.
So, if you can get a blood test from your doctor, I would definitely do so and adjust your dose accordingly. If you can't, maybe reduce to a lower maintenance dose when your current pack runs out. Maximum improvement due the D3 has probably occurred. If possible, get at CBC etc at the same time.
>I was 20 when my depressive symptoms first surfaced and 27 when the psychosis and likely mania emerged.
In men, schizophrenia with severe negative symptoms and a bad prognosis usually has an earlier onset, with psychosis well before 27. Women often have a later onset. Psychosis with a later onset, like yours, usually has a better prognosis and mild/moderate negative symptoms. This doesn't make it any less distressing, unfortunately. Those with severe mood disturbances during psychosis (eg. schizoaffective disorder) may be very agitated while unwell, but even so, the prognosis is generally somewhat better than schizophrenia without affective disturbance. In schizoaffective-type illness, the response to 'mood stabilisers' is usually poor when compared to bipolar disorder, but the response to APs is often good... and may be better than in schizophrenia. I think you do right to continue low-dose Abilify. You seem to have found a dose which provides good control of psychosis and relapse prevention without too many side effects. Although you have some residual psychosis-like phenomena, attempts to suppress these with higher doses of APs might lead to more side effects rather than any great benefit. Furthermore, it doesn't appear that these symptoms are very problematic in comparison to your depressive-like amotivational symptoms.
>As far as the extent to which my psychosis might drug-induced is concerned, I was taking tranylcypromine with SAM-e
I don't know whether SAM-e or aminoguanidine would truly represent the problem, but tranylcypromine is dopaminergic and as a result, I assume it presents a risk of inducing psychosis, mainly in those who are biochemically predisposed to it. Others on p-babble have reported psychosis on MAOIs. I think you should avoid all dopaminergic drugs and stimulants based on your past history. They may produce a brief period of stimulation, but this could be followed by a psychotic relapse.
>Toxoplasma gondii infections.
Are you seropositive for toxoplasma antibodies? And have you had a cat? Mind you, a very high percentage of the US population show serological evidence of past infection, so such tests may not be very revealing.
>I'm avoiding taking more SNRIs and TCAs because Cymbalta and Anafranil left me feeling quite agitated and irritable.
Was Cymbalta very different to the SSRIs for you? How long did you take it for?
>I experienced extreme rage and aggression following ingestion of a single dose of mirtazapine and did not take any more of the stuff.
A yohimbine-like agitation.
>I suspect that it might be the NRI actions of Anafranil and Cymbalta that led to the agitation and irritability that I experienced on those medications
It certainly could be. It's difficult to assess. Your reaction to SSRIs suggests they can produce mood instability... I don't know whether the NRI effect of Cymbalta was a problem in its own right, or whether its combination with the SRI property was bad for you. Anafranil is more complex because it hits so many different receptors.
Was your response to Anafranil very similar to your response to Cymbalta, or different?
>but desipramine might be something to consider
Cautiously, perhaps. You're well aware of the possibility of side effects. NRIs can produce a 'start up' agitation in some people, which tends to pass as the brain adapts and the resulting AD effects begin. The agitation may be less likely to pass in those with bipolar tendencies, but Abilify might keep you stable. I'd mainly be concerned about you trying anything likely to induce psychosis, especially in the absence of an AP. I don't think desipramine is a huge risk in that respect, unless it induced mania. I would be more concerned if you experienced a worsening of psychosis on Anafranil or Cymbalta. You've not mentioned that though. It's awful to feel agitated though, so I fully understand why you feel wary.
>I've responded differently to fish oil during different stages of my illness.I think many of the possible benefits would not occur until you'd been taking it for several months. Perhaps you could consider a balanced EPA/DHA formulation, and spread the doses out across the day, with meals, rather than taking loads at once? I've started to spread my doses out to try and mimic a natural high-fish diet.
Take care.
