Visual Distortions & Continuous Pain
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Q:  Visual Distortions & Continuous Pain


Hi!

I have some tough questions for you regarding symptoms. I have one of the most well-respected doctors in thenation for this disorder by the name of Dr Mark Frye (UCLA). I have bipolar II, but he is at a loss to explain a few symtoms and I would like see if you have seen them in any of your patients. During the depressed phase of this illness (~99.9% of the time) I can walk into a room and the amount of light seems to change- the room literally seems to get darker. In addition there are other visual distortions- if I were to describe it I would say it is like having fuzzy tunnel vision. The severity of these visual distortions fluctuate but they are present almost every day at some level or another. In addition, I wanted to ask about the strangest symptom- pain. Although diffuse itractable pain is a hallmark symptom of depression, the levels I experience seem abnormal. Not only do I feel severe pain (expenciened as continuous throbbing headaches) but also pain that feels like it is literally "behind my eyes" - as if my eyes "burn". These symptoms of pain are present just about every day but fluctuate in severity - (seemingly congruently) with the visual distortions. Dr Frye maitains that these are all depression related despite the fact that he has almost no patients with symptoms this severe or of this nature. I have tried roughly 15 antidepressant or mood stabiling medications over the past three years with almost no success other than brief hypomanic weeks following the introduction of TCA's. Every mood stabilizer in the current arsenal has been tried with no effect- (none whatsoever) despite adequate dosages and trial lengths consistent with Dr Frye's instructions. My questions are : Have you heard of these types of symptoms ? What do you do when EVERY single class of medications fails to make a dent ? ECT is not something I would consider.

Short of finding the genes and a genetic treatment I don't see effective symptom mitigation in my future. Any advice ? :) Have you heard of these visual distortions ? Patients in continuous pain ? Burning pain behind the eyes ?



Dear Chris --
I agree that Dr. Frye represents one of the best minds and most experienced bipolar researchers in the nation. While he was at the NIMH he saw a very large number of patients with bipolar disorder variations. My "data base" in terms of patients is surely smaller. So while I'm flattered to be asked, my "sample size" probably does not really represent much of a step compared to what you've already had. However, I do have a few thoughts.

First, I can say without hesitation that I've had patients with sensory disturbance as part of their bipolar disorder symptom set. Dr. Frye surely has too, as in my experience it's been fairly common for people to have sensory hypersensitivity that is very bothersome: light, touch (e.g the seam on a pair of pants "driving me nuts"), hearing, and once even smell (although we immediately referred that patient for an EEG, but the test was not abnormal). Haven't heard of taste problems -- before medications anyway -- yet.

But you have visual distortions. I haven't encountered that one. I suspect Dr. Frye or someone before him has ordered an EEG test (electroencephalogram) for you too; and I presume it was normal since your treatment has not veered off in that direction. This test comes to mind for anyone who has somewhat "neurologic" symptoms, you see.

As for the pain (and perhaps the visual symptoms as well, though I'd be less certain of that), there's one obvious question (which I imagine you've also discussed with Dr. Frye): during the hypomanic phases on TCA's, what happened? Did the pain diminish? or worsen? Obviously, if as best you can recall the pain diminished or disappeared during that time, then the "depression" hypothesis for explaining it is supported; and conversely, if not, it weakens that hypothesis a great deal.

Now for the harder part: "What do you do when EVERY single class of medications fails to make a dent ?" Well, first it's crucial to note one detail in your story: you had hypomania on TCA's (if I follow your syntax correctly, this may have happened more than once). So diagnostically, this means, well, for one thing it means you've got the right doctor all right. It also means that treatment approaches should be structured around the risk of producing manic symptoms while you otherwise do very aggressive things to treat the 99.9%-of-the-time depression symptoms. If you've had hypomania at times other than the TCA's (e.g. that 0.1% of the time mathematically speaking), then you could be regarded as still having "cycling". If that cycling was "rapid", at least 4 times a year -- I'd guess listening here it might be much more often, but excruciatingly brief, perhaps as little as hours when it once in a while shows up? -- then I'd shift the emphasis slightly to place even more emphasis on avoiding cycling while aggressively treating depression.

Right, right, but with what? you've already had most everything? Well, based on who your doctor is, you may well have had good serious trials of nearly everything. But I will throw out a few things just to have you check them with him. First, have you looked at the data on fish oil lately? It's getting stronger re: depression, even more so than re: bipolar cycling. I'll bet you haven't had the 20-pills-or-more-a-day approach the Chinese group is using?

Second, Dr. Frye may have described to you the transcranial magnetic stimulation technique. They may have a research trial on that at UCLA soon, the way the data are piling up to support its use as an alternative to ECT; or you might have to look at research protocols elsewhere (South Carolina is one of the biggest; pretty far, though). There are apparently a few U.S. practitioners already using it, as I hope to do soon, even before the FDA approvals now being sought (e.g. per this 2003 editorial from an Australian researcher).

Finally, although for this one I really have to defer to Dr. Frye as its his area of research, I've had a handful of patients respond to T3/T4 thyroid combination who did not respond well to either alone. He's seen my small data set on this already.

From there it's back to all the usual suspects. Have you had lamotrigine plus lithium plus fish oil? That would be piling up all the known "antidepressant" mood stabilizers on top of one another. Sometimes antidepressants can seem to over-ride the benefits of mood stabilizers, so if most of your mood stabilizer trials have been conducted with an antidepressant on board, I'd consider trying again without the AD (e.g particularly this trio; or even fish, lithium, lamotrigine, and T3 thyroid as well). Many patients I see with your symptoms ("99.9% depression") have had antidepressants through all of their mood stabilizer trials!

Which raises another question: did any of the antidepressants you've tried ever seem to make either the pain or the visual distortions worse? I'd almost expect that if those symptoms are really tied into the mood process somehow. If not, that lowers the likelihood, in my view, that you can get at those symptoms by trying to get at the depression.

Oh, and then of course there's "going off the map". If you're ready to look at medication approaches that don't have some data behind them (I guess the T3/T4 trick doesn't really either, but at least it's a variant of approaches that are, plus if you don't get hyperthyroid, it has virtually no risks, making it something one can try before looking at higher or unknown-risk approaches), what about good old "EMPowerplus"? Ask Dr. Frye what he thinks of Dr. Roy Chengappa's work on inositol, which has one report of inducing hypomania (i.e. potent antidepressant?). That's one of the possibly principal ingredients in EMP+.

One more med-set to consider: there are case reports of hypomania on all the new-generation antipsychotics (see link for references), again suggesting potent antidepressant potential in some people. If you haven't tried them all, they should probably be on the list of options alongside the mood stabilizer list.

Good luck with the process. My respects to Dr. Frye.

Dr. Phelps


Published February, 2004
 

 

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