17 replies to this topic

[TheSpartanWoman]

Hi all! My appointment's today (feel free to discuss after as well) My pdoc isn't actually too knowledgeable on neurochemicals, etc. Scary.

I have: Bipolar II Disorder, Complex PTSD, ADHD, and some sensory problems (usually mood related). I've been taking Adderall IR 10mg (3x/day) for about 9 months, and I've been on Trileptal (Oxcarbazepine) 150mg (2x/day) for BPD Mood stabilization for a month now. I need to add an antidepressant, and possibly up both meds due to reduced duration of effectiveness on both.

I am considering an NDMA antagonist for both antidepressant effects and to protect against excitotoxicity. (DXM helps SO much with Adderall, and it works on this action. Found this out when I was sick a while back).

I'm mostly considering Lithium (not sure what form), and Memantine (Namenda).

QUESTIONS:

• If I go with Lithium or Memantine, should the Trileptal (mood stabilizer) be cut out as they both also stabilize mood?
• Which is "better"?
• Does Lithium also help with Adderall tolerance?
• What studies should I print to show my doctor?
• Anything else that might work better?

THANK YOU!!!!
____________________________
Please be kind. I may ask questions answered elsewhere.
I have a research addiction because I over-prepare due to PTSD and can spiral out of control. Please feel free to post links, but if you are able, please summarize for me. It may literally save me a day lost in my life.

[hooter]

You have bipolar and PTSD and they let you have amphetamines, you joking?

I would recommend you try tianeptine instead of adderall / lithium / memantine, it's an anti-depressant and mood elevating drug that improves ADHD and PTSD. Also, it's a nmda antagonist and a stimulant.

http://www.tianeptine.com/

. It is therefore relevant to note that tianeptine ameliorates symptoms in people with post-traumatic stress disorder (PTSD) [134] and in recent work has been shown to block the effects of intense stress on behavior and cardiovascular systems in an animal model of PTSD [212]. Thus, the well-described antidepressant and memory protective properties of tianeptine indicate that, in addition to its effectiveness as a treatment in mood disorders, it potentially has broader applications, as in the treatment of anxiety.

This preliminary study indicates that tianeptine might be a slightly effective beneficial and useful treatment for ADHD, reducing hyperactive behaviors and enabling greater attentional ability with minimal side effects.

Edited by hooter, 15 March 2013 - 09:34 AM.

[TheSpartanWoman]

Thanks Hooter!

Yes, they put me onto Adderall before the more recent bipolar rx, but kept the Adderall because I'm doing so well on it, cognitively. I was also in (I guess you could say) "remission" with my PTSD until I was triggered badly a few months ago, so my doc put me on celexa and I went all hypomanic and stopped sleeping. *There's* a sign for ya!

I actually tend to have more mood problems *off* of Adderall (this is confirmed by my husband, too). Quite probably because when I'm not medicated, the executive functions are quiet so not prioritizing/deleting incoming info, so I can get more PTSD flareups (Adderall alone stopped flashbacks). I've been able to externalize myself a lot more and that's been awesome. I also can be easily triggered into hypomania by my hyperactivity, especially if there are other people around. So there's that, too.

But yes, I'll definitely check out Tianeptine.

[Tom_]

Mentamine is a bad idea. No real evidence and most people report dosing problems and little positive effect.

Tianeptine is a good suggestion other than antidepressants shouldn't really be used in bipolar.

Your diagnosis seems a bit messy. Complex PTSD and Bipolar affective 2 (which cannot be diagnosied if your only hypomanic episode/s have been caused by antidepressant use?) could well be more of a borderline like disorder. Even more so if the manic episodes are short lived <2 days. Even if you don't have borderline symptomology it could simply be that your expression of the disorder is different while the cause is the same.

Would you describe your depressive symptoms as more like:

1. constant low mood, lack of energy, lack of appetite, disinterest, early awakening
2. mood low but can briefly improve, increased appetite (for carbs especially), difficulty getting to sleep, social anxiety and being sensitive to rejection

I would recommend a drug treatment something more like:

Omega 3 1 gram
lithium - antidepressive, antimanic
aripiprazole - antidepressive, antimanic, cylicing control, evidence in PTSD
pregabalin - mood stabilizing, potent anxiolytic

Unless you have been suffering from ADHD symptoms before the trauma its likely the 'ADHD' is part of the PTSD and stimulants are better left out. Especially when treating a bipolar disorder, even if they were present before I would try the above before using stims again.

[TheSpartanWoman]

No, I've had hypomanic episodes before I tried the antidepressant. My depressive symptoms usually manifest as #1 , however I don't wake early. I do get anxiety, but that's gone down with the stimulant and down again with the trileptal. But it's not generally social anxiety. I'm great with people, but I get anxiety when I feel "trapped" (PTSD) and when overwhelmed. I can get randomly awkward and nervous and my moods can cycle quite quickly at times, however.

