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Q: Benefits of Lamictal Outweigh Side Effects?
Hello Dr. Phelps,
First off, Thank You for being both knowledgeable and bold; by putting so much
high quality information on web sites you have helped myself and probably
thousands of others gain an orientation to the BP diagnosis and (with fabulous
detail and thoughtfulness) to courses of treatment.
Enough with the flattery.
I am presently on Lamictal (see background info below) and have had minor
instances of numerous side effects mentioned on your sites. I would like
your opinion as to whether the Lamictal is the culprit, and whether the
combination of minor symptoms warrants revising my treatment.
Here are some of the effects that have appeared since I began the Lamictal five
months ago:
1. Unusual sensitivity to normally minor skin irritations during Lamictal
introduction: a case of Poison Ivy on my wrist resulted in huge blisters
and quicklyspread to other extremities and produced small rashy spots on my
torso, which all subsided after three weeks; and a normal summer evening
outdoors would result in 10 to 20 mosquito bites as opposed to the normal one or
two I would have expected. (Inconsequential stuff, easily explained by a
patient's nervous hyper vigilance)
2. Very short-lived episodes of total disorientation. For periods of two
to five seconds I have completely and absolutely lost any sense of temporal and
spatial orientation. These are infrequent -- maybe once a month or less --
and not scary enough by themselves to warrant concern. (Perhaps this isn't
relevant, but episodes always occur in small spaces like in the pantry or in the
shower.)
3. Short-term memory is very diminished. However medium and long-term
memory seems unaffected. This is accompanied by a feeling of dissociation,
as reported by another of your correspondents. On the other hand,
"dissociation" from the depressive stimulus of my environment was exactly what I
was hoping for!
4. Irritable-bowel syndrome, general disinterest in eating, diminished sense of
taste (my mouth senses things like irritation and numbness, but I never enjoy
the taste of what I eat).
5. More pronounced physical symptoms of stress such as occasional racing
heart-beat and shortness of breath while at rest, and increased blood
cholesterol. Note however that at 50 years old I am an avid, competitive
soccer player and do not have any heart/lung symptoms during or after 90 minutes
of sprinting during a game.
BACKGROUND
{This is where I flatter myself by thinking you are interested, or even that
you've read this far! :)
I am currently on a "trial diagnosis" of BP II. I began seeing a therapist
and psychiatrist two years ago to help with severe feelings of depression caused
by personal tragedies:
= eldest daughter died of heroin overdose;
= oldest son suffered what used be called a nervous breakdown resulting in
numerous suicide attempts and violent and destructive outbursts bordering on
homicidal rage
-- ultimately diagnosed BP I and removed from our home to a group home;
= youngest son succumbed to extreme symptoms of rapid-cycling mixed mode BP I
and after three other school placements is now in a residential school;
= meanwhile I was laid-off from my job as a high-tech manager and have been out
of work for two-and-a-half years; and
= I have to care for my wife who suffers from severe anxiety disorder, PTSD, and
agoraphobia understandably resulting from all these traumas having occurred in
the space of 3 years.
My own level of depression varied from Severe to Extreme, based on various
evaluation instruments. So I began treatment with a diagnosis of
"adjustment disorder" and a suspicion of pre-existing adult ADHD. (Btw the
short- erm memory and dissociation problems could be interpreted as a strongly
pronounced increase in the distractibility that was already present and was a
crucial indicator for the ADHD.)
In addition to Adderall for the ADHD, my doctor put me on Celexa and
subsequently Effexor. Neither antidepressant really made a dent in my mood
over the course of 18 months. (And although I have doubts about the ADD
diagnosis the Adderall has probably helped me considerably in shouldering my
day-to-day burdens).
Five months ago it occurred to my psychiatrist that perhaps I have BP II.
This suspicion was based on: my lack of response to antidepressants; the family
history of BP I which includes my own brother has as well as my two sons [and
probably my heroin-addicted daughter]; and a perhaps liberally-interpreted
personal history of life-long low- rade depression punctuated by short-lived
snatches of release, happiness, and unrealistic ambition. So the doctor
reasoned that Lamictal was worth a try.
After an appropriately staggered introduction of Lamictal (in five two-week
intervals up to 125mg), my feelings of depression have *completely vanished*.
Wow! I had always thought that everyone had more or less the same degree
of unhappiness that I endured my whole life, but now I realized that I've been
living under a handicap!
So I'm overjoyed at the benefits of Lamictal in my case. But there are
those side effects. Most are beneath the threshold of concern, and I might
not even have linked them to Lamictal but for the references I read on your web
sites. But I'm particularly concerned that the dissociation and short-term
memory loss are becoming serious impairments in my efforts to find a job.
(The flatulance might also make it tough, but I think I could make it through an
interview:)
My doctor recommends a cautious lets-just-wait-and-see approach that I agree
with. (Btw, he's also continuing the Effexor until he has another few
months of run-time on the Lamictal.) But I'd be very interested in your
opinion in the meantime.
Sorry for the rambling self-indulgence (and the over-use of hyphenated words and
parenthetical expressions). It seems my "dissociation" has removed some
editorial inhibitions and the self-doubt about the importance of my own words.
Even if you haven't read along this far, I thank you again for offering your ear
and for providing so much stimulating and helpful information.
