8 replies to this topic

[Tom_]

Hi all,

I'm from M&M (mind and muscle),

I am an 18 year old male with a history of severe and treatment resistant dysphoria, generalized, phobic and obessional anxiety, longstanding learning difficulties (dyslexia, dyspraxia, dyscalclia), long term attentional problems, repetitive moderate to severe self injury, childhood onset sleep disorder which includes hypersomnia and onset insomnia of up to 6 hours with central sleep apnoea, obesity. There are also signs of anhendonia or reactive affect (they seem to swap), increased or decreased apetite (seem to swap), occaional short lived paranoia or manic like disorders (never more than half a day), irritability, Suicidal Idealtion, psychomotor retardation or agitation and as mentioned treatment resistance; two plus years. reucccrence is a problem multible episodes at least 5.

I am currently on:
Agomelatine 50mg at night started about 2 months ago
buspirone 5mg t.i.d started about a week ago
melatonin 3mg at night
clonazpam 1mg t.i.d PRN

I have tried in varing combnations:
Sertraline
citalopram
methylphenidate
quethiapine
mirtazapine
lamotragrine
escitlopram
airipriazol
DLPA
sulbutramine
L tryosine
NAC
omega 3
and others I can't recall I'm sure. All to very little effect.

I am with a mental health team and on occation have been hospitalized, only this last episode (3 years) has gone treated due to severity/bucking up and seeking treatment. I continue to work with therapists, psychotherapy, self help technquies and behavioural activation all to no avail.

Feel free to ask any other questions you might feel nessary. There are plenty of things I have tried that I can't currently recall so if I seem to be rejecting your ideas out of hand that isn't the case.

Any and all advice welcome guys,

thanks

Tom

[jadamgo]

Well, it sounds like Emotionally Unstable Personality Disorder (aka Borderline Personality Disorder). I hate to offer such a stigmatizing diagnosis; this condition has a somewhat unfair reputation for being harder to treat than it actually is. You also describe chronic sleep problems and cognitive difficulties. Some of these problems are probably part of the same problem as the emotional dysregulation, but they may also have their own causes. (Sleep apnea and learning disorders don't usually go hand in hand with the affective disorders spectrum, though all the other troubles you mentioned are commonly associated with EUPD.)

Things that help: Dialectical Behavior Therapy. Not "DBT-based" therapy or "DBT-inspired" therapy -- I mean the real deal. Weekly individual psychotherapy with someone trained in dialectical behavior therapy AND ongoing participation in a DBT skills training group. All I can say is that it works, eventually. Sometimes you have to stick with it for several months, perhaps even an entire cycle of skills training before it starts working, but sooner or later you'll find the keys you've been looking for.

Bright Light Therapy: Since you mentioned "hypersomnia and onset insomnia" (which implies a Circadian Rhythm Disorder like DSPS or insufficient circadian amplitude), you're highly likely to respond to bright light therapy for at least the sleep problems, and very possibly also the depression.

You've already gone through several mood stabilizers, SSRIs, and atypical antidepressants. From the pharmacological standpoint, here are the next logical steps to try:

SNRIs (venlafaxine, duloxetine, or milnacipran)
Wellbutrin, especially in combination with a calming antidepressant
Tricyclic antidepressants (try at least 3 because there are many TCAs that are very different from one another, and treatment non-response with one doesn't imply non-response to a different one)
MAO Inhibitors: in your case, phenelzine would be the first one to try, followed by tranylcypromine if that doesn't work. You'd have to quit the buspirone in order to take an MAOI, and if your psychiatrist is cautious, they might pull you off all other antidepressants. That's fine -- MAOIs are very very strong, and if you have the clonazepam to help you with anxiety and insomnia, you might find a winning combination.

Also worth considering if you find an antidepressant that helps somewhat, but doesn't totally make you normal (which will definitely happen):
Lithium augmentation: low-dose lithium can sometimes break through treatment resistance when it's added to a strong tricyclic antidepressant, MAOI, or atypical antidepressant.
Valproate augmentation: same as lithium, you can add a low-dose valproate drug to a partially effective antidepressant to break through treatment resistance.

Questions?

