1 reply to this topic

[whiteelephant]

Hi all,

 

I wanted to post here to see if I could glean some collective wisdom.  I have a pretty healthy lifestyle, eat a good diet, run, and see a CBT therapist.  I have had persistent issues with a collection of anxiety/depression/attention issues since I was young.  Officially, I've been diagnosed as ADD/anxiety/depression.  But admittedly, my issues seem to supersede that.  I have tried a variety of attention/mood stabilizer and medicine combinations and nothing helps enough with my blend of issues.  I'm hoping to at least not get as overwhelmed and emotional during stressful/busy times so that I can focus on using emotional and procedural techniques. 

 

The main problem now is that while therapy helps, the problem is that I am not consistent enough over time.  Right now, I fall into slumps where even simple routines like brushing teeth or cleaning the dishes takes effort.  While some of the energy issues may originate from attention issues, I find that the fact my mood can shift depending on how much work I have ahead of me or the stressors of the week, and overcoming these mood hitches requires a lot of energy and keeps me from being in problem solving mode.  It is these mood issues that I have had some, but not enough success with, that I wanted to see if there are additional suggestions.

 

I'm not sure how to best characterize the mood issues to see what ways are most effective in the literature.  They resemble many different characterizations, but each has different ways of dealing with it successfully. In some ways, it seems that the mood issues resemble atypical depression.  In some ways it seems like it resembles elements of borderline personality disorder.  When I'm stressed is when the issues are most severe.  But it turns out that stress can even be induced by life decisions, I'm highly perfectionist and have high life standards, so can't contemplate decisions logistically without the emotional weight.

 

Are there any ways to try to figure out what different biochemical abnormalities to target that could help with my issues and help me leverage the therapy that I am already using and committed to?

 

Mood Regulation Targets:

 

MAOI-I know that atypical depression has elements of frustration tolerance that have been linked to successful treatment with MAOI inhibitors.  Haven't tried any.

 

Serotonin- I am on 40 mg of prozac.  This helps a bit, but I take more and get tired or manic. 

 

Gaba- I used to be on 400 mg tegretol.  This helped a tiny bit with not feeling as frustrated or emotional during tough times, but made me foggy and also in many more stressful moments, my thinking got clogged. 

 

Taurine-  Seemed slightly effective, but made me incredibly tired at higher doses.  Haven't tried it out during period of extreme stress.

NAC-

Other-My psychopharm put me on guanfacine once.  It seemed to help me reduce a lot of brain clutter that would come about with overwhelming tasks and stress.  But insurance doesn't cover it for adult ADHD and the generic Tenex didn't help as much, it only made me feel incredibly tired.

 

Choosing which targets to address:

My trial and error and assessment over the past has maybe been ineffective and i would be helpful if there were any clarity on parsing out my symptoms and which biol. mechanism to target.

 

 

[Tom_]

Atypical depression, while included in DSM-4 isn't a hugely well researched sub-type and is actually not correlated with response to MAOIs, just a better response than to TCA's. Flouxetine actually tended to perform as well as Phenlezine (all be it at a slightly higher dose (60mg)). MAOI's do have reasonable support in treating highly reistant depression, while they tend to only do as well as others in non-intractable depression. Also, you haven't really tried enough drugs (certainly not at high enough dosages) to recommend an MAOI. The side effects, dietry restrictions and drug interactions aren't really worth it, when there are plenty of other less unplesant options. Although it certainly shouldn't be ruled out in the long term.

 

Its certainly possibile you have some personality type pathology, although more than likely with a depressive/anxiety disorder (I'm not even going to get into the attention arena, until the depression and anxiety are in remission no firm diagnosis can be made either way)). Drugs CAN help improve symptoms but the mainstay of treatment should be medium-long term psychotherapy. Group analytic therapy can be very helpful for people to develop a better understanding of whether their problems have developed, how and in fact, what they are (rather than just having symptoms of the problem).

 

Solution focused approachs can be good in the short term for dealing with strong emotions. As can DBT approaches.

 

The gold standard for emotional regulation is DBT. Normally a full treatment isn't needed but mindfulness, going over incidents with a therapist and distraction technequies when struggling are excellent additions that can often be added without interupting ongoing CBT.

 

Practicing mindfulness daily would be a great addition to developing tolerance and greater emotional stability. Do a little research into it and you will find a wealth of information.

 

Meds wise, it may be best to increase the dose of Fluoxetine to 60mg (the dose is effective for depression and has some evidence for use in personality disorders at doses between 60-80mg). Despite the side effects. Its likely the least heavy side effect option. There is also a reasonable chance that given 2-6 weeks the sleepiness will ware off. Otherwise the best option is probs to treat the depression/anxiety with a standard algorthim driven approach. Since fluoxetine is having some effect even if its small its probs best to stick with it. The addition of an atypical antipsychotic is the most evidence based treatment for depression and also MAY increase emotional regulation. Quetiapine at 150-300mg XL is a good choice, although it will make you sleepy - although this tends to significantly reduce within a few weeks. Aripirpazole 5-15mg is the best tolerated and is well supported. Another possibility but much less well supported is a trial of Lamotragine 200-400mg and as such I wouldn't recommend it until you have tried one or more atypical antipsychotics (in combo with an antipsychotic) and calafornian rocket fuel (mirtazapine and venlafaxine).

 

 

 

 

 

 

 

 

Edited by Tom_, 21 May 2014 - 07:33 PM.