Therapist Wants to Help Patient
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Q:  Therapist Wants to Help Patient

I am a mental health  therapist who has been working with a 52 yr old woman for 3 years with a history of PTSD and, in the past, Major Depression...She was recently hospitalized for suicidal ideation and severe agitation, poor sleep, chronic loss of appetite.....She has been diagnosed  with Bipolar II Disorder, although she doesnt present with many of the symptoms...She is not manic, never has been, nor is she impulsive with her behavior and she does not overspend or have impulsive sexual encounters...In fact, she is rather isolated, with high self discipline, very bright with a Master's degree and careful with her behaviors...She has never made a suicide attempt, although has had one previous hospitalization for suicidal ideation.....She had a bout with alcohol abuse 7 years ago and has been sober for 6 years, never having any relapse and very few urges to drink after becoming sober...I suspected she was just medicating her depression.....Her previous meds were S! erzone, Effexor, Remeron and Nueronten..... This combo did not help her reduce the depression, nor did it help her sleep, other than the Remeron "knocking her out and doping her up"..  While in the hospital 2 months ago, her meds were changed to Lamictal, Effexor, Nuerontin and Zyprexa ( Zyprexa given temporarily to stabilize her mood with a calming effect)....Im wondering what you think of this med combo?...Will the introduction of the antidepressant  Effexor combined with the mood stabilizers cause her to "rapid cycle"??, although I have never seen her "rapid cycle" and am not totally convinced she is Bipolar II....To me, her symptoms indicate Post Traumatic Stress Disorder, which she was diagnosed with 4 years ago, having grown up with an abusive father who has PTSD himself as a WWII veteran...In her worst periods, she comes across as very depressed, hypervigilent, racing thoughts, poor sleep,  irritable, suicidal in thinking,...but never manic or impulsive in her behavior ! and never grandious in her thinking....She also was very  bothered because she could not sleep or eat, not grandious that she didnt need the sleep or the food...She has had alot of problems in the past with finding meds that will help her , along with psychiatrists who wont listen to her or change her meds....Im sorry this letter has been so long but I am frustrated and baffled as to how to help her with this....Any info/education/advice would be appreciated.. ....Thanks

Dear Ms. S' -- 
Good on ya' for wondering about the accuracy of the diagnosis as a first question, because obviously the treatment at this point (medications-wise) is hinging on that, and if it's not on target, that could present an ongoing problem.  On the other hand, as you've gathered from experience, including this woman's case in particular, differentiating PTSD and bipolar II is pretty tricky sometimes.  Continuing for a moment on this diagnostic question, you may have read already my little e-treatise on Diagnosis in the
Bipolar II section of my website; in it you'll have seen that anxiety can be a bipolar symptom, although I grant you that is not at all specific (here's an essay on that issue of Anxiety as a Bipolar Symptom with some more references).   Similarly, insomnia can be a bipolar symptom, also not at all specific.  Difficulty concentrating, often due to racing thoughts which you have noted, is also a bipolar symptom without good specificity.  Irritability, likewise.  Suicidality, even if it's phasic, not constant or clearly related only to stressful situations, which is the more "rapid cycling" type pattern, still lacks any specificity. 

Despite that lack of specificity, though, in diagnosing BPII we must look beyond grandiosity, impulsivity, or other more typical "manic" symptoms.  Other symptoms are now regarded by multiple experts as sufficient.  For example,  I haven't finished polishing it up on my site, including no answer key yet (soon), but here's a new questionnaire for BPII, the Bipolar Spectrum Disorders Scale (BSDS) that its well known authors tout as more sensitive in detecting subtle "bipolar spectrum" conditions which don't look typically manic.  Look at the kinds of symptoms they're looking for therein; it's gone well beyond typical manic symptoms.  

I wonder how your patient would score on the more widely used Mood Disorders Questionnaire.  Pies et al built the BSDS precisely because they felt the MDQ was not sensitive enough -- so if your patient has a positive MDQ, that's a positive on a relatively more conservative instrument.  (Here's a downloadable MDQ; or you can just send the patient to the above MDQ link on my site, so she can read the essay about scoring afterward). 

As for the medications issue, note that she started out with 4 agents known to have the capacity to induce cycling (3 antidepressants plus Neurontin); then went on to substitute for one antidepressant Lamictal, a mood stabilizer with indeterminate efficacy for maintaining stability in the face of antidepressants.  They kept the Effexor and the Neurontin, and (probably rather desperately, if this is really bipolar disorder) added Zyprexa, a solid mood stabilizer and famous weight gain agent.  So, yes, I'd be concerned about the Effexor effects, but the trend is in the right direction (ie. toward bona fide mood stabilizers, as she's certainly had a good go on multiple antidepressants, including several simultaneously).  

Even if she "only" has PTSD, it looks like it might be time for a trial of Zyprexa alone (one of my colleagues with specific interest and expertise in PTSD thinks Zyprexa is very effective for PTSD, especially when it's looking somewhat BP-like), after slowly tapering away the antidepressant types, last to go being the lamotrigine -- just my opinion based on data here, mind you.  

Good luck sorting all this out over time, and with your collaboration (and your client's) collaboration with the psychiatrist. 

Dr. Phelps  

Published December, 2002


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