[Tom_]

I have to say I agree with you - or at the least I am on my way to developing BPD/EUPD, my last psychiatrist describing me as being in a psychological rut thats spiraling out of control (at risk of personality disorder) as well as a moderate depressive episode (other disorders are going undiagnosised as they are as I've met him once and spent half of the meeting in a haze). I don't have access to DBT (a DBT skills group is another thing altogether - focused on affective regulation).

psychosocial treatments being put into place for/with me are:
intensively supported behavioural activation - including regular cardio (may start weights soon), volunteer work, maybe payed work...etc
self based mindfulness study & attending weekly mindfulness classes at the local buddist center
either an analytical therapy, CBT or your favouiate DBT-like therapy. They seem keen to have me in analytical therapy, I think to maintain and increase awareness - they were clear the main reason for no formal personality diagnosis was awareness

biologically based - you have seen my meds
the psychiatrist (a leading CAT therapist and in general highly skilled therapist I am assured) isn't the person I'd be hoping to lead my medication. He is determined to follow as slowly as possible TRD algorthisms. Ususally a choice I would support other than his insistance any medication started unless needed to be axed because of side effects must be trialed for three months regardless of earlier response rate. I seriously doubt he will be willing to try a TCA or MAOI (which is what I think is both clinically warrented and the most evidence based progression) next.

I would like to see myself on in no order

amitriptyline + lithium + PRN research shown most potent AD with every study I've ever read having a 100% response rate (I take with a pinch of salt)

or

moclobemide (evidence of improved cogntitive function) + PRN +...

or (both of these have fairly manageable side effects although are no safer in combo than an irriversable MAOI)

selegiline (would almost certainly help with attentional/motavational) + PRN +...

I would then consider an irrivesable MAOI.

I intend but never seem to get round to instagating bright light therapy

I would like to carry on with melatonin supplementation as I agree there is a circadian rythem disorder.

While my medication suggestions do differ I think they both seem to land along the acceptance that I am on the affective disorder spectrum (atypical MDD, Bipolar type 2, EUPD) and we are also in agreement of which classes would be most useful. MAOI's having the clear advantage followed by TCA's and mood stabilzers. Am I right in you thinking this? Do you have anything else to add?

and thank you

[jadamgo]

I have to say I agree with you - or at the least I am on my way to developing BPD/EUPD, my last psychiatrist describing me as being in a psychological rut thats spiraling out of control (at risk of personality disorder) as well as a moderate depressive episode (other disorders are going undiagnosised as they are as I've met him once and spent half of the meeting in a haze). I don't have access to DBT (a DBT skills group is another thing altogether - focused on affective regulation).

psychosocial treatments being put into place for/with me are:
intensively supported behavioural activation - including regular cardio (may start weights soon), volunteer work, maybe payed work...etc
self based mindfulness study & attending weekly mindfulness classes at the local buddist center
either an analytical therapy, CBT or your favouiate DBT-like therapy. They seem keen to have me in analytical therapy, I think to maintain and increase awareness - they were clear the main reason for no formal personality diagnosis was awareness

biologically based - you have seen my meds
the psychiatrist (a leading CAT therapist and in general highly skilled therapist I am assured) isn't the person I'd be hoping to lead my medication. He is determined to follow as slowly as possible TRD algorthisms. Ususally a choice I would support other than his insistance any medication started unless needed to be axed because of side effects must be trialed for three months regardless of earlier response rate. I seriously doubt he will be willing to try a TCA or MAOI (which is what I think is both clinically warrented and the most evidence based progression) next.

I would like to see myself on in no order

amitriptyline + lithium + PRN research shown most potent AD with every study I've ever read having a 100% response rate (I take with a pinch of salt)

or

moclobemide (evidence of improved cogntitive function) + PRN +...

or (both of these have fairly manageable side effects although are no safer in combo than an irriversable MAOI)

selegiline (would almost certainly help with attentional/motavational) + PRN +...

I would then consider an irrivesable MAOI.

I intend but never seem to get round to instagating bright light therapy

I would like to carry on with melatonin supplementation as I agree there is a circadian rythem disorder.

While my medication suggestions do differ I think they both seem to land along the acceptance that I am on the affective disorder spectrum (atypical MDD, Bipolar type 2, EUPD) and we are also in agreement of which classes would be most useful. MAOI's having the clear advantage followed by TCA's and mood stabilzers. Am I right in you thinking this? Do you have anything else to add?

and thank you

Oh, CAT should be great, it's one of the few therapies other than DBT shown to improve EUPD symptoms. That, together with behavioral activation and mindfulness training, should be an excellent psychotherapy plan.

