Fun Female Patient

[Zenman1]

I just picked up a 38-year-old female with H/O childhood emotional and physical abuse. Mood swings since teen years. She has been dx with Bipolar II disorder but I think she is Cyclothymic with seasonal pattern. She gets more depressed in fall and winter. She seems to only be slightly hypomanic with slightly less desire for sleep, no impulsive spending, hospitalizations, or legal problems. Just talks a little faster and with her hands, happier, gets more work done. When depressed just wants to isolate, has less motivation, passive SI, and carb cravings. Breaks out crying all the time. Never feels she stays at a normal stable mood.

She has experienced severe side effects with Paxil at 40 mg as well as severe discontinuation side effects, rendering her barely able to move. She goes up to 30 mg in the fall and winter and back to 20 mg in the spring and summer.

Also seems to have PDD and has been seen for many somatic complaints and reports her providers all think it's in her head. She did fractured her nose after lying face down on an inversion table then "shooting" herself into what I bet was a beautiful face plant, knocking herself out.

She is also on Lamictal 100 mg. I'm increasing that but was wondering about slowly weaning Paxil. She's been on it for about 18 years. Fun times ahead.

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[MLT2MT2DO]

I just picked up a 38-year-old female with H/O childhood emotional and physical abuse. Mood swings since teen years. She has been dx with Bipolar II disorder but I think she is Cyclothymic with seasonal pattern. She gets more depressed in fall and winter. She seems to only be slightly hypomanic with slightly less desire for sleep, no impulsive spending, hospitalizations, or legal problems. Just talks a little faster and with her hands, happier, gets more work done. When depressed just wants to isolate, has less motivation, passive SI, and carb cravings. Breaks out crying all the time. Never feels she stays at a normal stable mood.

She has experienced severe side effects with Paxil at 40 mg as well as severe discontinuation side effects, rendering her barely able to move. She goes up to 30 mg in the fall and winter and back to 20 mg in the spring and summer.

Also seems to have PDD and has been seen for many somatic complaints and reports her providers all think it's in her head. She did fractured her nose after lying face down on an inversion table then "shooting" herself into what I bet was a beautiful face plant, knocking herself out.

She is also on Lamictal 100 mg. I'm increasing that but was wondering about slowly weaning Paxil. She's been on it for about 18 years. Fun times ahead.

Any specific reason you aren't leaning towards Borderline?

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[Zenman1]

I always look for that in the background.

 

[SourceOfDenial]

Any specific reason you aren't leaning towards Borderline?

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Why not look at addressing the trauma and subsequent reactive behavior instead of jumping to dx with a PD?

 

[Zenman1]

I didn't jump to a PD dx, just consider it in most cases. I doubt it in this case with 18 year stable marriage, no self-harm, etc..

 

[splik]

the periods of depression would be too significant for a dx of cyclothymia. she just sounds bipolar spectrum disorder. i think you just wanted to make a cyclothymia dx since it's not something we diagnose much of because these patients dont tend to seek help.

 

[Doc1401]

I just picked up a 38-year-old female with H/O childhood emotional and physical abuse. Mood swings since teen years. She has been dx with Bipolar II disorder but I think she is Cyclothymic with seasonal pattern. She gets more depressed in fall and winter. She seems to only be slightly hypomanic with slightly less desire for sleep, no impulsive spending, hospitalizations, or legal problems. Just talks a little faster and with her hands, happier, gets more work done. When depressed just wants to isolate, has less motivation, passive SI, and carb cravings. Breaks out crying all the time. Never feels she stays at a normal stable mood.

She has experienced severe side effects with Paxil at 40 mg as well as severe discontinuation side effects, rendering her barely able to move. She goes up to 30 mg in the fall and winter and back to 20 mg in the spring and summer.

Also seems to have PDD and has been seen for many somatic complaints and reports her providers all think it's in her head. She did fractured her nose after lying face down on an inversion table then "shooting" herself into what I bet was a beautiful face plant, knocking herself out.

She is also on Lamictal 100 mg. I'm increasing that but was wondering about slowly weaning Paxil. She's been on it for about 18 years. Fun times ahead.

Sounds like borderline personality disorder to me. The trajectory is important. They can get married, often to a very passive / dependent husband. Self harm can take place in substance abuse, over eating, food restriction, and other ways as well. It does not have to be classical self cutting.

 

[Attending1985]

What has been your experience with disclosing borderline personality disorder? I am seeing an epidemic of young women diagnosed with bipolar disorder who seem to fit borderline personality disorder much better and are constantly attributing their behaviors and decisions to “mania.” They also seem to never make any lasting improvements. I don’t buy bipolar spectrum disorders. I think there’s a subset of individuals with very intense temperaments that predispose then to a host of relational problems but they don’t benefit significantly from medications.

