View Full Version : Treatment resistant??


Fuzzy12
06-17-13, 06:51 AM
60mg of Duloxetine and 125mg of Lamotrigine. I know that neither are very high doses, but with all my previous anti depressants, we kept increasing the dose higher and higher with no benefit but worse side effects. Duloxetine, I think, never did much for me. Lamotrigine seemed to help in the beginning but now I'm depressed again and I've still got bad mood swings.

Exercise doesn't help, doing things I love only helps marginally, omega 3 and multi vitamin supplements don't help. Reducing stress and getting more sleep doesn't help either. The only thing that helps is stimulation, novel, exciting and stupid stimulation but the things that stimulate me are becoming fewer and fewer.

Psychotherapy? I haven't tried that one before. It seems to be the main hope of my psychiatrists. I'm not sure sure, but I'll give it a good shot. Well, whenever I get a space, which could be months or years.

I know, I haven't tried every anti depressant out there and I could give lithium a shot but I'm not keen. I'm terrified of the potential weight gain.

I'm just sinking and sinking. Maybe this is just the way I have to be but I can't accept that.

daveddd
06-17-13, 06:55 AM
:grouphug::grouphug:

i can empathize

tudorose
06-17-13, 07:04 AM
Is it really bipolar?

After I got dx I got really depressed and was put on an SNRI called effexor. Duloxetine is an SNRI. They made me feel like absolute cr@p and after putting on 20kg I gave them up.

Exercise and herbal stuff isn't going to help if the chemicals in your brain are not balanced. And when they are not balanced it is like the worst form of torture.

I don't know if you have or can try tricyclics. My HFA son has been on then for over 10 years. It also helps with his ADHD.

The problem is that until they find the right mix of chemicals you can end up feeling like a lab rat.

And no you don't have to accept that this is how it has to be. It shouldn't be. It is possible to be stable and you deserve that.

Fuzzy12
06-17-13, 07:12 AM
Is it really bipolar?

After I got dx I got really depressed and was put on an SNRI called effexor. Duloxetine is an SNRI. They made me feel like absolute cr@p and after putting on 20kg I gave them up.

Exercise and herbal stuff isn't going to help if the chemicals in your brain are not balanced. And when they are not balanced it is like the worst form of torture.

I don't know if you have or can try tricyclics. My HFA son has been on then for over 10 years. It also helps with his ADHD.

The problem is that until they find the right mix of chemicals you can end up feeling like a lab rat.

And no you don't have to accept that this is how it has to be. It shouldn't be. It is possible to be stable and you deserve that.

Sigh, I wish I knew if it's really bipolar, something else, or just nothing at all.

I've tried effexor. It made me super sleepy, gave me horrible mood swings and when I was awake I just wanted to be dead. Duloxetine makes me sleepy too but doesn't have any other side effects that I'm aware of. Neither does it help with the depression (I think...). I really, really, really don't want a tricyclic. My mom is taking a tricyclic (because no other anti depressant worked for her) and well, since then I've only seen her either hypomanic/manic or severely depressed (she isn't taking a mood stabiliser though).

tudorose
06-17-13, 07:27 AM
I really, really, really don't want a tricyclic. My mom is taking a tricyclic (because no other anti depressant worked for her) and well, since then I've only seen her either hypomanic/manic or severely depressed (she isn't taking a mood stabiliser though).

Each person reacts to them differently. DS coped really well and it's made his life better. DD on the other hand turned into a manic pain in the @rse. It really depends. I would have thought that what would work for one sibling would work for the other so maybe it could be good for you even though it doesn't work so well for your Mum.

Fuzzy12
06-17-13, 08:30 AM
Why is this so difficult to bear? I've spent nearly 10 years in depression. I should be used to it. I was used to it before I started taking anti depressants. Why isn't it getting any easier? Maybe before I had hope that once I start treatment things would get better. Well, they did, just not enough and not for long enough. I don't even want to feel better. I just want to sleep.

