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two poles, not one [IMPORTANT] - helen-louise
two poles, not one [IMPORTANT]
It's always somewhat complicated when one of your long-term diagnoses gets changed.

I have known since the summer of 1995 that I have clinical depression. Unipolar, atypical, with psychotic features and severe premenstrual disorder on top. Not very exciting to me here in 2008.

Well, apparently I actually don't. It's bipolar II, sometimes called "Depression Plus". ARGH!

I thought I knew what unipolar and bipolar were. I swear last time I looked things up I was definitely still unipolar with mood cycling on top. In fact this DSM description (yes, I know I don't live in the US so the DSM isn't directly relevant) claims you can't be bipolar II if you've ever had a Mixed Episode. Bah. Apparently, while I was busy doing other stuff with my life, doctors were fiddling with the definitions. Now, there is something called the Bipolar Spectrum - just like the Autistic Spectrum, only with mood disorders! Personally, I've had what that site calls "Roller coaster depression", "Depression with profound anxiety" and "Depressive episodes with irritable episodes", sometimes all at the same time.

So yes, I've been in a Mixed State since April when I quit taking mirtazapine, and have been increasingly bad since the end of June. Hence quite a lot of madness and cryptic posts about health stuffs. Haven't had sufficient spoons to explain any further. Not even to partner-people who don't live with me.

Everything is kinda complicated because the treatment plan for Bipolar II/Depression Plus is completely different from mainstream unipolar depression. It involves coming off antidepressants and going onto mood stabilisers instead. I have been remarkably resistant to this, for several reasons:

1. All of the mood stabilisers have scary side-effects. The one I was given, carbamazepine, has a couple of really unpleasant "you might die" side-effects. The possibility of me having an HLA-B*1502 gene is decidedly higher than for "most people", especially as I couldn't find any research detailing the prevalence of the gene in specific Asian populations, and I have Heinz 57 varieties genetics anyway. The leaflet that comes with the drug has four sides of tiny print detailing all the possible interactions with other drugs and horrible side-effects!

Other mood stabilisers are not much more pleasant. Valproate/depakote is often used for bipolar, but its main serious side-effect is crazy weight gain. I just came off a drug that causes that, I really don't want another! Also, valproate may cause PCOS, and I'm already in a high risk group for that. (Plump, dark colouring, lots of body hair, weird menstrual cycles, many Type I and II diabetics in my family - no thanks!). I wasn't offered lamotrigine, and am rather glad because I'm afraid enough of the Stevens-Johnson syndrome/Toxic Necrotic Dermatitis risk with carbamazepine - lamotrigine's life-threatening rash has even higher probability of happening!

2. Coming off Efexor makes me want to shoot myself in the head. Not out of any kind of suicidal urge, but because that's what coming off Efexor will be like. Venlafaxine is famous for having a terrible withdrawal syndrome with featured delights including migraines, pins and needles, ants crawling over the skin, brain freezes, weird electrical discharge stuff going on in nerves, itching and twitching. Not to mention the nausea, vomiting, IBS, dizziness and sweating. Wikipedia says "The high risk of withdrawal symptoms may reflect venlafaxine's short half-life. Missing even a single dose can induce discontinuation effects in some patients." And yes, I am totally one of those people.

Unfortunately, I really do need to come off Efexor. I have been on it since September or October 1998, which is ten years! And apparently it is officially not approved in the US for the treatment of depressive phases of bipolar disorder, as it is especially prone to induce mania, mixed states, rapid cycling and/or psychosis (more so than other antidepressants). I maybe should have guessed this from the time I got given tablets instead of extended release capsules, and went completely mental. 2 hours of extreme hypomania, 2 hours of feeling pretty good, 2 hours of feeling depressed, 2 hours of feeling so awful I just wanted to die, rinse, repeat.

Also, reducing the dose is going to be a bugger. Apparently, some parts of the world have 37.5 mg extended release capsules, but the documentation I have from Efexor packets here only mention 75 mg and 150 mg capsules. Chopping the dose down from 225 mg to 0 mg by reducing it by 75 mg at a time sounds nightmarish. The Wyeth website suggests reducing the daily dose by 75 mg at 1 week intervals, but the thought of that really does make me want to die now to save the inconvenience.