I always bring up BPD
to these patients as a possibility. I encourage them to explore it with trusted friends or family and see if it fits. No one has had a negative reaction yet and for some it has lead to improvements. I know the language we use with patients and the labels we apply are very powerful so I try to careful and gentle in my discussing this while maintaining that I may not be right. I just feel it doesn’t serve the patient to think it but not share it with them but it seems like no one wants to tell the patient about a PD even if it’s written all over the chart. Wish they were called something else personality is so pejorative.

 

[Salpingo]

I just picked up a 38-year-old female with H/O childhood emotional and physical abuse. Mood swings since teen years. She has been dx with Bipolar II disorder but I think she is Cyclothymic with seasonal pattern. She gets more depressed in fall and winter. She seems to only be slightly hypomanic with slightly less desire for sleep, no impulsive spending, hospitalizations, or legal problems. Just talks a little faster and with her hands, happier, gets more work done. When depressed just wants to isolate, has less motivation, passive SI, and carb cravings. Breaks out crying all the time. Never feels she stays at a normal stable mood.

She has experienced severe side effects with Paxil at 40 mg as well as severe discontinuation side effects, rendering her barely able to move. She goes up to 30 mg in the fall and winter and back to 20 mg in the spring and summer.

Also seems to have PDD and has been seen for many somatic complaints and reports her providers all think it's in her head. She did fractured her nose after lying face down on an inversion table then "shooting" herself into what I bet was a beautiful face plant, knocking herself out.

She is also on Lamictal 100 mg. I'm increasing that but was wondering about slowly weaning Paxil. She's been on it for about 18 years. Fun times ahead.

Check out Groves “Taking Care of the Hateful Patient,” particularly the “dependent clinger.”

Following the counter-transference in this case — right now it sounds like there’s excitement building around a new, interesting case, with a cloying dread that things are going to fall faster than a 38 year-old down an inversion table. Sort of like opening a big box of donuts, excited by the possible flavors, but in the end realizing its more than anyone can stomach. That may explain her anxious/manic mental status, as she embarks on a new and novel relationship with you, giving you this extensive history in a short time.

So she may have a stable marriage (a little hard to imagine given her presentation), but it could be the unstable relationships are with the various treaters she presents to with somatic complaints, seeking comfort and reassurance and security but unable to find it for long. Is she able to find stable work, or is it jumping from one odd job to another?

But yeah, I feel like lamotrigine helps these patients gain some stability. Ultimately I find less is more, and much of the work is keeping the ship on a steady course without jumping to new medications or crazy combinations, keeping the goals of care reasonable and attainable.

 

[3lefts]

Sounds like borderline personality disorder to me. The trajectory is importaynt. They can get married, often to a very passive / dependent husband. Self harm can take place in substance abuse, over eating, food restriction, and other ways as well. It does not have to be classical self cutting.

Wow, seems like a pretty low threshold for considering someone borderline. I would argue it is more common than not for women to cope with certain types of stressors by over- or under-eating and by somaticizing. Borderline patients are just a small subset of those folks who get dysregulated and would benefit from therapy more than medication.

 

[enoughsaid12]

I just picked up a 38-year-old female with H/O childhood emotional and physical abuse. Mood swings since teen years. She has been dx with Bipolar II disorder but I think she is Cyclothymic with seasonal pattern. She gets more depressed in fall and winter. She seems to only be slightly hypomanic with slightly less desire for sleep, no impulsive spending, hospitalizations, or legal problems. Just talks a little faster and with her hands, happier, gets more work done. When depressed just wants to isolate, has less motivation, passive SI, and carb cravings. Breaks out crying all the time. Never feels she stays at a normal stable mood.

She has experienced severe side effects with Paxil at 40 mg as well as severe discontinuation side effects, rendering her barely able to move. She goes up to 30 mg in the fall and winter and back to 20 mg in the spring and summer.

Also seems to have PDD and has been seen for many somatic complaints and reports her providers all think it's in her head. She did fractured her nose after lying face down on an inversion table then "shooting" herself into what I bet was a beautiful face plant, knocking herself out.

She is also on Lamictal 100 mg. I'm increasing that but was wondering about slowly weaning Paxil. She's been on it for about 18 years. Fun times ahead.

Your diagnostic reasoning is more convuluted then the plot of inception. When your getting this complex in formulation of a diagnosis you got to step back and take a simple approach. Common things are common, as people have already suggested , her trauma history and mood swings yell personality disorder. But even simpler then that what about drug use ?

