Feels Like is Losing Control
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Q:  Feels Like is Losing Control

Dear Dr Phelps:  Your website is very informative, and a great resource.

I was recently diagnosed with bipolar II .  Before I went to my pdoc I went to my medical doctor to get antidepressants for my "depression"  . I started taking celexa and this threw me into a near constant hypomania or agitated anxious depression , and very fast cycling.  I went to my pdoc and he immediately took me off the  antidepressants and put me on lamictal. I just started the lamictal, so I have received no therapeutic effects from this.

My question is about my mood.  I am extremely irritable, unable to sleep much, I feel enraged.  I cannot stand to have any external input, its all I can do to control my temper when someone is just talking to me normally. I cannot stand any noise .  I feel like I need to run out of the house so I will not lose my mind and my temper. I have psychomotor agitation .  I feel like I am going to go beserk.  This is very uncharecteristic of my personality, although this has happened one other time that I can remember.  I feel like I need to lock myself into a room because I feel like I am losing control .  Is this depressive? Is this hypomanic or a little of both? Is this charecteristic of being bipolar?  Ususally my hypomania is euphoric and mostly enjoyable, not like this .  I get sad when I think about it cause it hurts the people around me.

Secondly, will the lamictal help with this? I know it has good antidepressant properties , but what about the cycling and hypomania? DOes it help this also, or is there a need for other medication?  If so , what types of medication would this be?

Thank you for your time. I hope you can answer my question, especially regarding the "rage-like " behavior.  I feel like an absolute nut.


Dear Jen -- 
There's a very good chance that what you're going through now is a result of the Celexa or stopping the Celexa quickly; the good news being that this may not be reflective of your version of bipolar disorder as such, but rather a temporary worsening, and that therefore lamotrigine may not even have to be good at treating this, because it could settle down over time (going back to the symptoms you had before the Celexa, which would then be the primary target for the lamotrigine. 

For other readers may I point out that your description of symptoms is clear, and note that it includes one feature I hear frequently from patients but which is not included in the typical lists of bipolar symptoms:  " I cannot stand to have any external input...I cannot stand any noise".   

My patients with these symptoms often also have migraine headaches (which usually get better with effective treatment, but which unfortunately can get worse with lamotrigine; although they often get much better with low-dose Depakote, though then you have to watch out for the interaction between the two medications, where Depakote will raise lamotrigine levels as it goes past 500 mg), and say that this "sensory-overload" symptom is like they feel when they have a migraine.  They want to be in a dark quiet room, with no noise (e.g. music coming from the next room) and no light, and particularly no people to deal with.  Strangers are worse and a crowd of strangers at these times is the worst of all.  I'm just mentioning that in case it helps you to know that other people go through this too, and that yes, it gets better in this respect when the bipolar mood symptoms get better. 

So, will lamotrigine control this?  Since usually I use it targeting depression or rapid cycling, I'm not sure about how often lamotrigine alone will work for symptoms such as you describe (which we could call "bipolar mixed state", depression and manic symptoms at the same time, with an emphasis in this case on the manic -- irritable -- side).  The studies of lamotrigine so far have not focused on mixed state symptoms.  However, a colleague just described using lamotrigine for two men whose primary symptom was irritability, with excellent results, so perhaps the lamotrigine alone may be sufficient. 

In the meantime, there are some very fast-acting options to control your current symptoms (again, presuming it's possible that later you'll not need these, if you get past what might be a Celexa-induced phase).  Zyprexa is very likely to be able to help with virtually all the symptoms you describe, within an hour in many cases.  The downside is that it often makes people too sleepy or slowed down to function very well; so they'll take it before they need to go to sleep anyway (it also helps with sleep, which most people with symptoms like yours are having great difficulty getting).  The other downside is that it can cause weight gain, really major and really fast, and perhaps diabetes as well in some individuals, so it's a poor long-term plan if you have alternatives, for most people -- in my opinion.  But in the short run it can be really helpful.  The same principles apply (fast, but weight gain and perhaps insulin resistance-type shifts in metabolism) for another option, short-run at least, namely Depakote (but the interaction with lamotrigine makes using this temporarily somewhat tricky, though not impossible).  Ask your doc' about her opinion of the risks and benefits of adding something like Zyprexa or Depakote, at least in the short run.  

One of the remarkable things about your letter is how aware you are of the symptoms you're having.  That's a huge advantage you have, compared to people who might behave similarly but not be able to recognize it as something that needs treatment.  I hope you're able to capitalize on that advantage soon. 

Dr. Phelps

Published November, 2004


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