Posted by Lamdage22 on February 15, 2015, at 14:31:51
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 15, 2015, at 13:09:26
Whats the difference?
There is none.
Pdocs piss me off with this.
Posted by Tomatheus on February 15, 2015, at 14:50:28
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 15, 2015, at 13:09:26
Hi Ed,
Thank you for responding to what I've written again and for offering your thoughts on my responses to your questions. As I've said before, I very much appreciate the fact that you've taken the time that you have to respond and to assess my case.
Now, for my responses to what you've written...
> >I was initially wary of taking vitamin D3 because I had noticed what seemed to be a worsening of my psychotic symptoms when I tried taking it previously when I wasn't taking any antipsychotics.
>
> Do you think it was related? Side effects seem possible if you were taking doses which were grossly in excess of normal physiological requirements over a prolonged period of time, but that doesn't appear to be the case. The body can manufacture thousands of units of D3 per day when adequate areas of skin are exposed to the summer sun... or at other times of year near the equator.I don't know for sure. I would say that I also noticed some worsening of psychotic symptoms when I spent more time in the sun than usual during unmedicated periods that I went through prior to starting Abilify. It also seems that vitamin D may boost tyrosine hydroxylase activity, leading to increased dopamine synthesis, which offers a possible explanation as to why vitamin D might have influenced my psychotic symptoms in the way that it seemed to. The worsening of psychosis that I noticed that time I tried vitamin D3 without any antipsychotic symptoms was somewhat mild, so again, I suppose it can be difficult to say for sure whether the vitamin had anything to do with it.
> Although it's impossible to be certain without a blood test, your regimen is consistent with what is likely to be an adequate replacement dose for the treatment of proven deficiency. Do you know how severe your deficiency was?
I was at the low end of the "insufficiency" range: 21.9 ng/mL.
> So, if you can get a blood test from your doctor, I would definitely do so and adjust your dose accordingly.
I will see if I can do that.
> Are you seropositive for toxoplasma antibodies? And have you had a cat? Mind you, a very high percentage of the US population show serological evidence of past infection, so such tests may not be very revealing.
I haven't been tested for Toxoplasma gondii antibodies. I just think that a T. gondii infection might be one possible explanation for my psychosis, given the degree to which being seropositive for T. gondii antibodies has been found to be correlated with schizophrenia, and also given the fact that my white blood cells always come back as being elevated. But I might not be infected with T. gondii, and even if I am, I don't think that there would be enough evidence to say for sure that it's a cause of my psychosis. I'm merely saying that a T. gondii infection represents a possible explanation for my psychosis.
I have not had any cats as pets, but can't T. gondii also be caught by eating undercooked meat? I think that most people, myself included, can probably say that they've eaten undercooked meat at some point in their lives.
> Was Cymbalta very different to the SSRIs for you? How long did you take it for?
Well, I stopped taking Cymbalta after the agitation and irritability surfaced about three to four days in, so I didn't stay on it for very long. But I haven't noticed any significant agitation or irritability during my SSRI trials.
> Was your response to Anafranil very similar to your response to Cymbalta, or different?
There were some differences between my responses to Anafranil and Cymbalta, the main one being that the agitation and irritability was stronger on Anafranil and surfaced on the first (and only) day I took the medication. But I would say that the "feel" of the two medications was almost the same. Mind you, I didn't stay on either one for very long. Agitation and irritability (and the rage and aggression I experienced on Remeron) probably get me into more trouble with other people than any other symptom, psychotic symptoms included, so I tend to have a low tolerance for agitation and irritability.
Tomatheus
Posted by Tomatheus on February 15, 2015, at 14:59:21
In reply to Re: Depression vs. 'negative' psychotic symptoms, posted by Lamdage22 on February 15, 2015, at 14:31:51
Lamdage22,
Thank you for your input. I do think that there's some evidence that psychotic disorders and mood disorders may share some common biological underpinnings, so perhaps (at least in some cases) depression and "negative" psychotic symptoms might be more similar to one another than most make them out to be.