 

[Salpingo]

Wow, seems like a pretty low threshold for considering someone borderline. I would argue it is more common than not for women to cope with certain types of stressors by over- or under-eating and by somaticizing. Borderline patients are just a small subset of those folks who get dysregulated and would benefit from therapy more than medication.

Yes people (probably not just women) cope in less than ideal when under stress, but it sounds like this particular person has been under a chronic stress since childhood.

Never feels she stays at a normal stable mood.

I think the point is you wouldn't want to exclude the diagnosis just because there isn't any overt self-injury, but I agree you would need more information around self-image/identity, interpersonal functioning, etc. before making the diagnosis. But regardless, the consensus seems to be that the childhood trauma/mistreatment alone suggests she's going to need more than just medication (Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma)

I would point out that this thread seems to be generating some antagonistic and divergent opinions... or maybe the internet is just in a permanent split.

 

[3lefts]

Yes people (probably not just women)

I was gonna write something to that effect, but since the point was made even in the title of the thread that this patient is a female, I guess I found myself wanting to defend the experience of being a woman floundering in a stressful world as not by default a characterological issue. I do think we all agree that this patient could use some help with coping better though.

 

[Crayola227]

check out psycheducation.org

Dr. James Phelps is a practicing psychiatrist who does work around the topic of bipolar spectrum disorders. I do think it is a real clinical entity that can be treated with more than one modality, and he does a good job of citing a lot of research on the topic.

That said, I certainly think it's a great idea to strongly consider other dx including personality disorders.

I have seen it said that there is some overlap in sx and comorbidity of BPAD and BPD, and that both can actually respond to psychotherapeutic techniques like CBT, AND medications.

I think it is reasonable to take an approach to dx and tx of BPD if that seems best.

HOWEVER since I do believe in bipolar spectrum disorders, keeping in mind that we don't want to use medications where improvement could likely be placebo effect (ie we think the medications are doing something more), and considering that because of side effects we don't want to throw meds at someone when we're not sure we're getting more than placebo. Basically doing a cost/benefit analysis.

What I happen to think is a common-sense approach to psychiatry I have been taught by psych attendings, "the proof is in the pudding." Sometimes patients don't fit in to DSM or CPT dx categories, but you happen to find a medication regimen that provides good benefit. In that case the dx may not matter so much in the scheme of clinical improvement.

A history of trauma might support a dx of BPD or such. It is NOT a good reason to dismiss dx like cyclothymia or bipolar spectrum disorders.

TLDR:
going the BPD route and using non-pharmacological tx is great
I wouldn't write off bipolar spectrum disorders and
you can look at psycheducation.org Dr. Michael Phelps' work on the topic
I wouldn't write off the possibility of medications having a place in this
Trauma history and associated issues is common in many psychiatric conditions and is not terribly diagnostic

 

[Crayola227]

I agree that if you try reasonable pharmacological interventions for bipolar spectrum disorders (and the Phelps site gives some good evidence-based approaches) and don't get a good amount of response, then bipolar doesn't really fit. Because most bipolar will respond to meds, but you might have to try more than one thing.

Or perhaps, more controversially, you have hit on BPD that might have some medication-responsiveness. I know this is controversial but I know there have been some studies in this area.

Rheum frequently deals with this ambiguity in dx. Sometimes you don't know exactly what it is, you try meds, and what sticks sticks. If it doesn't than and move on to something else.

 

[Crayola227]

100 mg lamictal from what I know, is useless. You use doses in the 500-800 mg range for seizures, and 300 mg what was what I saw studied for effectiveness in bipolar depression.

As long as you go slow, I think it would be best to get that dose to at least 300 mg and reassess, unless you get improvement before then. Sounds like it isn't helping much at this point, but she's on too low a dose to determine you've had a significant medication trial.

I know providers who have pushed it to 600 mg for bipolar depression as that dose is safe for humans, if it is tolerated and helps.

SJS aside which is easily avoided with titration and patient education to monitor for rash, the main side effect is issues with equilibrium, and this is dose dependent. I hesitate in this patient with the face plant you mentioned. You didn't say what this was from - do you suspect that was from lamotrigine?

I know a patient that take their lamotrigine qHS, and fell like a tree in the forest heading for the bathroom in the middle of the night, swaggering like a sailor in the AM. Divided doses is a strategy for this, but daytime sedation can be an issue.

You also need to be sure this is a patient that will titrate safely, and that if they miss 3 days of meds with the half life of lamotrigine being what it is, they will need to retitrate almost from the beginning or risk SJS. I saw a patient that did this and got a very impressive and scary rash. There are a few papers that discuss lamotrigine rechallenge in these cases, but you're getting into dicey territory, and the authors recommended this only for patients for whom no other medication regimens would be effective, essentially patients backed into a corner for whom the cost/benefit analysis justified the risk.