As for the pharmacological issue... that kind of sucks. Is your psychiatrist also conducting cognitive analytic therapy with you? If so, perhaps putting up with the slow TRD algorithm might be worth it to get time with someone on the leading edge of an empirically supported therapy. ... IF and only if you get along well with him during therapy. If you don't like the guy, it won't matter what his credentials are, you would have to get someone else to do the therapy and at that point you might as well switch your medication management to someone else.

As for mood stabilizers, I still think it's a great idea to try low-dose stabilizers as antidepressant augmentation. But I definitely don't recommend mood stabilizer monotherapy unless you're showing clear and obvious bipolarity that can't possibly be interpreted as a manifestation of the EUPD. None of that "chronic mixed episode" crap -- I mean dramatically visible (hypo)manic episodes that are well-defined and separated from major depressive episodes.

The strongest pharmacological treatment responses in the clinical literature are for amitriptyline+lithium, nortriptyline+lithium, and MAOI+lithium. What algorithm is he using that doesn't eventually end up at one of those options? Both STAR*D and TMAP eventually end up with TCA or MAOI treatment, and TMAP suggests trying lithium augmentation every step along the way if there's a partial response. Has he told you which algorithm he's going by?

[Tom_]

No I had a session of CAT with a clinical psychologist and it was decided it wouldn't be useful for me after 16 weeks. If I'm entered for an anlytical therapy it will be full blown medium-long term psychodynamic. Plus unless you are paying in the UK no psychiatrist has the time to provide psychotherapy themselves, any psychotheraputically trained psychiatrist (either via Msc/pg Dip etc or via three years consultancy training in psychotherapy) will spend most of there time in supervision, training and research.

I think its safe at this point to accept stabilizers (baring lithium which could almost be its own class) can't do much for me having given Quithiapine, lamotragine, pregabalin (not so much), arirpriazol and NAC a fair try. Between three months and a year on each bar the pregabalin.

I think he is following STAR*D, sorry I wasn't very clear at total treatment resistance I imagine he will be willing to prescribe the ususal combo of TCA/MAOI + lithium but I can forsee that being between 1 and 2 years before he deems it nessary. Then again he is using the Mauldesy prescribing book which could mean hes just picking and choosing any group of studies he likes the look off at the time mixed with 'clinical experiance'.

I expect he will first want me to try multible SNRIs, Wellbutrin, multible TCA monotherapies (You may think thats a good idea, i'm gunning for rational polypharmacy here) all of these being given 3 month trials regardless of treatment response within the first 6-8 weeks. He also likes to up doses once monthly.

Atypical depression, Bipolar 2 and EUPD all respond best to MAOI's and the last two to mood stabilzers. There is clear treatment resistance to multible modes of action, I'm not suffering from just a depressive episode and the TRD algorthims focus on only unipolar depressive episodes so he should be prescribing differently. He has drawn a nice little line between the depression and my 'psychological rut' (as he described it) when both contain biopsychosocial componets. Oh and he also mentioned T3..I have smack bang normal thyoid function.

Sorry I'm ranting, I'm pissed off, not at you even if it seems i'm going off on one at you.

[jadamgo]

I'm not taking any offense; it doesn't seem like you're pissed off at me. It's pretty clear that you're upset about getting suboptimal healthcare, as any perceptive person would be.

As for the psychotherapy, psychodynamic therapy is a crapshoot. If you have a good therapist and develop a good working relationship with them, it usually works fine. It may take longer than the more modern therapies, but it can get the job done, especially when personality disruption is one of the main concerns. (The psychodynamicists did, after all, invent the concept of disordered personality.)

But if you don't have a skilled therapist whom you like... you may have to switch. I'm not familiar enough with NHS policies to advise you on how that might work; you probably know more than I do.

The whole "multiple SNRIs, Wellbutrin, multiple TCA monotherapies" thing is more cautious than I would be, but that's because I don't believe "biological MDD and also a separate psychological rut" is proven to be the best way of looking at your situation. It's certainly not indefensible, and the guy has way more experience and training than I do, so take that for what it's worth. I just usually see this sort of thing as going together more than being apart in most cases.

It's true that the evidence supports a cautious strategy like STAR*D for the more classic varieties of MDD, but the EUPD literature hints that you might as well go straight to the MAOIs if (Es)Citalopram and Venlafaxine don't work. Then again, most of the EUPD literature says time and high-quality psychotherapy are the most important things, since we don't yet have great treatments for the biological side of it yet.

Unless, that is, unless you could be coaxed into actually trying that bright light therapy...