Tomatheus
Posted by ed_uk2010 on February 15, 2015, at 15:04:00
In reply to Re: Depression vs. 'negative' psychotic symptoms » Christ_empowered, posted by Tomatheus on February 14, 2015, at 23:05:17
>I definitely agree with you that schizophrenia and schizoaffective disorder seem to be poorly defined, and I do think that a lot of overlap exists between schizophrenia, schizoaffective disorder, and bipolar I disorder with psychotic features.
It's true. Most psychiatric disorders are quite poorly defined, in fact. Different psychiatrists are likely to have differing opinions about what falls into the schizoaffective category.
>Another thing that I find odd is that the descriptions of the "negative" symptoms all seem to be from the perspective of those who observe patients with psychotic disorders instead of from the perspectives of the patients themselves.
That's very true. I must say this is not necessarily the fault of psychiatry, mainly because those with severe negative symptoms are rarely forthcoming about how they feel. Unfortunately, there is a tendency in psychiatry to give less consideration to the feeling and opinions of those with psychosis than those with other conditions, essentially because such people are considered to 'lack insight'. This approach is understandable in the sense that some people with severe psychotic illness profoundly lack insight and are not able to safely care for themselves. On the other hand, this paternalistic attitude seems to have gone too far - here, at least. I've seen people with psychosis be treated as if their opinions don't matter at all, even when their feelings seems entirely rational. In this sense, a diagnosis of a psychotic disorder can apparently lead to a reduction in the person's ability to be 'taken seriously' by the profession. This is quite sad.
>With other disorders, such as the mood disorders, the symptoms listed describe how the patients feel
I think this is mainly because those with mood disorders are usually more able to describe how they feel, and are more likely to spontaneously and understandably do so. In addition, the abnormal emotions are the prominent feature of the illness. In psychosis, the more severe end of the 'negative syndrome' spectrum often occurs in people with considerably disorganised speech. Not only do such people rarely provide detailed descriptions of how they feel, attempts to find out through questioning may lead to vague or confusing replies.
Mr. Smith, could you tell me how you feel? How is your mood?
Long pause. 'Erm. Erm. Uhm. Not moody, but the internet is coming and Josie is painting the greenhouse'. Silence.
In this situation, there isn't much to go on apart from observation. In those with milder negative symptoms who have more to say, it's not always clear what the cause of the 'negative symptoms' actually is, as in your case. Like C_E said, at least some degree of NS is to be expected in any highly unstimulating environment, regardless of the diagnosis.
>Maybe part of the reason for this is that "negative" symptoms may involve a lack of feeling
That does seem to be part of it.
>I don't take what the "pseudohallucinations" tell me too seriously (it seems like they often try to deceive me, which makes me take them even less seriously)
What might they say? Do you tolerate 7.5mg Abilify? What dose do you find causes further impairment?
I think it's clear that any large changes in your dose would be unhelpful. But I do wonder if some fine tuning could be beneficial, particularly considering the potency of Abilify.
Posted by ed_uk2010 on February 15, 2015, at 16:28:37
In reply to Re: Depression vs. 'negative' psychotic symptoms » ed_uk2010, posted by Tomatheus on February 15, 2015, at 14:50:28
Hi Tom,
>Thank you for responding to what I've written again and for offering your thoughts on my responses to your questions.
You're very welcome, I enjoy writing to you.
>It also seems that vitamin D may boost tyrosine hydroxylase activity, leading to increased dopamine synthesis, which offers a possible explanation as to why vitamin D might have influenced my psychotic symptoms in the way that it seemed to.
That's very interesting. I didn't know that so I just looked into it a little. Thanks for the information.