I know that patient rechallenged and did fine.

 

[Crayola227]

I would really like to know what her full history of medications, response, and side effects she has.

Also if you think there is a seasonal component (and a lot of bipolar spectrum disorders can have this), I wonder if you could try light therapy. The Phelps site discusses this in detail.

There have been reports of hypomania or that type sx in bipolar spectrum disorders with light therapy, so monitoring and going low and slow relative to typical recommendations for SAD seems wise. And not to attempt that without a good mood stabilizer in place first.

Personally I don't like Paxil, it doesn't sound like she's getting a lot of benefit, is having side effects, and and if she's not on a good dose of mood stabilizer (100 mg of lamotrigine is a joke imho), could account for some of her negative symptoms.

A dysphoric sort of hypomania could account for some of the symptoms you mention, and her current medications could account for that.

If you really want to take an approach for some sort of bipolar spectrum disorder with prominent depressive symptoms and mood swings, I just wonder if a higher dose of lamotrigine, an approach for SAD with light therapy, and some DBT/other psychotherapeutic techniques might be a good approach in this patient. If d/c Paxil might help, and possibly try another agent once you see what if any benefit you get from a proper dose of mood stabilizer in lamotrigine.

I realize I'm going more down the bipolar spectrum disorder and medication pathway, but what could be suboptimal treatment of it doesn't seem to me to be a good reason to toss out the dx and assume a personality disorder. One can often get better with meds and the other typically doesn't much. Just sorta hate to miss it.

 

[Crayola227]

Maybe you guys can refresh me on the latest evidence for vitamin D and fish oil in mood.

I would tend to stick patients on both for a myriad number of reasons not always related to mood.
(I frequently cure chronic constipation with vitamin D).

 

[clausewitz2]

check out psycheducation.org

Dr. James Phelps is a practicing psychiatrist who does work around the topic of bipolar spectrum disorders. I do think it is a real clinical entity that can be treated with more than one modality, and he does a good job of citing a lot of research on the topic.

FTFY, unless the famous swimmer's post-Olympic career has taken a very strange turn.

 

[WingedOx]

My skepticism for bipolar spectrum as a thing that exists comes from the fact that it seems more than anything to be a way to retroactively come up a scientific rationale for psychiatry's tendency to throw mood stabilizers/atypicals at patients that have complex formulations.

 

[hamstergang]

100 mg lamictal from what I know, is useless. You use doses in the 500-800 mg range for seizures, and 300 mg what was what I saw studied for effectiveness in bipolar depression

Can you cite some sources? The ranges you list for bipolar disorder and seizures are above the FDA-approved maximums, so I'm suspicious. Not that the FDA is the final word on science, but it does take some justifications to go outside their guidelines.

 

[Neuro111]

i have seen patients with DID or PTSD with dissociative features who presents with bipolar like symptoms and bpd like personality. exploring those features, and addressing and exploring trauma may be worthwhile.

 

[Attending1985]

I think you can think of bipolar spectrum akin to calling someone with an avoidant or dependent personality as having a GAD spectrum disorder. They are harm avoidant, passive and have a low sense of efficacy and of course anxious but don’t quite fit with the discrete entity of GAD. They might get some benefit from an SSRIS but never fully recover and tend to stay stuck with medications only.

These people aren’t loud, intense and externalizing so they don’t get as much attention and tend to just drop out of treatment quietly. We don’t spend as much time thinking about them as bpd and bipolar spectrum folks.

It’s evident by these responses that a PD diagnosis evokes a lot of emotion not only in patients but in psychiatrists. Like how dare you jump to the awful notion that she has BPD. I think personality is much more malleable than we currently believe and the people we see know something is wrong that’s why they’re in our office. They deserve honest answers not to lie to them to protect them in some paternalistic way.

If the terms we’re using are offensive and not useful we need to change them to something that communicates without damning. That’s offers hope and a better way of understanding our problems. Personality is simply patterns of thoughts and behavior, our temperament combined with our environment. No one’s fault, not a condemnation. We all have personalities. We all have PD traits. We are not so different from our patients.

 

[Crayola227]

Can you cite some sources? The ranges you list for bipolar disorder and seizures are above the FDA-approved maximums, so I'm suspicious. Not that the FDA is the final word on science, but it does take some justifications to go outside their guidelines.

I am looking for the sources for dosing in BPAD.

I literally just got off the phone with a neurologist with whom I discussed dosing for seizures in adults, and I'm just going with their information on that since primarily we are not talking about treating seizures here, when my point was about what are generally safe doses overall.