I'm not sure where the beginning of the PTSD began and it could very well be just seen as Developmental Trauma Disorder. However, ADHD is is seen all throughout my family, as well as other mood disorders and a grandmother who is almost certainly on the autistic spectrum.

I went off of stims for a little bit this week to try just the mood stabilizer, in case it was able to correct ADHD symptoms alone. It didn't and I actually was in a fairly down state, but that could be a matter of if trileptal is the correct med/dose. Some of the ADHD symptoms that I have definitely effect my cognitive ability to regulate my own moods, usually independent from my pervasive underlying mood (ie: I can think my way out of being upset with some situation, by changing my viewpoint, physiology, etc. but I can't think my way out of an overall depressed or hypomanic mood-shift). So while on Adderall, I can see things more objectively and logically. Of course, that's just the effect I get from it and something else may be better.

From Dr Charles Parker's "The New ADHD Medication Rules":

Afternoon: Thinking to Depression-Feeling Shift The initial 'Stranger Appearance' becomes very whiny and fussy in the afternoon after the stimulant wears off. Moods can shift from "I don't care" to, "You hurt my feelings," and becoming inappropriately mad over slight, nonexistent insults. The angry/hurt shift int he afternoon is considered bipolar but often is not, as the depressed moods are revealed after using stimulant meds.

I do have this while on Adderall. It only happens when the stimulant is wearing off and usually only at night. It may have to do with the frustration of not being able to think clearly. My self-awareness reduces, and my external/sensory awareness goes haywire (sensitive). But if I re-dose I'm fine. I don't think it's normal withdrawal as I can wake up and not take the medication, and/or go for days without. This doesn't mean I *don't* have Bipolar or Borderline, especially as I had depressed episodes prior to Adderall (and more often), but before Adderall I didn't have the *type* of depressed mood that is described in Dr Parker's book.


Q: Isn't it that if you're Borderline, adding antidepressants would have a positive mood altering effect and not send someone into hypo/mania (as it would with Bipolar)?

[TheSpartanWoman]

As another note to my post above this... It's also quite possible that the PTSD has colored the type of depression that occurs, and that the ADHD colors the manic-ish moods. As yes, I have mood swings that last only a few hours at a time, so I'll definitely be bringing Borderline up to the doc. I'll have longer periods of time where I'll be depressed or happy more *often*... not sure if that changes anything.

(To give you an idea of how much I don't trust my doctor... in the session where he diagnosed me Bipolar II, he didn't ask how quickly I cycle)

Now... add to this that my hormones are ca-raa-zay to the point of PMDD (which, boys, is like... mega-PMS. horray...) and yeah... it's confusing.

[TheSpartanWoman]

ok. 3rd post in a row (HA!). I also feel better emotionally and cognitively when I have caffeine. However, I am wondering if that is aiding in my late-night irritable moods. Maybe upping too much glutamate? I've always had a sort of... shut-off time. Once it gets past 1:00 AM I snap over into someone else, no matter what time I woke that day. When I'm on adderall, I get irritable. When I'm not, I get crazy depressed. Depending on the day, I get hyper-focused (not dependent on Adderall).

[Tom_]

What you are describing to me seems like an usual presentation for bi-polar. Most bi-polar depressions present with an "atypical" presentation (number 2). PTSD is more likely to present with number 1's. PTSD can present with severe and sustained changes in affect as well as swift changes.

PTSD is highly comorbid with borderline traits to the point they can be indistinguishable. SSRI's can have some seriously negative effects in BPD and in PTSD(borderline personality disorder(BAD (bipolar affective disorder)).

Summed up in to a few words: your presentation is not the right type of depression, not long enough and to up down and left right to be a pure BAD disorder.

I am still uncomfortable with the idea of you on stimulants, although you have managed to convince me you likely to have some kind of attentional deficit - although its more likely mediated though the PTSD than being ADHD. If you could obtain guanfacine for example this might be a better way to manage the attentional problems and will regulate higher cognitive functions without causing tolerance, addiction and irritability or making your illness more severe in the long term.

A mood stabilizer hear is clearly going to be of primary importance. Lithium I think is your best choice. I also stand by the suggestion of aripiprazole. Combined its going to have an awesome kick.

An antidepressant due to bipolar like symptoms is just not going to be a good idea. Instead of pregabalin maybe guanfacine would be a good idea or atomoxetine.

Your hormones are gonna be fucked. PMDD is probably not a problem with you, rather hormones having a normal effect added on top of your already serious problems.

Omega 3, B complex, vit C and a multi vit is a good idea.

[TheSpartanWoman]

Thank you so much!! I've felt crazy alone in this...
I also found out (when I got there) that my appointment is actually for THIS Friday, not last (oops)! So I have a bit more time to formulate what I'll be talking to him about.

