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Old 04-04-2013, 01:07 PM   #1
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Brand new Suspected Diagnosis of Bipolar II ("Soft" Bipolar)

In the past 72 hours I was just told I have possible undiagnosed Bipolar II (Soft Bipolar) by my psych and I was litterally shocked, terrified, angry, and depressed all mixed together. Other than schizophrenia and dillirium spectrum disorders, Bipolar was the one mental disorder I truely feared - and I didn't even know Bipolar existed outside Bipolar I. I have previously suffered from anxiety, panic, depression, chronic pain, ADHD, and a few other less notable things (all of which are current issues I continue dealing with). My pain is actually what caused me to find these boards and why I joined, though it has since been fairly effectively brought under control by my anesthesia pdoc who continues to manage it as agressively as warranted so far. As for mental disorders, I was diagosed with Anxiety & Panic disorder as a teen after a new onset panic attack while waiting in my PCP's office for a check up; then a few years later had a major depressive episode he also diagnosed. The depression began to cycle, though even when symptomatic I could more often than not at least function enough to get by (or so I thought). I was treated for years for comorbid depression and anxiety with varying combinations of SSRIs (Paxil, Zoloft, Celexa), SNRIs (Cymbalta), DNRIs (Wellbutrin), Tricyclics (Elavil / amitriptyline), Tetracyclics (Remeron / mirtazepine), Benzodiazepines (Xanax, Valium, Klonopin) and I specifically discounted Bipolar as a potential diagnosis because I never remembered a manic episode (didn't know about hypomania). Yet a few more years later I was treated for Adult ADHD with Adderall (I had been suspected of it as a kid but my parents refused to put me on stimulants, a move I praise them for), which coincided within 12 months of my progressive injury and chronic pain onset. Affecting several systems, the neurogenic component of the pain is treated with Neurontin 900mg TID, everything else with MS Contin 120mg BID and Norco 10/325 PRN (max 2 / 4H or 8 / 24H). At least, that's the current dose, but opioids of some type plus often a gabapentinoid since the onset.

All the psychotropic meds I take plus the draining qualities of chronic pain clouded an idea of my baseline mental condition in a state without acute or chronic distress, so the diagnostic ability and treatment of my former psych was largely based on history and observing progression with knowledge that my mentation was to some extent altered by the opioids, benzos, antidepressants, and stimulants. I accepted it at face value, no reason to doubt it, and then after recently starting to see my new psych it was all turned upside down. He did a comprehensive screen and assesment, took both a 1 hour phone history before my first appointment at no charge or obligation, then continued from there at our first meeting digging more with the screening profiles - all of course with knowledge of my psychotropic use).

The flag (to the best I can tell) causing suspicion of Bipolar II was a combination of the cyclic depression, situations of mild-moderate hypomania as a kid and since my teens more subtle episodes, the ADHD thing (potential hypomania misdiagnosed), and a few others maybe. After my denial of hypomania, he explained the definnition and suddenly I saw that many of the experiences I had related could be called as such. Still not wanting it to be true I asked why I had a primary anxiety disorder if Bipolar II was in his differential diagnoses (I thought they couldn't occur comorbidly), and he explained it is actually fairly common. He reinforced that although it was his suspicion, he also had to consider the complex pharmacology between all the psychotropics I am on while considering a differential, so no conclusive diagnosis could be made immediately or easily. Additionally, the oppressive effects of the pain, even treated (it never goes away it only fades some), could serve to mask some aspects of hypomania via simple physiologic overload. Once when I had a near total epidural block at the mid thoracic level, the pain was minimal for a short time ( < 90 hours), and as the systemic meds were metabolized mostly, I experienced a fairly intense hypomanic state (near manic but not) for about 36 - 48 hours from no known etiology. Either 1) I was so jazzed to be 90% pain free without narcotics/adjuvants that I was on a natural endorphine rush, or 2) I was experiencing emerging fully symptomatic conditions of underlying Bipolar II in hypomanic state. That said, the history of symptoms prior to when most pharm therapy was started pointed to Bipolar II.