Now for some speculation!! :)
I was thinking, unless vitamin D deficiency is actually beneficial for psychosis by reducing tyrosine hydroxylase activity, which seems a little unlikely, it also seems improbable that therapeutic dose supplementation in the treatment of biochemically proven deficiency would be psychologically harmful - supplementation should help to normalise rather than disrupt your metabolic functions. Even in the unlikely event that vitamin D deficiency actually is antipsychotic, low dose oral supplementation would presumably lead to a very gradual change in symptoms, following the gradual increase in serum levels.
I can think of some reasons why your worsened psychotic symptoms might perhaps have been due to some other cause:
1. At the doses of D3 you were taking ie. not mega-doses, it would take weeks or months to fully treat the deficiency. I would therefore not expect any rapid change in symptoms. During the early stage of treatment, your vitamin D level was probably still sub-normal and increasing very gradually. A 300 000 unit single dose can often normalise D3 levels within a week, but you didn't do that.
2. D3 (cholecalciferol) is a pro-hormone. Except in huge overdose, toxicity is uncommon because it requires a two-step metabolic process to produce the active substance, 1,25-dihydroxy D3. As a rule, the body only produces as much active vitamin D as it needs.
First, vitamin D3 (cholecalciferol) is converted to 25-hydroxy D3 (calcidiol) in the liver.. and then 25-hydroxy D3 is converted to 1,25-dihydroxy D3 (calcitriol) in the kidney. The body does not produce more active calcitriol than it needs unless it is subject to a massive vitamin D overdose, or because of some physiological abnormality of vitamin D metabolism, as occurs in the disease sarcoidosis.
Patients with chronic kidney failure need to take active vitamin D because their diseased kidneys cannot product enough, calcitriol itself can be used, or more commonly a related synthetic such as alfacalcidol or paricalcitol. These active vitamin Ds require much more careful dosing than standard supplemental D3 because there is no safety net; they are already active and too much will cause toxicity. None of these active Ds are suitable for the treatment of simple deficiency; there are only used in chronic renal failure. The latest, paricalcitol is especially useful for the bone disease which occurs in kidney failure.
3. Massive vitamin D overdose causes symptoms, in some cases, which appear to be due to hypercalcaemia. Toxicity may require several hundreds of thousands, or millions of units. Reducing calcium levels appears to relieve the symptoms. I doubt that overdose would increase tyrosine hydroxylase levels to above normal levels.... It's often possible to inhibit enzyme activity with drugs, but stimulating it to supra-normal levels is difficult, so many factors are involved.
4. Those with primary hyperparathyroidism and sarcoidosis are often sensitive to vitamin D supplements. PH is most common in post-menopausal women. If you had sarcoid you'd probably have symptoms. Even so, a blood calcium level may be advisable during long term vitamin D supplementation if any unexpected symptoms develop. Your doctor can easily measure your calcium at the same time as your vitamin D level (in general, 25-hydroxy D3 is measured). Serum calcium is a very cheap and routine test. Much more so than vitamin D levels.
Symptoms of hypercalcaemia (elevated calcium) include depressive symptoms, fatigue, abdominal discomfort 'stomach acid', constipation and bone/join aches and pains. I seriously doubt you're hypercalcaemic, but there's little reason not to check the next time you have a blood test, particularly considering your symptoms.
>21.9 ng/mL.
>I will see if I can do that.Exeellent. See if you can get a D3 level and a calcium level (often done as part of a 'bone panel' including phosphate, albumin and alk phos).
Also, consider asking about a CBC *with* differential, an ESR and a thyroid panel (TSH and fT4, or just TSH for screening)... plus anything your doctor wants to check. Everyone on antipsychotics should have occasional fasting glucose tests and plasma lipids. All of the above tests are fairly routine, nothing obscure.
>my white blood cells always come back as being elevated....
