Q: GAD plus Cyclothymia -- or BPII? or Adult ADD?
My wife has been on a campaign to find a medication that will help
with her depression and concetration problems. After trying a vast array of
SSRI's and TCA's she sought the care of a psychiatrist. In one sitting she was
diagnosed bipolar II. She was started on Topomax+Risperdol. Initially it
showed great promise but she went into a manic state. By the way this was the
first time I have ever witnessed her in a manic state. So, she was taken off
those drugs and immediately put on Lithium+Klonopin+Effexor. Almost overnight
she bottomed-out. A week later she was in the hopital. The new diagnosis was
Bipolar mixed-state with rapid cycling + GAD. She was treated with Depakote +
Desipramine and dischared after a week. This did not proved effective either.
She was put on Geodon + Depakote + Desipramine. Still no relief. My wife has
had attention and concentration problems from childhood. The muddled-mind as
she calls it has been there since childhood. The psychiatrist would not really
discuss was going on. He would basically say that the current treatment was
not working and then prescribe new med's. We decided to return to my GP and
get her off of the antipsycotics and start a regimen of Paxil. We have slowly
taken her off of the Geodon, Desipramine and Depakote. She is better than she
was after seeing the psychiatrist, but not as good as she would like though.
We are two weeks into the Paxil and I encourage her to be patient with this
and we could look at another mood stabilizer in a while. We are interested in
considering Lamictal, Neurontin or Topomax again (although we had a
not-so-good experience earlier). The Topomax really showed promise. Here !
comes the much waited for question. Does it seem resonable that she is
presenting first GAD with a possible underlying cyclothymia, bipolar II or
even adult ADD? What are your thoughts given this brief history?
Dear Mr. H' --
You have learned enough to know that this is a difficult question, yes?
I would be a fool to go very far in answering it. But you also have
figured out just how to proceed: "be patient and look at another mood
stabilizer in a while". The diagnosis is not going to matter too
terribly much at this point, given all the things that have been tried.
What matters more now is just what step to take next, and even more
importantly, to proceed slowly and figure out one agent at a time, as you
My other though would be that
somewhere along the way a trial of a mood stabilizer, just one, without an
antidepressant, is going to be worth doing. If at that point there was
some moderate improvement, but far from enough, the next step would be to
decide whether to add another mood stabilizer, or a low dose of an
antidepressant. As you may have gathered from reading my site on BPII,
my inclination would be to go with the mood stabilizer, if for no reason than
that it is less likely to make things worse. If at that point
there was yet further moderate improvement, I would probably resolve to
continue tinkering with mood stabilizer combinations and avoid the
antidepressants until really pushed into it.
Mind you, Neurontin, Topomax,
and even Lamictal have all been associated with inducing hypomania. So
has risperidone. So it seems to me that when things are all confused,
it's best to use agents that are less likely to confuse things
GAD plus cyclothymia -- or BPII?
Or adult ADD? As you probably have learned also, these are distinctions
for which we do not have any biologic or even psychologic underpinnings.
So once someone reaches the point of having tried all these things, I don't
worry to much about trying to make these distinctions anymore. There
might be a role for a good psychotherapist, one might wonder, just to
complement all the other strategies that have been tried (not because I
can detect some underlying dynamic issue, obviously). Good luck to the
both of you.
Published May, 2001