They said that they regularly use 200 mg BID as just an introductory dose (after slow titration to try to prevent SJS), and that 600 mg total daily is not uncommon, and that 800 would be high, uncommon, but not unsafe. I'll see what other info on safe dosing I can find.

You mention FDA approved doses, do you think you are just as familar with dosing of lamictal for seizures as this neurologist is?

 

[MacDonaldTriad]

The original starter packs took you to 100mg BID, 50mg BID if on Depakote and 200mg BID if on Carbamazepine. The fixed does study I remember had a 50mg/day group and a 200mg / day group. The 200mg group got better faster, but both groups were the same by week 6. I'm not sure of the study design, but it takes 6 weeks to titrate so I think they called day 1 the first day after titration. At any rate, if anyone knows of a BPD fixed dose study that goes to 600 or 800mg, I would love to see it.

 

[Crayola227]

The original starter packs took you to 100mg BID, 50mg BID if on Depakote and 200mg BID if on Carbamazepine. The fixed does study I remember had a 50mg/day group and a 200mg / day group. The 200mg group got better faster, but both groups were the same by week 6. I'm not sure of the study design, but it takes 6 weeks to titrate so I think they called day 1 the first day after titration. At any rate, if anyone knows of a BPD fixed dose study that goes to 600 or 800mg, I would love to see it.

My point was never that one should take 800 mg daily for bipolar disorder. Just that it's silly to think 400 mg is an unsafe dose in bipolar when it is the introductory dose for seizures, and that neurologists will use even 500-800 mg.

I am still looking for the study that looked at 300 mg for BPAD, but perhaps I am wrong and the studied and recommended dose was 200 mg as you say.

I have regularly seen 300 or 400 mg of lamictal in bipolar patients, with good effect and well tolerated. That may not be FDA recommended but it is not a dangerous amount of lamictal. Of course I am not accounting for drug-drug interactions here.

I did just run across a paper that said 50 mg can be beneficial to sleep in BPAD, so I may be wrong that 100 mg is a useless dose.

I still think that if one isn't getting benefit it would be reasonable to increase that dose before deciding it was pointless, taking how well tolerated it is into account. And I would never say that increase should be to 800 mg. I said that 300 or 400 might be the place to get to, reassess efficacy, before deciding it was a treatment failure. That is all.

 

[MacDonaldTriad]

I agree with everything you say. I think someone should do the 300 - 400mg study. The truth is that we just don't have anything close to a dose response curve yet.

 

[hamstergang]

my point was about what are generally safe doses overall.
...
You mention FDA approved doses, do you think you are just as familar with dosing of lamictal for seizures as this neurologist is?

1) You were talking about more than just safety. You stated that 100mg was a "useless" dose and recommended going up to 300mg for efficacy reasons.

2) I think I am more familiar with Lamictal dosing than you, even if you just spoke with a neurologist on the phone. Your post didn't match what I thought to be true, and I only mentioned FDA guidelines to help demonstrate that some actual evidence was needed to support your claims.

 

[Crayola227]

1) You were talking about more than just safety. You stated that 100mg was a "useless" dose and recommended going up to 300mg for efficacy reasons.

2) I think I am more familiar with Lamictal dosing than you, even if you just spoke with a neurologist on the phone. Your post didn't match what I thought to be true, and I only mentioned FDA guidelines to help demonstrate that some actual evidence was needed to support your claims.

Interesting. I didn't know you treated epilepsy.

 

[Crayola227]

Lamotrigine - StatPearls - NCBI Bookshelf

 

[Crayola227]

StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2017 Jun-.

Lamotrigine
Nicholas T. Betchel; Abdolreza Saadabadi.

Author Information
Nicholas T. Betchel1; Abdolreza Saadabadi2.

1 Midwestern University- Glendale
2 Western University/ Kaweah Delta
Last Update: December 3, 2017.

For Bipolar I: Maintenance is 200 mg to 400 mg, with consideration given to medication given concurrently with lamotrigine.

 

[Crayola227]

For seizures:

If not being used concurrently with carbamazepine, phenytoin, phenobarbital, primidone, rifampin, lopinavir/ritonavir, atazanavir, ritonavir and valproic acid, dosing instructions are as follows. Initially, 25 mg should be given daily. At week three the dose should be increased to 50 mg daily. At week 5 increase by an additional 50 mg every week or every other week. Typical maintenance ranges from 225 mg to 375 mg to two divided doses.

Seems that my neurologist friend is rounding up to 25 mg, likely for easy of dosing.

 

[MacDonaldTriad]

None of their references include a bipolar study. Not sure where the 200 to 400 comes from.