And it's annoying me that I spelt "resistant" wrong in the title of my post. Stupid fuzzy :doh: :lol: :(

keliza
06-17-13, 08:35 PM
Tricyclic antidepressants DO have a greater tendency to cause mania in bipolar patients than newer antidepressants (SSRIs and SNRIs), but that can be mitigated by taking a mood stabilizer with the TCA.

Fuzzy, what other medications have you tried for bipolar disorder? Have you tried Trileptal, Tegretol, Neurontin, Lithium, Depakote, Seroquel or any of the other atypical antipsychotics, etc.? There are soooooo many medications that you haven't tried yet, it's not fair to say that you are "treatment refractory" when you have only tried one mood stabilizer so far. Especially if you haven't tried the combination of a mood stabilizer/AAP with another antidepressant, like Abilify and Zoloft, or something like that. You've really only just scratched the surface of what is available to treat bipolar disorder.

Also, when you say that you've tried exercise and it didn't work, how long were you exercising per day and how long did you try it for? To see any major improvement you need to be doing 30-60 minutes of vigorous physical activity per day (like jogging, swimming laps, riding a bike, etc.) every single day for several weeks. Not some exercise for a couple of days, but 30-60 mins of moderate exercise every day for a month or longer. That's the only way you will know if exercise is actually helping or not. Anything less is simply not giving it a fair shot.

Ditto for supplements. You have to take them every day for several weeks before you can see if there's been any real difference or not. They aren't fast-acting, if omega 3's are going to help you it's going to be over a period of weeks, not days. And reducing stress is a pattern of mental and environmental changes that you have to implement over weeks to see any difference, it's not something that will change if you drop a stressful event and just wait a few days.

I don't mean to sound like a hard ****, but I'm just telling you that none of these things is going to work quickly. They all require dedication and time. Exercise is one of the absolute best documented non-medicinal treatments for depression and it works so well for most people, but you have to do it in a dedicated, long-term way. It's not easy, but it's worth it... because even if it doesn't help your mood, it will definitely help your physical health and also improve your sleep quality.

I tend to agree with your psychiatrist, that you really need to see a therapist to get the best results out of your mental health treatment. I hope that you get bumped up on that list and are able to see someone soon. I am not entirely convinced that what you have is bipolar disorder (I truly think it's more likely to be BPD), but I am not a professional either, I'm just a person. Either way though, therapy is going to be helpful for you, as soon as you can get it.

Big hugs. I know this is difficult and frustrating. I wish it weren't this way for you.

Fuzzy12
06-18-13, 12:36 AM
kel, what makes you think it might be bpd?

tudorose
06-18-13, 05:32 AM
Why is this so difficult to bear? I've spent nearly 10 years in depression. I should be used to it.

I only got used to it when it went away. Before that I had always been depressed. My first memory of being depressed goes back to when I was 3. I really struggled as a child, more as a teen and terribly as an adult especially after having the kids. It took me 3 decades to finally get a handle on it but I still really really hate it when it starts to resurface.

My Pdoc taught me how to re-think depression in that I could see myself as an observer and notice that depression was there but to not take it on board. It took me about another 7 years to actually figure out what he meant and apply it.

Do you clinically meet all the symptoms of bipolar under DSM IV?

daveddd
06-18-13, 06:27 AM
fuzzy

your main problems are emotional regulation? along with the depression?

i havent found a good med for the emotional regulation issues(stimulation seeking)

but prozac plus buspar helped a lot



i wish they would just burn all the DSMs

keliza
06-18-13, 01:15 PM
kel, what makes you think it might be bpd?

Your mood shifts are very fast, and relatively short in duration. You're very emotionally labile, highly reactive to things going on in your environment. You often report that you felt okay "until X" and then spiraled into a deep depression. You talk about having formed very few bonds with people, and when you do, you feel extremely (sometimes unhealthily) attached to them. All of those things are more BPD-like in nature.

Bipolar disorder is much less reactive than BPD, and typically the mood episodes come on more gradually and last longer (except in rapid cycling). I understand that your depressive episodes can be quite long, but you also report that major dips come on abruptly, and usually in response to something you perceive as negative. In bipolar disorder, the onset of depression is often gradual and insidious. You don't realize it's happening until you begin to get this sense of slipping backwards, but by the time you realize what's going on and try to claw your way out, it's too late. What you describe sounds more like being kicked into a giant hole 300-style.