So. I've been on megadose folic acid (15 mg split into 3 doses) since Tuesday 29th July. That has been helping with the stability but not enough. And, having spent 4 months faffing about side-effects, I started taking 100 mg of carbamazepine on Friday 15th August. This is a deliberate decision by me to start on the lowest possible dose (half a tablet) in an attempt to avoid the worst side-effects. If it works for the hideous lamotrigine Rash Of Doom (scroll to Specific guidelines for lamotrigine and lithium (and valproate)), then it may well work for carbamazepine. Worth a try, anyway.

It's weird, though. A diagnosis of bipolar could well explain the severe PMS/PMDD, as well as why despite lots of cognitive behavioural therapy removing the main causes of my anxiety and depression, I still go mental every so often. Most shocking of all, it could even explain my delayed sleep phase disorder. Mood cycling, mood disturbance linked to hormone cycling, and circadian rhythm disorders all go together. Huh.

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Current Mood: indescribable indescribable

26 comments or Leave a comment
redbird From: redbird Date: 19th August 2008 23:27 (UTC) (Link)

Which is to say, I am reading, and agree this is important, and have nothing else useful to say.
micheinnz From: micheinnz Date: 21st August 2008 05:53 (UTC) (Link)
What she said.
From: ext_4143 Date: 21st August 2008 18:49 (UTC) (Link)
A me too on this.
xiphias From: xiphias Date: 19th August 2008 23:34 (UTC) (Link)
I'm Bipolar II. I'm glad they came up with a name for it -- just a couple years ago, when I got the diagnosis, it was just something that a couple doctors were kicking around as a, "hunh, do you think maybe THIS could happen?" Fortunately, I drew a psychopharm who thought it could . . .

Lexapro changed my life. And it's now apparently available generic, because my most recent 'scrip that I got the other day has a generic version.
baratron From: baratron Date: 21st August 2008 14:00 (UTC) (Link)
Huh. I'm really surprised, because you're another person who seems very unipolar from the outside. It's always been depression that you've complained of, rather than agitation, rage or hypomania. Whereas I've had a monthly mood rollercoaster since puberty.

I think I'm at the stage where I need to come off antidepressants in general, except possibly for trazodone because it's ancient and often given along with carbamazepine. Bloody annoying though, because Efexor changed my life and made me stable for many years. Bah.
xiphias From: xiphias Date: 21st August 2008 14:07 (UTC) (Link)
I have never had a manic episode in my life, which is why it took quite a while to diagnose Bipolar II. And I meant "Lamictal", not Lexapro, by the way.

Why do you feel that you should come off of antidepressants?
baratron From: baratron Date: 21st August 2008 22:59 (UTC) (Link)
It's in the main post. The treatment plan for Bipolar II/Depression Plus is completely different from mainstream unipolar depression. It involves coming off antidepressants and going onto mood stabilisers instead. See http://www.psycheducation.org/depression/03_treatment.html for more details. What you're on, Lamictal/lamotrigine is a mood stabiliser with antidepressant tendencies, not an antidepressant. Whereas the one you said originally, Lexapro/escitalopram, is a standard SSRI :)
xiphias From: xiphias Date: 22nd August 2008 02:35 (UTC) (Link)
Oh, I see what you mean. Does going onto mood stabilizers require going off of SSRIs, though? I never went of Lexapro, and am currently on Lexapro and Lamictal.
From: judiff Date: 19th August 2008 23:35 (UTC) (Link)
lots of bunnys !!!
I'm like a bit conbfused becos you don't seem like the bipolar type 2 (or type 3/medication induced) people that we know.
But hopefully this will be helping.
We used a very short term course of diazipam to help with venlafaxine withdrawl - so we mosty lept instead of the shaking and throwing up which was nice. I expect there are resons why that would be less god for you but is there anything like that you can use?
baratron From: baratron Date: 20th August 2008 10:52 (UTC) (Link)
Whereas Richard has been saying that I'm bipolar for years, which is why I kept looking up the symptom list to see if it had changed. I suspect you haven't actually seen me at my worst. There was a Sunday quite recently when I came down to Brighton and was annoyed and irritable about everything, but you may have interpreted that as "just tiredness", and I was going out of my way to try not to be too bad-tempered with you.