 

[Crayola227]

Epilepsia. 2007 Jul;48(7):1292-302. Epub 2007 Jun 11.
An international multicenter randomized double-blind controlled trial of lamotrigine and sustained-release carbamazepine in the treatment of newly diagnosed epilepsy in the elderly.
Saetre E1, Perucca E, Isojärvi J, Gjerstad L; LAM 40089 Study Group.

Maximum studied dose in elderly over 65 yrs was 500 mg

 

[Crayola227]

I don't have access to paid databanks for papers. I'm just sharing what I've learned in training. I'm not a psychiatrist.

If you guys want to help me out by finding sources, I'd sure appreciate it. I'm doing the best with what I can access. If you have better access I'd love to see the papers too.

 

[Crayola227]

This is medscape and I don't see where the references are. I'll keep digging.

Lamictal, Lamictal XR (lamotrigine) dosing, indications, interactions, adverse effects, and more

Partial-Onset Seizures (Conversion to Monotherapy)

Taking valproic acid, conversion to immediate-release lamotrigine

• Initiate and titrate to lamotrigine dose of 200 mg/day, THEN
• Decrease valproic acid dose by 500 mg/day at intervals of 1 week or longer to valproic acid dose of 500 mg/day; maintain this dose for 1 week, THEN
• Increase lamotrigine dose to 300 mg while valproic acid is decreased to 250 mg/day; maintain this dose for 1 week, THEN
• Discontinue valproic acid
• Increase lamotrigine dose by 100 mg/day at weekly intervals to achieve a maintenance dose of 500 mg/day

CONCLUSION: in *some* patients (monotherapy partial onset seizures), 500 mg/day of lamotrigine is safe

Likely if I've seen neurologists give 600-800 mg doses it wasn't monotherapy. My bad.

 

[Zenman1]

the periods of depression would be too significant for a dx of cyclothymia. she just sounds bipolar spectrum disorder. i think you just wanted to make a cyclothymia dx since it's not something we diagnose much of because these patients dont tend to seek help.

The last time she was seen was 2 years ago for 2 visits and the only reason I saw her the other day was because primary care referred her for med management.

 

[Zenman1]

Sounds like borderline personality disorder to me. The trajectory is important. They can get married, often to a very passive / dependent husband. Self harm can take place in substance abuse, over eating, food restriction, and other ways as well. It does not have to be classical self cutting.

I haven't seen that yet but it's only been one visit. She's married to a combat arms Soldier so I bet he's not too passive.

 

[Zenman1]

What has been your experience with disclosing borderline personality disorder? I am seeing an epidemic of young women diagnosed with bipolar disorder who seem to fit borderline personality disorder much better and are constantly attributing their behaviors and decisions to “mania.” They also seem to never make any lasting improvements. I don’t buy bipolar spectrum disorders. I think there’s a subset of individuals with very intense temperaments that predispose then to a host of relational problems but they don’t benefit significantly from medications.

I always bring up BPD
to these patients as a possibility. I encourage them to explore it with trusted friends or family and see if it fits. No one has had a negative reaction yet and for some it has lead to improvements. I know the language we use with patients and the labels we apply are very powerful so I try to careful and gentle in my discussing this while maintaining that I may not be right. I just feel it doesn’t serve the patient to think it but not share it with them but it seems like no one wants to tell the patient about a PD even if it’s written all over the chart. Wish they were called something else personality is so pejorative.

I have some articles, off FB I think, that I hand out if I suspect BPD. I also ask them to share it with their friends for feedback. They usually come back with, "That's me!" One came back with, "That's me and my roommate!" Turns out I was treating both.

 

[WingedOx]

I haven't seen that yet but it's only been one visit. She's married to a combat arms Soldier so I bet he's not too passive.

Eh..... As a VA provider, let me warn you not to make assumptions on that front.

 

[Zenman1]

Check out Groves “Taking Care of the Hateful Patient,” particularly the “dependent clinger.”

Following the counter-transference in this case — right now it sounds like there’s excitement building around a new, interesting case, with a cloying dread that things are going to fall faster than a 38 year-old down an inversion table. Sort of like opening a big box of donuts, excited by the possible flavors, but in the end realizing its more than anyone can stomach. That may explain her anxious/manic mental status, as she embarks on a new and novel relationship with you, giving you this extensive history in a short time.

So she may have a stable marriage (a little hard to imagine given her presentation), but it could be the unstable relationships are with the various treaters she presents to with somatic complaints, seeking comfort and reassurance and security but unable to find it for long. Is she able to find stable work, or is it jumping from one odd job to another?