What you are describing to me seems like an usual presentation for bi-polar. Most bi-polar depressions present with an "atypical" presentation (number 2). PTSD is more likely to present with number 1's. PTSD can present with severe and sustained changes in affect as well as swift changes.

Totally. I am very sensitive to rejection (number 2) but that's also a symptom of BPD. I have difficulty getting to sleep, but I think that's more ADHD as I can sleep more easily when I am on Adderall (as I'm calmer and can shush my brain up more). Most issue with sleep is not actually GOING. I have problems with feeling I've done "enough" in a day. When I am emotionally charged at night: I stay up, upset. When I'm doing well cognitively/emotionally/etc: I stay up and try to "hold on" to it, too afraid to sleep, least I wake up and my confidence, momentum etc be gone. But I'm usually thought of as a "naturally" happy, grandiose-ish, talented, outgoing ADHD chick.... who has emotional problems and has been messed up. I'm kinda match all of Histrionic too... so... there's that..

PTSD is highly comorbid with borderline traits to the point they can be indistinguishable.
SSRI's can have some seriously negative effects in BPD and in PTSD(borderline personality disorder(BAD (bipolar affective disorder)).

Yeah. I guess "Complex PTSD" is now in the ICD-11, but here in the states they say "complex trauma", which is PTSD + dissociative and/or personality disorder/s.
Would it put someone into a hypo-manic state tho, if they did not have Bipolar? .... Maybe I have both BP2 & BPD??

Summed up in to a few words: your presentation is not the right type of depression, not long enough and to up down and left right to be a pure BAD disorder.

Exactly. My moods can change sometimes hourly if it's a bad enough day. And it's not JUST a manic to depressed scale. My other emotions swing too.

I am still uncomfortable with the idea of you on stimulants, although you have managed to convince me you likely to have some kind of attentional deficit - although its more likely mediated though the PTSD than being ADHD. If you could obtain guanfacine for example this might be a better way to manage the attentional problems and will regulate higher cognitive functions without causing tolerance, addiction and irritability or making your illness more severe in the long term.

Does guanfacine have effects on dopamine as well? From what I see, it says it might have a little effect on it. I ask because that's definitely been huge for me. With the increased dopamine from the Adderall, I'm able to more easily feel/celebrate my own accomplishments, have more positive emotional and physical effects from exercise, and have less generalized pain (due to dopamine's pain regulation actions). One of the first signs that the Addy's wearing off is that my knee will start hurting. I completely agree that that I want to make sure I don't get worse long-term. That's actually one reason I didn't run to L-Dopa, as I've heard that the body stops making Dopamine when supplemented directly in a far faster and greater way than from using a re-uptake inhibitor.

A mood stabilizer hear is clearly going to be of primary importance. Lithium I think is your best choice. I also stand by the suggestion of aripiprazole. Combined its going to have an awesome kick. An antidepressant due to bipolar like symptoms is just not going to be a good idea. Instead of pregabalin maybe guanfacine would be a good idea or atomoxetine.

Awesome. Do you suggest starting with Rx Lithium, or OTC? The Trileptal seems to be helping somewhat at this low dose for mood stabilization.

Your hormones are gonna be fucked. PMDD is probably not a problem with you, rather hormones having a normal effect added on top of your already serious problems.

OMG!! You're awesome. lol! and yeah. Makes total sense.

Omega 3, B complex, vit C and a multi vit is a good idea.

I've Fish Oil and Krill Oil, sub-lingual B12. Looking into getting a better muli than I use now. I have B complex and I'll usually either take one of those a day or a few of the Focus Factor I'm trying out (has a good amount of C and B vitamins). It is strange what works sometimes for my moods. Fish Oil, B complex, niacin, pregnenolone (which works amazing, usually), DHEA, iron, potassium, low carb, glucose tab, magnesium, choline, a mouth full of coconut oil.... ugh.. maybe I'm just incredibly sensitive to every little freaking thing.I *was* told to read "The Highly Sensitive Person" because as my last therapist said "your sensory system is ALL messed up, girl". (No therapist at the moment... no cash, insurance or job...)

I'll write another post with some more info on my Adderall experiences (in case that helps)...

Edited by TheSpartanWoman, 20 March 2013 - 11:12 AM.

[TheSpartanWoman]

Wow. That was a long post I did... and so... of course I feel bad now. =/ blrrg OK. here's part 2:

Improvements w/ Adderall: A lot more calm, can watch movies without talking all the way through (ha!), increase in self-awareness, decrease in inappropriate loudness, interrupting talking through people and inappropriate social behavior (I can actually hold a *conversation* now), all executive functions greatly increased esp Working Memory and Activation, ability to actually see people as "different people" and recognize their boundaries, ability to externalize self for observation, decrease in depression, anxiety, frustration, flashbacks (gone), and sexual problems (were hindered intensely by flashbacks and distractability), plus I can read better!