[Tom_]

An update:

Ordered 10,000 lux light box - be here on monday. Taking 3mg melatonin at night, planning possibley on buy extra 1mg tabs and taking them an hour before nightfall. Hoping to treat the circadian rhythem disorder more effectively and treat depressive symptoms.

Still on Agomelatine 50mg, stopped the busirpone.

I have ordered nooept and Pramiracetam with alpha GPC. Planning on spending a month on them - my psychiatrist/mental health team are understandabley displeased with my participation in behavioural activation.

I am hoping this is going to improve motivation and help me engage more effectively with behavioual activation, mindfulness and the like.

In regards to my psychiatrists appointment, the NHS is split into trusts, about 45 mental health (or foundation) trusts, my trust has one of the leading (Psycho)pharmacists (non-clinical pharmacist) on tap and I will be meeting with him before my next appointment about 5 weeks away to discuss and develop a personalized treatment algorithm for the next 1 to 2 years.

I am planning once I stop the Agomelatine next month to try if its agreeable to them:

Possibly Venlafaxine first although its not a convincing idea with possible argumentation with Li+/wellbutrin/mood stabilizer

Monotherapy with MAOI -A/B (Moclobemide or selegiline)
no response: switch to Moclobemide or selegiline partial response add Li+
no response: switch to Tranylcypromine
no response: switch to Amitriptyline partial response add Li+
no response: switch to Clomipramine partial response add Li+
no response: MAOI + TCA partial response add Li+
no response: AMPHETAMINE & ELECTRICAL SHIT TIME :D
no response: psychonaut time with K/analog, psychedelics etc
no response: psychosurgery - like i could get hold of it :L
no response: I'm not going to get better

Where ever there is partial response determined by 6-8 weeks after monotherapy and then lithium fails before moving on to the next stage I would like to leave time to try anything else that takes my fancy such as; retrial of Aripiprazole, Topimate, Volporic acid, SSRI argumentation, SNRI trials and wellbutrin etc.. The idea would be that I end up on no more than three meds at a time: original monotherapy + lithium + second argumentation (for example ariprirazol)

[jadamgo]

Good strategy; laundry lists of medication aren't generally helpful so limiting it to only one major antidepressant + lithium and augmentation is a good idea.

As for the TCAs, amitriptyline is a good choice, but I wouldn't really suggest clomipramine because it's basically a dirty SSRI. It's mostly used in veterinary medicine nowadays, and only because it's so old that it's cheaper than the real SSRIs. Nortriptyline, desipramine, and the tetracyclics amoxapine and oxaprotiline are worth looking into.

Venlafaxine can work pretty well. If it kind of helps but isn't that great, you might try milnacipran before messing with MAOIs and TCAs.

EDIT: Added the TeCAs.

Edited by jadamgo, 10 April 2013 - 01:44 AM.

[Tom_]

Update:

Still alive and still taking the Agomelatine at 50mg and melatonin at 3mg and clonazapam 1mg TID PRN (taken maybe 3 doses in the last three weeks).

I've started bright light therapy but haven't managed to use it consistently yet for more than 4 days. I'll be using a timer to set it light up about an hour before I want to be up.

My self harm has decreased significantly although my suicidal idealation is much more prominent, my mood is not all that low, I am very irritable almost to the point of aggression (I haven't and can't ever see myself crossing that line), my hypersomnia is fairly severe (sleeping 12 hours a night) with some fatigue during the day, without medication night somnolence doesn't appear until 3-5 in the morning, I am somewhat anhedonic but there is still significant affective tone and I can laugh and have fun. I'm not massively tearful but more than I have been. My mood is somewhat blunted.

I'm about to be starting CPAP therapy and have ordered some modafinil (will be started 200mg and will fiddle with both lower and higher doses to see what happens) with the hopes of helping to improve the sleep disorder, depressive/cognitive problems and provide more energy for behavioral activation.

I am having this appointment with the pharmacist in about a week and the appointment with the psychiatrist in about three weeks. I'm actually thinking more and more about staying on the Agomelatine for up to 5 months. I'm considering along side the modafinil adding in vanlafaxine, bupropion, Topiramate, Valproic acid and/or Li+ (this would be the last treatment before I start trying the 'heavy duties' TCAs, MAOI's etc...

I might have a pharm treatment something like:

Agomelatine, modafinil, vanlafaxine and or topiramte/valproic acid/Li+, melatonin.

I know its more than the maximum three I was considering but I think its a viable option as they all have different and interesting methods of action.