But yeah, I feel like lamotrigine helps these patients gain some stability. Ultimately I find less is more, and much of the work is keeping the ship on a steady course without jumping to new medications or crazy combinations, keeping the goals of care reasonable and attainable.

She has a stable job and a masters degree, which is required for her job.

 

[Zenman1]

Your diagnostic reasoning is more convuluted then the plot of inception. When your getting this complex in formulation of a diagnosis you got to step back and take a simple approach. Common things are common, as people have already suggested , her trauma history and mood swings yell personality disorder. But even simpler then that what about drug use ?

I usually look at whether mood swing occur due to triggers or not. The only triggers she has that I've identified so far are her menstrual cycle and seasonal changes. Well, she does break out crying for insignificant reasons, which is one thing that bothers her a great deal.

 

[Zenman1]

Yes people (probably not just women) cope in less than ideal when under stress, but it sounds like this particular person has been under a chronic stress since childhood. I think the point is you wouldn't want to exclude the diagnosis just because there isn't any overt self-injury, but I agree you would need more information around self-image/identity, interpersonal functioning, etc. before making the diagnosis. But regardless, the consensus seems to be that the childhood trauma/mistreatment alone suggests she's going to need more than just medication (Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma)

I would point out that this thread seems to be generating some antagonistic and divergent opinions... or maybe the internet is just in a permanent split.

I didn't mean to cause so much splitting! Nor be sexist. She is a fun female patient. I also have fun male patients...and today had a funny male patient married to a guy. I just have a fun time!

 

[Crayola227]

I tracked down the FDA data on lamictal.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020241s037s038,020764s030s031lbl.pdf

I'll put page number where you can check, otherwise I'll summarize.
page 9
Monotherapy for partial sz: transition from epileptics to 500 mg target dose.
(from multicenter, double-blind clinical trial enrolling 156 adult outpatients with partial seizures)

I'm not sure how crazy neurologists using up to 600-800 mg of lamictal for szs are, likely they are monitoring blood levels and response to treatment to guide going up that high.

page 13
Bipolar Disorder:
2 multicenter, double-blind, placebo-controlled studies in adults. Titrated to a target dose of 200 mg of LAMICTAL. 1,305 patients participating in the open-label. In Study 1, patients received double-blind monotherapy with LAMICTAL, 50 mg/day (n = 50), LAMICTAL 200 mg/day (n = 124), LAMICTAL 400 mg/day (n = 47), or placebo (n = 121). LAMICTAL (200- and 400-mg/day treatment groups combined) was superior to placebo in delaying the time to occurrence of a mood episode. Separate analyses of the 200 and 400 mg/day dose groups revealed no added benefit from the higher dose.
In Study 2, patients received double-blind monotherapy with LAMICTAL (100 to 400 mg/day, n = 59), or placebo (n = 70). LAMICTAL was superior to placebo in delaying time to occurrence of a mood episode.

It would seem that going up to 200 mg would be reasonable. 400 mg has not been proven to be superior, however it has been studied in bipolar disorder, does as well as 200 mg, and is safe. Not evidence based then to go up to 300 or 400 mg, but is not an unsafe dose. I propose if tolerated that some individuals might find benefit up to 400 mg, especially if you consider what drug-drug interactions they may have.

Since 200 mg was found to be as effective as 400 mg, it was not recommended to go past 400 mg. I know for a fact this is something that people do off label, it may not be supported by evidence, but it is NOT particularly unsafe nor an unstudied dosage, and I propose it may be something to try.

page 33 mentions 1,000 mg was use in patients on low dose valproate (which increases blood levels of lamictal) in the studies on side effects. I don't suggest this is a great dose, just pointing out that the ceiling on dosing is not low. I have ran across reports of fatality at 16 gm overdoses. I'll see if I can find the LD50.

Is this patient on oral contraceptives or HRT? Because apparently you may need to up the dose 2 fold.
"The effect of other hormonal contraceptive preparations or hormone replacement therapy on the pharmacokinetics of lamotrigine has not been systematically evaluated. It has been reported that ethinylestradiol, not progetogens, increased the clearance of lamotrigine up to 2-fold, and the progestin only pills had no effect on lamotrigine plasma levels."

 

[Zenman1]

100 mg lamictal from what I know, is useless. You use doses in the 500-800 mg range for seizures, and 300 mg what was what I saw studied for effectiveness in bipolar depression.

As long as you go slow, I think it would be best to get that dose to at least 300 mg and reassess, unless you get improvement before then. Sounds like it isn't helping much at this point, but she's on too low a dose to determine you've had a significant medication trial.

I know providers who have pushed it to 600 mg for bipolar depression as that dose is safe for humans, if it is tolerated and helps.

