Still Dissociates & Compartmentalizes
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Q:  Still Dissociates & Compartmentalizes

I came into my doctor in a psychotic depression having dissociation panic attacks given the diagnosis PTSD and bipolar later changed to schizoaffective.  I have discontinued my risperadal and have felt fine no hallucinations but I compartmentalize and dissociate still.  I also have bouts of anger and irritability which seem to be getting worse. I am on 100mg Lamictal and 4 mg xanax daily.  It was suggested I may have incongruent mood disorder and bipolar instead of schizo  affective.  My concern is the anger.  Is the mood stabilizer enough or should I approach my psych with new suggestions?  I have depersonalization issues as well with occasional suicidal ideation which has almost cleared with two counselors on board. If I can't handle a situation then I automatically compartmentalize and retreat into a sort of fantasy world.  I am better now than I was just concerned I might need a change in meds                  


Dear Krista --

While I cannot tell you specifically what to do with your medications, the following bit of information might be useful to you.

Schizoaffective disorder is a term that gets pulled out when a patient has psychotic symptoms in the absence of mood symptoms (yet at other times, clearly has mood symptoms as well). There is even a "schizoaffective disorder, bipolar type", which is supposed to mean that the overall presentation of this illness is closer to bipolar disorder than it is in "schizoaffective disorder, schizophrenic type". 

Secondly, it is also very important to know that bipolar disorder itself can cause psychotic symptoms. Lots of doctors seem to forget this and haul out the term "schizophrenia" when they see psychosis (e.g. hearing voices, having delusions). A crucial fact emerges from this one: it is possible to treat psychosis without an anti-psychotic. Mood stabilizers such as lithium and valproate (Depakote) can make psychosis go away and keep it from returning. In case you need to cite an example, here is a classic paper by McElroy, Keck and colleagues

Emerging from this confusion is a simple message, although many doctors seem to find it counterintuitive: patients with symptoms like yours can manage without an antipsychotic. However, your situation is probably much more complicated, with dissociative episodes on top of other symptoms. I can easily imagine that some dissociative symptoms may have been mistaken for psychosis in your case (even if at other times you had classic psychotic symptoms as well). that exactly what role each of your medications will play in keeping certain sets of symptoms under control can often take years to work out. Good luck with that process.

Dr. Phelps

Published April, 2008


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