Without conclusive evidence, I ended up back on similar therapy as before I saw him, however using a modified regimen of antidepressants. He didn't want to start "mood stabilizing" agents including atypical antipsychotics just yet (being intimately familiar with physiology and pharmacology myself, we had long discussions about all the pharmacotherapy available and pro/con of each). He thought my hypomania in recent years probably was suppressed by the Neurontin and other meds I was on, leading to atypical cycling with brief or un recognized hypomania and universally altered cycle state perception compared to those normally seen - regardless which I was in. Some of his rationale was that firstly, he disputed sufficient evidence exists that most so called mood stabilizers actually perform in that regard better than placebo when in controlled trial. As for the antiepileptics, he cited a mass movement by psychiatric practices over the last 20 years to embrace almost any new antiepileptic as also having mood stabilizing properties after early reports showing Lamictal had promise in the role, snowballing even more when it was FDA approved for the purpose. Just because one antiepileptic seems to work somewhat in Bipolar doesn't mean all of them do (or even any of the others), stating it would be like treating Bipolar with Dilantin (another very common and core principal antiepileptic introduced before the Lamictal craze) which caused me to immediately laugh in earnest due to the obserdity of the idea (considering the pharmacology of Dilantin). As for atypical antipsychotics, his preference (best to worst as far as benefit vs harm) was Geodon, with Seroquel, Risperdal, Zyprexa, Clozaril (not advised) and others following with rapidly decreasing preference.

I have a history of predisposition to Akathisia following a single small dose of prochlorperazine (Compazine) for nausea - it's a typical antipsychotic phenothiazine about 15X more potent per unit weight than Thorazine. This was repeatable all 3 times I took it. For anyone unfamiliar, Akathisia (AKA the Thorazine Shuffle) is without a doubt the most hated and evil side effect I have ever experienced from anything, consisting of a constant need to move, walk, pace, etc while extreme and complete dysphoria and discomfort seizes you, followed immediately (less than 1 minute) by a need to sit or lie back, no sooner of which (less than 20 seconds) needing to get back up and move - an endlessly repeating cycle lasting over 18 hours the first time I experienced it. Researching my symptoms I put a name to it, and found that it is often treated in the ER with dyphenhydramine (Benadryl) and sometimes a Benzo like Ativan/Valium/Klonopin. Loading up on Benadryl and taking my next 2 doses of Klonopin thankfully aborted this torture. Took Compazine a second time for the nausea a few days later, experienced the first signs of Akathisia again and figured maybe the neuroleptic sedative properties of Compazine would help (after all, Benadryl and Klonopin are sedatives too) so I took 1 more to head it off. WRONG! I wen't into massive Akathesia distress while realizing I couldn't tolerate Compazine under any circumstances, loaded up again on Benadryl and Klonopin, and still almost went to the ER for an IV bolus of Ativan or Valium to immediately terminate the episode it was so unbearable.

Even though atypicals are not phenothiazines/typical antipsychotics/neuroleptics, they share a similar (if less common) extrapyramidal side effect profile with phenothiazines / typical agents - enough that my history/predisposition to Akathisia, the risk of Tardive Diskinesia and Neuroleptic Malignant Syndrome (NMS), plus potential serious metabolic disturbances had both my psych and I in strong support of avoiding the class unless a 4th or 5th line of meds helped and clear indication for directed Bipolar therapy was present.

The longstanding Neurontin, while not shown in doubleblind studies to be superior to placebo in mood stabilization, *does* supress manic or hypomanic tendencies for me when I look back in retrospect *IF* I maintain a steady state plasma level. While on a drug holiday from Neurontin or between having it prescribed (I was off it for awhile), I have had hypomanic states resulting from Wellbutrin and SSRIs that I know of (I just didn't know what was going on at the time). Due to poor tolleration of SSRIs and to avoid SNRIs, Wellbutrin (a DNRI) is currently what I am trying for depressive symptoms, the Klonopin for anxiety, and of course being on Neurontin already, I am now being mindful of my mood and keeping a log of how a feel, why, and any time I drink/eat/take a psychotropic food or drug. This will let me chart my cycling (whether subtle or rapid and pronounced) on the current therapy to see if I can do without adding another psychotropic agent like Lamictal. The psych and I will obviously re-evaluate at strategic intervals in hopes of minimal changes needed. It really takes my breath away to think (and believe) there's a chance of Bipolar hidden (or sometimes exacerbated commonly enough in the past) under the effects of the meds and pain, but knowing what I do now I can't pretend it's not obvious to me, retrospectively anyway....

Any ideas on something I may not have considered, coping ideas, general helpful information is much appreciated ...
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