Q:  Would Topamax Be Better for My Daughter

Hello.  My 20 year old daughter has been diagnosed with Bipolar II, OCD, Social Anxiety Disorder (fairly mild) Postramatic Stress syndrome (a neighbor child sexualy abused her- a girl only a few years older.  This happened when my daughter was 6-9 years of age.  My daugher didn't tell me until years later.) and she abuses alcohol.  When she met with him, she didn't tell him she had "cut" herself before.  She admitted to me she has done this about 5 times over the last several years.  Is she telling me the truth about the frequency?  I don't know.  Anyway, I think she has Borderline Personality Disorder due to the cutting and the sexual abuse being part of her past.

Anyway, the doctor wants to meet with her father and me (with her present) in a few days.  Should I approach the issue of the cutting with the doctor?

He has put her on Lamictal.  She is winging herself off of Prozac, as per the doctors orders (her general physician put her on it).  Another issue with my daugher is her weight and severe low self-esteem.  She is about 60 pounds or so overweight.  Maybe 75.  Would Topomax be a better drug for her?  Can she take Topomax and the Lamictal?  I know nothing about Lamictal.  Will it help with the depression?  She seems depressed most of the times with the "small mania" phases coming much less often.  I am  worried that the Lamictal won't help with the depression.  But maybe I am wrong here.

Can you give me some guidance?

Thank you very much.

Dear Ms. D' -- 
Cutting does not Borderline Personality Disorder (the diagnosis) make, although that's a very common conception (including amongst a lot of mental health providers).  I've seen self-harm behavior in people (granted, all women) who as far as they know, and with no evidence to the contrary, have not had sexual or physical or even emotional abuse in their upbringing.  One woman was plain "normal", although very bright and fun and creative, until she started having OCD-like symptoms at age 39; since then she's had extremely severe rapid cycling that has finally responded to taking away all the antidepressant elements (including Ritalin, Risperidone, as well as typical AD's) and relying on a combination of 3 mood stabilizers (including thyroid hormone).  

So I don't feel that the cutting necessarily changes the diagnostic point of view (e.g see my essay on Borderline "versus" Bipolar), but it does clearly convey the severity of symptoms, so it relevant for sure in that sense. 

Lamictal clearly has strong antidepressant properties, so much so that at least so far I have avoided giving it with an antidepressant for fear of exacerbating cycling even more than the antidepressant alone. 

Weight is an important issue for many reasons.  At least avoiding any approach that runs the risk of weight gain would be a smart idea, but targeting weight over other priorities may not be such a good idea (e.g. Topamax: it has some pretty severe cognitive side effects, so you have to taper it up very slowly, and thus you wouldn't be able to figure out if it was actually helping over and above the lamictal trial, which also will take a while to get up to speed). 

One step at a time; at least it looks like things are going in a potentially very helpful direction at this point. 

Dr. Phelps

Published August, 2001