But I'm no professional, I'm just a person. I try to listen, though, and remember what you say over time. Over the past several months it seems (to me, anyway) more and more like your mood swings are reactive and shorter lived, and your relationships are self-reportedly unstable and difficult to initiate and maintain, unless they are one particular type of person who you become profoundly attached to very quickly. That all, to me, seems more BPD than bipolar. But again, I'm no doctor.

Raye
06-19-13, 06:36 AM
Fuzz-

I have tried every med that Keliza mentioned, plus many, many anti d's to no avail. But she's right- YOU haven't tried them all, so don't give up. If you feel the lamictal isn't helping, I'd talk to your GP.

Fuzzy12
06-19-13, 07:02 AM
Keliza, you are right. (As usual...grrrr :mad: ;) :grouphug:)

I haven't tried everything. I haven't tried all meds or all combinations of meds and I'm just taking 125mg of lamotrigine so there's still the option of going higher. I need to get myself to do the things you mentioned. 30-60min of exercise, phew, that's a toughie. I'm happy if I manage to do 10-15min of rigorous cycling in the morning.

I've been taking omega 3 for years. I stopped a few months ago (just because I finished one bottle of pills. I've got another one in the cupboard but haven't managed to take it out. :doh:Tomorrow...)

And I need to go regularly to play the piano. Even when I don't feel like it (which I don't when I'm depressed inspite of loving it because I don't feel like doing anything). But I know that the more I play, and when I can see progress in my playing, I feel better. Anything productive makes me feel better about myself. I need to try harder at work as well.



fuzzy

your main problems are emotional regulation? along with the depression?

i havent found a good med for the emotional regulation issues(stimulation seeking)

but prozac plus buspar helped a lot



i wish they would just burn all the DSMs

Yup, emotional regulation along with depression. Buspar is an anxiety med isn't it? I don't have anxiety, so I don't think that my GP (or psychiatrist) will prescribe it. They aren't that keen on prescribing meds off-label here. I could ask her though if there's anything else I can try. My GP is funny. She apparently has BP II as well and she tends to prescribe me whatever is working for her at the moment. So currently, that's lamotrigine and duloxetine.

Your mood shifts are very fast, and relatively short in duration. You're very emotionally labile, highly reactive to things going on in your environment. You often report that you felt okay "until X" and then spiraled into a deep depression. You talk about having formed very few bonds with people, and when you do, you feel extremely (sometimes unhealthily) attached to them. All of those things are more BPD-like in nature.

Bipolar disorder is much less reactive than BPD, and typically the mood episodes come on more gradually and last longer (except in rapid cycling). I understand that your depressive episodes can be quite long, but you also report that major dips come on abruptly, and usually in response to something you perceive as negative. In bipolar disorder, the onset of depression is often gradual and insidious. You don't realize it's happening until you begin to get this sense of slipping backwards, but by the time you realize what's going on and try to claw your way out, it's too late. What you describe sounds more like being kicked into a giant hole 300-style.

But I'm no professional, I'm just a person. I try to listen, though, and remember what you say over time. Over the past several months it seems (to me, anyway) more and more like your mood swings are reactive and shorter lived, and your relationships are self-reportedly unstable and difficult to initiate and maintain, unless they are one particular type of person who you become profoundly attached to very quickly. That all, to me, seems more BPD than bipolar. But again, I'm no doctor.

Sigh, I know Keliza. I'm suspecting BPD too though it's scaring the living hell out of me. I'm not sure why. Maybe it's just the idea that I am that kind of person though I know that that is not fair (I mean to other people with BPD..it's just another disorder after all).

I don't exactly fit the profile.
I've read some accounts of people who suffer with BPD and they sound nothing like me. Well, I can relate to the symptoms but not to those extreme levels. I've got 4 symptoms out of 9 and usually you need 5 for a diagnosis. Maybe I'm a mild case, or like I said in my other thread it's borderline - borderline personality disorder. :rolleyes:

Also, it seems that usually (though not always, I guess) there's a history of childhood abuse or severe neglect. I've had neither.