SJS aside which is easily avoided with titration and patient education to monitor for rash, the main side effect is issues with equilibrium, and this is dose dependent. I hesitate in this patient with the face plant you mentioned. You didn't say what this was from - do you suspect that was from lamotrigine?

I know a patient that take their lamotrigine qHS, and fell like a tree in the forest heading for the bathroom in the middle of the night, swaggering like a sailor in the AM. Divided doses is a strategy for this, but daytime sedation can be an issue.

You also need to be sure this is a patient that will titrate safely, and that if they miss 3 days of meds with the half life of lamotrigine being what it is, they will need to retitrate almost from the beginning or risk SJS. I saw a patient that did this and got a very impressive and scary rash. There are a few papers that discuss lamotrigine rechallenge in these cases, but you're getting into dicey territory, and the authors recommended this only for patients for whom no other medication regimens would be effective, essentially patients backed into a corner for whom the cost/benefit analysis justified the risk.

I know that patient rechallenged and did fine.

I strongly cautioned her about ever stopping Lamictal and then restarting without supervision and she said she had already been told that. Her BCP are also lowering effectiveness of Lamictal anyway, which is another reason I went up on the dose.

 

[Crayola227]

None of their references include a bipolar study. Not sure where the 200 to 400 comes from.

It seems that they got it from the lamictal leaflet.

 

[Zenman1]

I agree that if you try reasonable pharmacological interventions for bipolar spectrum disorders (and the Phelps site gives some good evidence-based approaches) and don't get a good amount of response, then bipolar doesn't really fit. Because most bipolar will respond to meds, but you might have to try more than one thing.

Or perhaps, more controversially, you have hit on BPD that might have some medication-responsiveness. I know this is controversial but I know there have been some studies in this area.

Rheum frequently deals with this ambiguity in dx. Sometimes you don't know exactly what it is, you try meds, and what sticks sticks. If it doesn't than and move on to something else.

I'm strongly considering a slow taper off Paxil once I get Lamictal up.

 

[Zenman1]

I would really like to know what her full history of medications, response, and side effects she has.

Also if you think there is a seasonal component (and a lot of bipolar spectrum disorders can have this), I wonder if you could try light therapy. The Phelps site discusses this in detail.

There have been reports of hypomania or that type sx in bipolar spectrum disorders with light therapy, so monitoring and going low and slow relative to typical recommendations for SAD seems wise. And not to attempt that without a good mood stabilizer in place first.

Personally I don't like Paxil, it doesn't sound like she's getting a lot of benefit, is having side effects, and and if she's not on a good dose of mood stabilizer (100 mg of lamotrigine is a joke imho), could account for some of her negative symptoms.

A dysphoric sort of hypomania could account for some of the symptoms you mention, and her current medications could account for that.

If you really want to take an approach for some sort of bipolar spectrum disorder with prominent depressive symptoms and mood swings, I just wonder if a higher dose of lamotrigine, an approach for SAD with light therapy, and some DBT/other psychotherapeutic techniques might be a good approach in this patient. If d/c Paxil might help, and possibly try another agent once you see what if any benefit you get from a proper dose of mood stabilizer in lamotrigine.

I realize I'm going more down the bipolar spectrum disorder and medication pathway, but what could be suboptimal treatment of it doesn't seem to me to be a good reason to toss out the dx and assume a personality disorder. One can often get better with meds and the other typically doesn't much. Just sorta hate to miss it.

Yeah!

 

[Crayola227]

1) You were talking about more than just safety. You stated that 100mg was a "useless" dose and recommended going up to 300mg for efficacy reasons.

2) I think I am more familiar with Lamictal dosing than you, even if you just spoke with a neurologist on the phone. Your post didn't match what I thought to be true, and I only mentioned FDA guidelines to help demonstrate that some actual evidence was needed to support your claims.

I think it helps that I just reviewed the FDA info on this. 200 not 100 mg was recommended for bipolar disorder. I did run across a study about 50 mg in sleep for bipolar disorder, so it would appear there may be some utility even in low doses. I apologize I didn't hold onto to that to cite for you. Maybe you can find it and share with the class.

I'm sorry if what a neurologist told me in dosing for szs was not what you are familiar with. They must be wrong since you are so familiar.

 

[675015]

I'm sorry if what a neurologist told me in dosing for szs was not what you are familiar with. They must be wrong since you are so familiar.

I think the confusion is that you initially said that 100 mg is "useless" and that one should get to 300 mg and reassess when discussing a bipolar spectrum case. When this was pointed out that this does not match many of our experiences or understanding of lamotrigine for bipolar, you changed your point to being about safety/tolerability and seizure disorders...