Is There Day to Day Kindling in Hypomania?How Long to Wait before Increasing LithiumZyprexa & TD Risks
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Q:  Is There Day-to-day Kindling in Hypomania?
      How Long to Wait before Increasing Lithium
      Zyprexa & TD Risk

Dear Jim:

I am 36 and been on and off psychoactive meds since 13.  My dad, mom, sister, grandmother, suffer or have suffered from bipolar spectrum disorder.

Just this past year my mother and I went on Zoloft at the very same time.  It worked wonderfully for me and worked wonderfully for her as well.  With the Lithium, I suppose, I avoided the hypomania the Zoloft usually kicks in.

During a casual conversation with my mother, I mentioned how I had mapped out the topography of the inside of my mouth in 3D because of a newly acquired habit of feeling aroung the inside of my mouth with my tongue.  She said she was doing exactly the same thing and that her tongue was abrated in places from rubbing against the  sharp parts -- mine is too!

I can stop this tongue movement if I think about it but once I stop it starts again.  My doctor says it is tardive dyskinesia.  

I had recently been on Zyprexa, so it made sense, but my mother had not.  She then remembered having been on Triavil 20 years ago - a combo pill containing an anxipyschotic.  I found an article that said Zoloft could cause TD (very rarely) and was more likely to do so if one had previous experience with a neuroleptic.

This scared me so I VERY SLOWLY weaned off the Zoloft and have been been doing very well on 900 Lithium and 300 Wellbutrin for a long time.

I take 1600 of Vitamin E every day.  They say it helps with the TD.   I think the tongue movement has dimished.  Maybe I've just gotten used to it.

This past Fall my work life accelerated dramatically and so did I.  I have been fully hypomanic for months and enjoying it.  My pattern is months of it at a time.  

The stress at work did not abate  Family stress emerged and my hypomania took on it's charactertistic late stage irritability, frustration and that sense of being overwhelmed.  Two weeks ago I saw the lovely girl who serves me coffee in the morning and the sight of her kind face made be burst into tears.  I had to hide in the hall until the sobbing subsided.  

I knew that if I didn't do something to dial down the stress I would, as is my pattern, sink into major depression.  

I have a wonderful boss and she has allowed me to work from home these last two weeks.  My doctor agreed to raise my lithium to 1025.  I told all my friends and family I needed space -- no phone calls, no visits.  I felt not having to deal with other people, personal contacts and professional, would immediately bring my stress level down.

It did.  I have not gotten worse and the agitation is in check.

I did work from home -- seven day weeks, often till 2 or 3 in the AM.   I work constantly and compulsively, in good spirits.   If not work stuff I am re-organizing closets or setting up a wireless network in my apartment or color correcting a 2,000 pictures in iPhoto...

This weekend I made dates with my two best friends, to begin re-entry for return to work on Monday.  It was clear to them I was still accelerated and with one I of them I cried. 

It's 6 AM and I slept only half an hour tonight in spite of two Klonopin.  Interpersonal contact and the thought of return to work has me really wound up.

I think my mood will escalate again if I go to work.  Two weeks at 1025 Lithium does not seem to have helped.

I fear that my next episode needn't resemble my last.  There is no reason to believe they won't get worse.  I want to avoid the crest of my hypomania and the depression that follows --  if it is at all possible.

Forgive the long narrative.  The descriptions of bipolar episodes in books (most of them otherwise wonderful and life-changing) are often kind of generic.  I wanted the share the specifics of mine for those looking to recognize similar things in their experience.

It would be helpful if you could address these three points:

1 -  Is there day to day "klindling" in hypomania?  Would staying home, not working, and taking Klopin plus over the counter sleep aids slow me down in a meaningfull way?  I fear I would just pick up speed again once I stopped sedating myself.

2 - Would it be wise to give 1025 Lithium a third week?  How long do folks give lithium before upping the dose?

3 - Zyprexa 2.5 would slow me down pretty fast, it has before, the stuff works.  I could probably handle all that inter-personal contact at work and go back on Monday.  I just feel the TD risk is not worth taking.  Melarill and Haldol disfigured my grandmother with constant jaw movement and lip smacking.  I know Zyprexa is less threatening, but my tounge is scratching against the tartar  on the back of my teeth as I type.  I feel I can never take Zyprexa or Zoloft again, given my TD and the danger of making it worse.  Do you agree?

You are the first and best resource I came across in my road to self-diagnosis and treatment in this six minute consultation world of modern psychiatry.  Thank you!


Dear Raoul -- 
Taking your three questions: 

1.  Is there a day-to-day "kindling" -- minor symptoms leading to, indeed causing, big ones later -- in bipolar disorder? I start here knowing you asked about hypomania, because as you may know the idea of "kindling" is controversial even for bipolar disorder in general. That is, mood experts do not entirely agree as to whether this idea of kindling applies in bipolar disorder at all (it came originally from epilepsy research). So, whether the idea applies to hypomania; in other words, whether allowing yourself to stay hypomanic might be setting yourself up for a bigger problem later; is very unclear. 

As you've already seen, depression commonly follows hypomania. But you're asking if your condition could be made worse overall, if I hear you right. Can't say. It looks to me like that might be true for some people, but not for others: some can get away with all sorts of symptoms still going on and not worsen over time, at least in the 10 years I've been treating them; and others seem to get worse even when their symptoms are pretty well "locked down". 

2. How long to wait before turning up lithium? Sorry to be late with my reply, it's probably moot now. In general, at higher doses I check a blood level progressively more frequently as we're turning the dose up. So if your level was 0.7 at 900, I might go to 1200 before checking again; but if your level was 0.9 on 900, I'd look again at 1250 before going further, in most cases. Likewise your side effects might determine whether to check another level before going up. 

But as for "how long does it take before I'll know whether it's working?", that usually can be seen within a week; but yet the full effects, the full benefits you might eventually get from that dose, can take weeks or even months to really settle in.  Makes decisions like the one you're asking about pretty tricky, doesn't it? I hope you made the right guess by now. 

3. Zyprexa and the TD risk, given your experience so far: at best we would just give you information, and let you make the risk decision. But just how much risk might you take were you to try it again? for a day? for a week? We really don't know that. And if you got TD symptoms (worse), would they go back down later? Can't say that either, although if TD is really what's going on with your tongue, I'd agree it's pretty concerning that making it worse somehow might be an irreversible worsening, not just temporary. Too bad so much of this is just extrapolating from others' experience. Fortunately it sounds like, from your story, there are quite a few options to consider which are not associated with TD (here's a mood stabilizer list, in case you need one as you and your doctor consider options). 

Dr. Phelps

Published July, 2006


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