The strange thing is that my mother has classical BP II and though I never suspected it for myself till my GP mentioned it, I guess it's not too far fetched. But then I could have both and I guess in some families mental health disorders are just more common in general.

Maybe I should buy a book about Dialectic Behaviour Therapy. From what I've read though it depends a lot on the relationship between the therapist and the patient, but it would be still interesting and maybe I can adopt a few things.

I can't imagine that they offer it here in the UK or that it's easily available. I also don't think that any psychiatrist will ever diagnose me with BPD irrespective of if I have it not. I'm hesitant to suggest it as they seem to think that I'm a bit of a hypochondriac anyway (after suggesting ADHD). I've told them all the symptoms, the reactive mood swings, the emptiness, self harm, eating disorder, etc. but my NHS psychiatrists, I think, are still convinced that I'm suffering from severe depression. I'm not even sure if they agree with the diagnosis of BP II, which a private psychiatrist who specialises in mood disorders made (recommended by my GP). The NHS psychiatrists gave her a tough time for referring me to another psychiatrist anyway.

TygerSan
06-19-13, 08:28 AM
Maybe I should buy a book about Dialectic Behaviour Therapy. From what I've read though it depends a lot on the relationship between the therapist and the patient, but it would be still interesting and maybe I can adopt a few things.

FWIW, even though I'm pretty sure I don't have BPD, I've really, really connected to what I've read about Dialectic Behavior Therapy, moreso than with any other therapeutic approach.

My guess is that, while I don't have all of the features of BPD, certain childhood experiences have lead me to disregard my own emotional processing as faulty or wrong. (the number of times I was told I was overreacting, which I took as meaning that my emotions were "wrong" . . . I wasn't supposed to feel that anxious or annoyed or upset, etc).

Fuzzy12
06-19-13, 08:31 AM
FWIW, even though I'm pretty sure I don't have BPD, I've really, really connected to what I've read about Dialectic Behavior Therapy, moreso than with any other therapeutic approach.

My guess is that, while I don't have all of the features of BPD, certain childhood experiences have lead me to disregard my own emotional processing as faulty or wrong. (the number of times I was told I was overreacting, which I took as meaning that my emotions were "wrong" . . . I wasn't supposed to feel that anxious or annoyed or upset, etc).

Yeah, I got that as well. My mom kept telling me that I'm over sensitive and take everything too seriously.

tudorose
06-19-13, 08:31 AM
My guess is that, while I don't have all of the features of BPD, certain childhood experiences have lead me to disregard my own emotional processing as faulty or wrong. (the number of times I was told I was overreacting, which I took as meaning that my emotions were "wrong" . . . I wasn't supposed to feel that anxious or annoyed or upset, etc).

I really see that as an ADHD / Autism thing. Over-reaction and the resulting reactions to the over-reaction from others tends to end up like this and leaves you feeling like you're not allowed to have any feelings.

peripatetic
06-19-13, 09:33 AM
fuzzy,

someone very dear to me ended up with refractory mixed and depressive episodes and i just want to assure you: you have a LOT of options before you need to resign yourself to being treatment resistant.

one quick note on lithium: that was THE thing that kept him stable (so long as he took it at *therapeutic dosage*) for ....like, fifteen years and might've gone another fifteen and more if he'd stuck with it. i've known it to be equally effective for others as well. i'm sure a bit of weight gain isn't ideal...but being consistently medicated enabled them to live. i mean that literally in one case....and the other...it was the first time she felt in possession of her life and able to function without HER being always in the shadow of her mood.


good luck :) x

daveddd
06-19-13, 09:35 AM
I can't speak for autism

But yea. The emotional regulation issues with ADHD will definitely lead to adverse reactions from others

Leaving you to hide emotions

Your stimulation. Emotional regulation issues are the hallmark of ADHD. Everything else is secondary

Your mild borderline traits are also common in adult ADHD folks


Although that really rubs people the wrong way here


You should check out amtrams thread about how most drs don't know a thing about adult ADHD

Abi
06-19-13, 09:36 AM
I'm no doctor either, but I don't see you as BPD.