I noticed the private lab did a CBC without differential. All CBCs include a differential WBC count here. I think that's what your PCP would do too. A mildly elevated WCC on its own is not particular revealing. If it persists, follow up includes a repeat WCC with differential. If abnormal, a blood smear should be performed by the lab for microscopic analysis. In toxoplasmosis, the usual finding, I believe, is an elevated WCC due to lymphocytosis, with atypical lymphocytes visible on the smear. A similar picture is seen in infectious mononucleosis. These finding are typical during the acute infection, I don't know about chronically. Still, the same process can still be followed for initial investigation of an abnormal WCC on CBC.
>but can't T. gondii also be caught by eating undercooked meat?
I think so, yes.
>I tend to have a low tolerance for agitation and irritability.
I can imagine. Any type of aggressive irritation leads to trouble.
Take care.
Posted by Tomatheus on February 15, 2015, at 16:57:21
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 15, 2015, at 15:04:00
Hi Ed,
Thanks for writing again. You made a lot of good points in your post, as you tend to do. Now for my responses to what you've written...
> What might they say? Do you tolerate 7.5mg Abilify? What dose do you find causes further impairment?
Well, I already said that the "pseudohallucinations" respond to my thoughts and sometimes seem to be trying to predict things. I also said that they tend to be deceptive. I don't like getting into specifics of what they say, especially on the Internet. Heck, I even declined to get into specifics of what they say with the last therapist I saw, and so I hope you'll understand if I decline to share with you and all who are reading this what I didn't share with my last therapist.
As far as the dosing of my Abilify is concerned, 10 mg seemed to be too much for me, as it clearly seemed to exacerbate my fatigue. When I took 7 mg, I noticed a trend toward worsening fatigue like I did at 10 mg, but likely didn't give the dose enough of a chance and went back down to 5 mg after two to three days. It might be possible that 7 or 7.5 mg could be tolerable, especially now that I'm taking vitamin D3 (which tends to reduce my fatigue) as part of my regimen.
> I think it's clear that any large changes in your dose would be unhelpful. But I do wonder if some fine tuning could be beneficial, particularly considering the potency of Abilify.
I think you're right that some fine tuning might be beneficial. I actually tried reducing my Abilify dose to 3.75 mg not too long ago and ended up going back up to 5 mg after about two weeks on the lower dose because I couldn't stand the worsening of symptoms. So, I do think that just a little bit of Abilify might make a significant enough difference.
Tomatheus
Posted by Tomatheus on February 15, 2015, at 17:03:00
In reply to Re: Depression vs. 'negative' psychotic symptoms » Tomatheus, posted by ed_uk2010 on February 15, 2015, at 16:28:37
Thanks for your responses here, as well, Ed. As always, I think that you make sound recommendations that from my perspective at least seem to make sense. Take care.
Tomatheus
> Hi Tom,
>
> >Thank you for responding to what I've written again and for offering your thoughts on my responses to your questions.
>
> You're very welcome, I enjoy writing to you.
>
> >It also seems that vitamin D may boost tyrosine hydroxylase activity, leading to increased dopamine synthesis, which offers a possible explanation as to why vitamin D might have influenced my psychotic symptoms in the way that it seemed to.
>
> That's very interesting. I didn't know that so I just looked into it a little. Thanks for the information.
>
> Now for some speculation!! :)
>
> I was thinking, unless vitamin D deficiency is actually beneficial for psychosis by reducing tyrosine hydroxylase activity, which seems a little unlikely, it also seems improbable that therapeutic dose supplementation in the treatment of biochemically proven deficiency would be psychologically harmful - supplementation should help to normalise rather than disrupt your metabolic functions. Even in the unlikely event that vitamin D deficiency actually is antipsychotic, low dose oral supplementation would presumably lead to a very gradual change in symptoms, following the gradual increase in serum levels.
>
> I can think of some reasons why your worsened psychotic symptoms might perhaps have been due to some other cause:
>
> 1. At the doses of D3 you were taking ie. not mega-doses, it would take weeks or months to fully treat the deficiency. I would therefore not expect any rapid change in symptoms. During the early stage of treatment, your vitamin D level was probably still sub-normal and increasing very gradually. A 300 000 unit single dose can often normalise D3 levels within a week, but you didn't do that.