Issues w/ Adderall: Increased sensory sensitivity. Misophonia and general quiet-sound sensitivity (PTSD problem?) have increased, especially after using piracetam (too much glutamate?), anger (usually at night and when it's wearing off), emotional problems from dealing with certain positive effects above

Mixed stuff from Adderall: Awkwardness (I'm *aware* of when I feel/act awkward now. Husband says it's always happened, I was just not aware) this can lead to shutting down as I can see how strange I'm coming across, frustration comes back when I try to focus and am interrupted or when the medication is wearing off and I don't realize it (try to focus but can't very well), interests are more confused (possibly due to seeing myself as more independent so I can't rely on others as much (in a BPD way) to "create" my world for me), I still want to do EVERYTHING but now am painfully aware of the impossibility so this causes pain and triggers down moods (esp when combined with fear of cutting things out of my life and of making mistakes). Same thing for interests... I feel even more like I don't know what I want and again, could be because I feel more of my own person.

Trileptal (mood stabilizer/anti-epileptic): Seems to be working. Decreased sensitivity, highs and lows not as bad, can get sleepier at night, but get crazy sleepy sometimes during the day if no stimulants. More aware of my self-centered nature, and can ask people questions rather than just talk about me all the time... however doing so is still very difficult, painful and pushing down what I want to say is very hard and feels dis-genuine. But least I can see/do it now.

Edited by TheSpartanWoman, 20 March 2013 - 11:19 AM.

[TheSpartanWoman]

Hmmm... I wonder if the reaction I had to the SSRI due to the combination of the particular pill (Citalopram) PLUS Adderall in combination...

I have heard some sources say that if I actually do have Bipolar II, I would have had a similar reaction to SAM-e when I took it a few years ago, and I did not. Other sources say that it helps with Bipolar, so I'm not sure. But when I did take SAM-e , it seemed to help a great deal. Then again, I was also on a great diet and exercise program at the time as well.

Also very seriously looking at taking Pregnenolone on a more normal basis. I've been trying it out and 50mg sublingually seems to snap me right out of depression. This morning I was down and very tired and could feel the "helpless" feeling creeping in. 50mg later, and I'm quite happy and as sharp as a tack. Not sure how healthy it is to take daily for a person in her early 30s, but I'm looking into it.

[hooter]

I have ADHD and SSRIs gave me permanent damage and ruined my life, so proceed with caution. Preferably not at all with those...

http://www.psycholog...rdive-dysphoria

SSRIs cause lasting changes to dopamine transmission, which can SEVERELY worsen ADHD and bipolar illness: http://www.ncbi.nlm.nih.gov/pubmed/15323590

Edited by hooter, 22 March 2013 - 11:26 AM.

[brainslugged]

I have ADHD and SSRIs gave me permanent damage and ruined my life, so proceed with caution. Preferably not at all with those...

http://www.psycholog...rdive-dysphoria

SSRIs cause lasting changes to dopamine transmission, which can SEVERELY worsen ADHD and bipolar illness: http://www.ncbi.nlm....pubmed/15323590

And people think I am crazy when I say I would never take SSRIs because they cause brain damage. In my experiences, serotonin is poison. Of course, I guess some people need it, but it seems like it is pushed far too much as a "safe" drug. Certainly, it shouldn't be a first-line treatment IMHO.

Out of curiosity, do you know if there is any evidence to suggest that SSREs would reverse these changes, or if they would have positive effects on ADHD/BP? I can't find much on them except for this, but there are no real good sources.

[Tom_]

I rarely have met someone with BPD who I wouldn't also say is on the affective spectrum (symptoms of atypical depression and BAD 2 as well).

Pregnenolone is a bad idea both in long term impact on mental health and on somatic ("physical") health.

L-DOPA is a no no. re-regulation isn't worth it + no evidence base.

guanfacine has almost no effect

Another option is selegiline which will have similar effects to a stimulant as well as potent antidepressant effects with reduced chance of cycling/mania. I still urge you to try guanfacine first.

Lithium should be Rx.

Sorry i took a while to reply I was processing - I might have more to add in the next day or so.

Remember when you do decide on a course of action - stick with it. Other than the lithium which does need a while to start kicking everything should be tried for at least a month and a half. If it hasn't made any difference by then its likely not going to. If its made some difference it doesn't matter what your reason you come up with for coming off it (bar side effects) is telling you its clear you should be staying on it for 3 months,

[MrHappy]

Uridine stack should help here.

[Tom_]

What on earth would uridine do for her?!

[MrHappy]

What on earth would uridine do for her?!

It helps significantly with those issues. It's at the human clinical trial stage. Links in the main thread.

[MrHappy]

Link - http://www.longecity...ha/#entry478960