Now what was it I was going to do before I decided to write you a note:?
Rgds,
p.s. If you post my note along with an answer on your site, feel free to edit it
down for the benefit of your readers.
Dear Mr. C' -
Smart move, the flattery; it got me all the way through your letter. Other
readers are not encouraged to replicate this strategy, however ( :) --
that's the first time I've used this little internet thingy, but I needed
someway to indicate the spirit of the remark ). The humor, however, we should
all strive to replicate!
Two prefacing remarks: one, as to diagnosis, this awful
run of bipolar diagnoses in the rest of your family ought, in my opinion, to
indicate that your symptoms should be regarded as bipolar until proven
otherwise, rather than the other way around (as it went). Second, it is of
crucial importance, in my view, to know that you have remained on Effexor with all this going on,
which interestingly (I presume largely out of your wish to highlight the obvious
response to lamotrigine) was almost an afterthought in your story -- see
below.
Here we go then:
1. Unusual sensitivity to normally minor skin irritations
...... probably the poison oak interacting with your
immune system at the time of lamotrigine introduction. I gather your skin is
back to normal now? As for the mosquito bites, well, there's this thing they
didn't tell you about lamotrigine. It makes you really attractive to
mosquitoes. And to beautiful women, too, in case you're having any trouble
with that. Sorry, kidding on both counts, darn. Sorry, I can't even
speculate on the mosquito thing.
2., 3., 4., 5. --
With luck, my hunch would be right. The Hunch: all of
these could be considered manifestations of a "high-energy" component of bipolar
disorder, or an exacerbation of the bipolar disorder by an antidepressant, or
both (i.e. from the illness itself, and/or from the antidepressant). In order:
dissociation -- occurs in people with bipolar disorder and post-traumatic stress
disorder (PTSD), and often diminishes, usually disappears in my experience, when
mood stability is achieved. Memory: commonly impaired as long as symptoms
continue (there is a bunch of new evidence suggesting this is the effect of the
mood disorder itself, but I would also be unsurprised if it worsened if an
antidepressant was added to someone's mood stabilizer regimen and there were
other manifestations of worsening (e.g. sleep problems; I'd bet you still have
difficulty sleeping, particularly waking during the night and having difficulty
getting back to sleep, perhaps waves of this being worse and then phases of it
being somewhat but not completely better? (that's not diagnostic of bipolar
disorder, mind you, just happens a lot with it).
Uh, where were we, then? Oh yes, I skipped the total
spatial disorientation. Sorry, I don't recognize that. Unless it occurred
after Effexor was recently decreased, which can produce all sorts of odd
reactions somewhat like this. I'd still hold out hope this would stop when
Effexor is gone, per below.
Next: irritable bowel: very commonly a
manifestation of the high-energy side of bipolar disorder, as well as the
flatulence that goes with IBS frequently. Next: occasional racing heart,
shortness of breath at rest, in an athlete (who's had an evaluation for this by
his internist?) Easier to understand these as "high-energy" symptoms, although
the way they occur briefly is puzzling unless one invokes an "ultra-rapid
cycling" process, which many psychiatrists would regard as stretching "bipolar"
to absurd proportions. And yet, I've seen almost momentary symptoms seem to be
part of "rapid cycling" in that they disappeared after effective mood stabilizer
treatment, so its not at all outside my experience to lump these in with
"bipolar" symptoms.
Lastly, cholesterol is up. Interesting. Not sure what
to make of that.
Okay, here's my hunch-interpretation: we know that
antidepressants can make bipolar disorder worse. They cause cycling, and rapid
cycling in particular, and "mixed states". In mixed states one can lose sight
of "hypomanic" symptoms such as anxiety, irritability, insomnia, or profound
difficulty concentrating (note that's on my website's list of hypomanic symptoms
as a particular marker of hypomania, I didn't make it up for your case) because
they are not "cycling" anymore, and they're all tangled up with other symptoms
frequently, so it's hard to see them as part of "bipolar". Thus it is entirely
possible, and in my view likely, that the Effexor is contributing at
least in part to this list of symptoms. It's common, for example, for effective
mood stabilizer treatment to decrease IBS symptoms; and to treat anxiety
symptoms (here's my essay on
anxiety as a
bipolar symptom). Sometimes effective treatment consists just of gradually
withdrawing an antidepressant (to be discussed with your doctor, of course, as
is true for any readers here).
Therefore I would be very interested to hear back from
you after the Effexor is gone (you can
write me at
PsychEducation; in fact, would you write me now and let me know if I can
use your story, identifying information removed, to illustrate what's possible
with lamotrigine? Thanks). I'd like to know how many of these problems
persist. In case it's not your doc's usual approach, make sure you taper it
extremely slowly; I've had good luck taking 4 months to taper off, roughly
25% per month, maybe a little slower at the end -- which I heard suggested by
Gary Sachs, the Harvard bipolar guy.
The short answer you may have had in mind is "no, I've
never seen any of these develop in someone on 125 mg of lamotrigine, or any dose
for that matter" (though I've rarely gone past 200 mg so far).
Great that you've had such a response to lamotrigine.
I hope it just gets better from here.
Dr. Phelps
Published January, 2004
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