Ultradian cycling *is* an observed and recognised variant of bipolar disorder.

Atypical depression (as opposed to melancholic) is reactive and particularly common in bipolar 2

I'm rapid cycling, with episodes lasting as long as 6 months or as short as 5 days. Clearly not as rapid cycling as you, but I do have a formal bipolar diagnosis and I do respond to mood stabilisers (Depakote) and antidepressants (Celexa, Lexapro, Wellbutrin)

daveddd
06-19-13, 09:38 AM
Also the bus par has been proven as a very effective additive to anti ds for depression

Abi
06-19-13, 09:39 AM
I just saw Peri's post, and agree with her on trying the Lithium option.

daveddd
06-19-13, 09:43 AM
I'm no doctor either, but I don't see you as BPD.

Ultradian cycling *is* an observed and recognised variant of bipolar disorder.

Atypical depression (as opposed to melancholic) is reactive and particularly common in bipolar 2

I'm rapid cycling, with episodes lasting as long as 6 months or as short as 5 days. Clearly not as rapid cycling as you, but I do have a formal bipolar diagnosis and I do respond to mood stabilisers (Depakote) and antidepressants (Celexa, Lexapro, Wellbutrin)

They've had ultra rapid stuff around forever

They just called it a cyclothymic temperament

Or Barkley calls it emotional regulation issues

daveddd
06-19-13, 10:58 AM
One more very important and overlooked thing about borderline

At least on of "those" types. You know. The type we fear


Are the behaviors ego friendly

Or are you in agreement with and happy with the criteria you believe you have. An example. You take joy in manipulating people to get what you want

If not. Occurring during the course of an axis 1 disorder takes precedent.

Though that doesn't mean meds will fix everything either (but you already know that)

keliza
06-19-13, 11:36 AM
I haven't tried everything. I haven't tried all meds or all combinations of meds and I'm just taking 125mg of lamotrigine so there's still the option of going higher. I need to get myself to do the things you mentioned. 30-60min of exercise, phew, that's a toughie. I'm happy if I manage to do 10-15min of rigorous cycling in the morning.

I've been taking omega 3 for years. I stopped a few months ago (just because I finished one bottle of pills. I've got another one in the cupboard but haven't managed to take it out. :doh:Tomorrow...)

And I need to go regularly to play the piano. Even when I don't feel like it (which I don't when I'm depressed inspite of loving it because I don't feel like doing anything). But I know that the more I play, and when I can see progress in my playing, I feel better. Anything productive makes me feel better about myself. I need to try harder at work as well.

I know it can be totally overwhelming to think, "Man, I have to go from 0 to 60 with my exercise regiment" but it doesn't have to be like that. Work your way up. Commit to 15 mins of rigorous cycling in the morning one week, then the next week bump it up to 17 minutes, or 20, or whatever increments of increase you feel comfortable with. You're doing something, and that's WAY better than nothing, and you'll work your way up to 30+ minutes with time.

I think playing the piano more is a very good idea. I play instruments too, and it's so rewarding when you see yourself making progress, when you hear something beautiful that you've worked hard on, when you're in the zone and you can play for literally hours and not even notice the time passing you by. I can lock myself up with my piano for literally the entire afternoon if I'm not careful. It's such a great feeling. Dedicate yourself to that, even on the days you don't want to. It'll be worth it.

I don't exactly fit the profile.
I've read some accounts of people who suffer with BPD and they sound nothing like me. Well, I can relate to the symptoms but not to those extreme levels. I've got 4 symptoms out of 9 and usually you need 5 for a diagnosis. Maybe I'm a mild case, or like I said in my other thread it's borderline - borderline personality disorder. :rolleyes:

...

The strange thing is that my mother has classical BP II and though I never suspected it for myself till my GP mentioned it, I guess it's not too far fetched. But then I could have both and I guess in some families mental health disorders are just more common in general.