I've been mood disordered for so long that I'm generally good at realising when my brain chemistry is wonky and compensating for it. It's rare for me to have real attacks of madness except in front of Richard, my mum, or Tim and Peter. I think Alexa's seen a few too. Lately, I haven't been able to do that, and I've been visibly crazy a couple of times in front of other people - including Richard's potential new boss, which was just embarrassing. I didn't mean to be completely psycho, but I couldn't help it either.
otterylexa From: otterylexa Date: 19th August 2008 23:38 (UTC) (Link)
/me hugs you.
If the heralds a general improvement, that would be a very good thing...
From: kshandra Date: 19th August 2008 23:53 (UTC) (Link)
Yay for finding something resembling an answer. *hugs*
quiet000001 From: quiet000001 Date: 20th August 2008 00:07 (UTC) (Link)
And here I was just wondering why it is that it seems like citalopram isn't really working properly anymore... (And yeah, Prozac stopped working for me, too- the regular dose didn't do enough, and the next step up made my brain go funny.)

And more than once, my mom has been concerned because I seem 'manic' except I never get the delusions thing, just the elevated mood/fast speech/high energy.

So yay? And also not-yay, because what FANTASTIC sounding medication options. *beats pharmaceutical companies with a stick*
baratron From: baratron Date: 20th August 2008 10:59 (UTC) (Link)
Mmhmm. And you've got the arthritis thing to worry about as well :/ Joy!
quiet000001 From: quiet000001 Date: 21st August 2008 00:15 (UTC) (Link)
Yeah- though it looks like Omega-3 might be a reasonable treatment to try, and that's good for both problems. Apparently, there is much fish oil in my future. Blech.
quiet000001 From: quiet000001 Date: 16th October 2008 08:15 (UTC) (Link)
For amusement value, I just took one of those "you may be if..." online quizzes for bipolar spectrum disorder or whatever it's properly called.

Cut off score for "you probably should speak to a doctor" was 25+

I got a 45.

ailbhe From: ailbhe Date: 20th August 2008 00:09 (UTC) (Link)
From here, it all looks very like diagnosing dietary intolerance - eliminate the obvious, then gradually stop eating anything at all until something crops up which appears to match your symptoms, then confirm it. That's a lousy boring process to go through. I hope this is the last bit of honing in on diagnosis you need to do, and proper treatments are found sharpish!
aardvarkoffnord From: aardvarkoffnord Date: 20th August 2008 00:21 (UTC) (Link)
I knew about the Bipolar spectrum for a while. However, I was very suprised to find recently that my diagnosis was being shifted towards the clinical depression end.

Ho hum.
(Deleted comment)
barakta From: barakta Date: 20th August 2008 08:32 (UTC) (Link)
erk the med switchover sounds like it could be rather horrid but maybe longer term this could result in you getting better overall treatment? I really hope so and keep fingers crossed.
From: skibbley Date: 20th August 2008 08:39 (UTC) (Link)
So how are you?
purplerabbits From: purplerabbits Date: 20th August 2008 08:55 (UTC) (Link)

still listening

I just quietly didn't increase my prozac dose when my GP told me to because a) it was the Evil GP of Doom and b) it makes me hear voices and get suicidal every single time I change dose.

I just wish Brane Drugs were more better...
emperor From: emperor Date: 20th August 2008 10:04 (UTC) (Link)
That does sound rather un-fun :( I hope the drug-fettling results in a happier you!
mjl From: mjl Date: 20th August 2008 14:35 (UTC) (Link)
Well, labelling all these things discretely seems to be pretty hard. Spectrums seem to make more sense in the cases of lots of illnesses and people-related things, if they can even be kept to points up and down a line rather than having extra dimensions to vary in... I suppose the important thing is how well the treatment plan deals with the set of symptoms of the individual.

Transitions like this do sound rather horrible... I hope it turns out to be as not-horrible as possible for you, and mostly that the new stuff actually improves things for you...
36 From: 36 Date: 20th August 2008 17:44 (UTC) (Link)
I'm sure having a more accurate diagnosis will be a positive in the long run, but you have my sympathies about having to switch over meds in the shorter term...
firecat From: firecat Date: 21st August 2008 01:36 (UTC) (Link)
Sympathy. I've been struggling for nine months trying to get a dose of brane meds that addresses all my issues. So far I've discovered I can ratchet down the dysthymia so I only don't enjoy things and don't also feel suicidal, and I can take care of the wanting to crawl out of my skin and the feeling like everyone has abandoned me. But addressing those things leaves me completely uninterested in any form of physical movement. Experiments are ongoing...
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