>
> 2. D3 (cholecalciferol) is a pro-hormone. Except in huge overdose, toxicity is uncommon because it requires a two-step metabolic process to produce the active substance, 1,25-dihydroxy D3. As a rule, the body only produces as much active vitamin D as it needs.
>
> First, vitamin D3 (cholecalciferol) is converted to 25-hydroxy D3 (calcidiol) in the liver.. and then 25-hydroxy D3 is converted to 1,25-dihydroxy D3 (calcitriol) in the kidney. The body does not produce more active calcitriol than it needs unless it is subject to a massive vitamin D overdose, or because of some physiological abnormality of vitamin D metabolism, as occurs in the disease sarcoidosis.
>
> Patients with chronic kidney failure need to take active vitamin D because their diseased kidneys cannot product enough, calcitriol itself can be used, or more commonly a related synthetic such as alfacalcidol or paricalcitol. These active vitamin Ds require much more careful dosing than standard supplemental D3 because there is no safety net; they are already active and too much will cause toxicity. None of these active Ds are suitable for the treatment of simple deficiency; there are only used in chronic renal failure. The latest, paricalcitol is especially useful for the bone disease which occurs in kidney failure.
>
> 3. Massive vitamin D overdose causes symptoms, in some cases, which appear to be due to hypercalcaemia. Toxicity may require several hundreds of thousands, or millions of units. Reducing calcium levels appears to relieve the symptoms. I doubt that overdose would increase tyrosine hydroxylase levels to above normal levels.... It's often possible to inhibit enzyme activity with drugs, but stimulating it to supra-normal levels is difficult, so many factors are involved.
>
> 4. Those with primary hyperparathyroidism and sarcoidosis are often sensitive to vitamin D supplements. PH is most common in post-menopausal women. If you had sarcoid you'd probably have symptoms. Even so, a blood calcium level may be advisable during long term vitamin D supplementation if any unexpected symptoms develop. Your doctor can easily measure your calcium at the same time as your vitamin D level (in general, 25-hydroxy D3 is measured). Serum calcium is a very cheap and routine test. Much more so than vitamin D levels.
>
> Symptoms of hypercalcaemia (elevated calcium) include depressive symptoms, fatigue, abdominal discomfort 'stomach acid', constipation and bone/join aches and pains. I seriously doubt you're hypercalcaemic, but there's little reason not to check the next time you have a blood test, particularly considering your symptoms.
>
> >21.9 ng/mL.
>
>
> >I will see if I can do that.
>
> Exeellent. See if you can get a D3 level and a calcium level (often done as part of a 'bone panel' including phosphate, albumin and alk phos).
>
> Also, consider asking about a CBC *with* differential, an ESR and a thyroid panel (TSH and fT4, or just TSH for screening)... plus anything your doctor wants to check. Everyone on antipsychotics should have occasional fasting glucose tests and plasma lipids. All of the above tests are fairly routine, nothing obscure.
>
> >my white blood cells always come back as being elevated....
>
> I noticed the private lab did a CBC without differential. All CBCs include a differential WBC count here. I think that's what your PCP would do too. A mildly elevated WCC on its own is not particular revealing. If it persists, follow up includes a repeat WCC with differential. If abnormal, a blood smear should be performed by the lab for microscopic analysis. In toxoplasmosis, the usual finding, I believe, is an elevated WCC due to lymphocytosis, with atypical lymphocytes visible on the smear. A similar picture is seen in infectious mononucleosis. These finding are typical during the acute infection, I don't know about chronically. Still, the same process can still be followed for initial investigation of an abnormal WCC on CBC.
>
> >but can't T. gondii also be caught by eating undercooked meat?
>
> I think so, yes.
>
> >I tend to have a low tolerance for agitation and irritability.
>
> I can imagine. Any type of aggressive irritation leads to trouble.
>
> Take care.
>
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