Maybe I should buy a book about Dialectic Behaviour Therapy. From what I've read though it depends a lot on the relationship between the therapist and the patient, but it would be still interesting and maybe I can adopt a few things.

I can't imagine that they offer it here in the UK or that it's easily available. I also don't think that any psychiatrist will ever diagnose me with BPD irrespective of if I have it not. I'm hesitant to suggest it as they seem to think that I'm a bit of a hypochondriac anyway (after suggesting ADHD). I've told them all the symptoms, the reactive mood swings, the emptiness, self harm, eating disorder, etc. but my NHS psychiatrists, I think, are still convinced that I'm suffering from severe depression. I'm not even sure if they agree with the diagnosis of BP II, which a private psychiatrist who specialises in mood disorders made (recommended by my GP). The NHS psychiatrists gave her a tough time for referring me to another psychiatrist anyway.

You're right, you don't exactly fit the profile. That's the difficulty with your diagnoses in general I think, is that you don't "exactly" fit the profile for any one thing, but overlap across myriad different diagnoses. It's stuff like what you're dealing with that makes me kind of happy that NIMH is ditching the DSM-V in favor of symptom clusters. It makes so much more sense to treat the symptoms a person is dealing with than to try and treat their label anyway.

Is it nice to have a neat, tidy label you can slap on what you're dealing with so that at least you have a point of reference for it? Yeah, it is. I know from experience that it is, and I wish I could give you that, the ease of diagnostic labeling. But not having that doesn't mean you won't get treatment. It just means the treatment is going to have to be more tailored and maybe a little less conventional. It depends on how you continue to respond to Lamictal, or Lithium, or Depakote, or whatever else you try in the future.

What daveddd said is really important - is how you feel something you consider a "part of you" (egosyntonic) or something you view as disordered, as not a part of who you are, but a disease you have to deal with (egodystonic)? That is effectively the delineation between axis I and II disorders. Personality disorders (like BPD) are egosyntonic, meaning the person views the disordered personality as part of who they are. That's part of why axis II disorders are so hard to treat, is that often the patient in question doesn't see anything wrong with them. It's everyone else's fault, or it's "just how they are" and they don't believe it can, will, or sometimes even should change.

Egodystonic, on the other hand, means something that is out of sync with the ego, the self, how the person views themselves. Bipolar disorder is egodystonic. I know these mood episodes aren't a part of ME, they're just part of a disorder that I happen to share head space with. But when I have a manic or a depressive episode, that's not who I am, that's what the disorder does to me. That means I don't see it as part of my identity, it's egodystonic. Egodystonic disorders are a lot easier to treat because the patient is on board with the idea that these symptoms are negative, not a part of who they are, and need to go.

Anyway, I don't see any point in bringing up BPD to your doctors. It's not a label you want if you can avoid it (sounds awful of me to say, but it's true, medical "professionals" still stigmatize BPD horribly) and since it's not transparently clear that you have BPD anyway, it's not worth the struggle. As long as they're treating your symptoms, let the label say whatever it needs to say right now. And I agree that given the health care system you're in, the best thing you can probably do right now is go pick up a DBT workbook of your own to work on, since you likely won't be seeing a therapist face to face for a while.

Abi
06-19-13, 11:47 AM
Egodystonic, on the other hand, means something that is out of sync with the ego, the self, how the person views themselves. Bipolar disorder is egodystonic. I know these mood episodes aren't a part of ME, they're just part of a disorder that I happen to share head space with. But when I have a manic or a depressive episode, that's not who I am, that's what the disorder does to me. That means I don't see it as part of my identity, it's egodystonic. Egodystonic disorders are a lot easier to treat because the patient is on board with the idea that these symptoms are negative, not a part of who they are, and need to go.


I very strongly identify with this. Which is consistent with my having Bipolar Disorder and not an Axis 2 condition.

daveddd
06-20-13, 06:33 AM
the most important theme that will differ between the two is

actual LACK of remorse, guilt and/or empathy

vs.

experiential avoidance of remorse,guilt and/or empathy



they may be several more differences

but that is the most important