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Commentary on Gogo Lidz’s
“My Adventures in Psychopharmacology”
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In her 2007 article in New York Magazine, Gogo Lidz tells
of her life with bipolar-II more vividly than any psychiatric textbook can.
Ms. Lidz’s story illustrates how important it
is to be careful with psychiatric medications when someone has a complex
problem with mood. Although she has
some benefits from stimulants and antidepressants at first, over time these
cause her mood to darken.
Unfortunately, it is not uncommon for people with bipolar-II to be
misdiagnosed with depression, anxiety or attention-deficit disorder and
treated with these medicines. One study found that they spend an average of
10 years in mental health treatment before being accurately diagnosed.
Psychotherapy also has an important role in her
recovery. The two treatments which helped her, lamictal and Dialectical
Behavior Therapy (DBT) , both have scientific support for their
benefits in mood swings. There can
be uncertainties in the treatment of bipolar-II, but starting with
treatments that are known to work can offer people thebest chance of
success. It is sad but common for
people like Ms. Lidz to end with those treatments after exhausting the
others.
More detailed comments on her article are
below:
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Gogo Lidz’s Text
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Dr.
Aiken’s Commentary
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“I’d been a dreamy,
drifty child.”
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People with bipolar-II often have a creative
capacity for daydreaming that can be misunderstood as attention-deficit
disorder (ADD or ADHD). Their minds can be hyperactive, allowing them to
drift into multiple streams of thought even while engaged in unrelated
tasks.
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“The flood of hormones
seemed to unsettle my mind.”
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The brain is protected by a tight filter called the blood-brain barrier. Hormones are among the few things which
can pass through this filter, and by doing so they allow the brain to
communicate with the body. Mood
swings can get worse after events that disrupt hormones, such as stress,
seasonal changes, puberty, menses, pregnancy and sleep disruption. Read more about how you
can reduce mood swings by regulating these hormonal changes.
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“I was silly and giddy
one minute, bursting with rage the next; running around excitedly in the
afternoon but impossible to rouse out of bed in the morning.”
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Her mood shifts rapidly from Sunny Hypomania to Dark
Hypomania and then to Depression. Moods tend to shift faster during the
teenage years than in adulthood.
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“I described my symptoms
and family medical history (depressed aunts, a schizophrenic
uncle)…”
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People with bipolar-II often have a family member
with a severe mental illness, and may be afraid of becoming like them. Chronic depression, substance abuse and
bipolar disorder are common in their family members. Recently it has been discovered that the
genes involved in schizophrenia are similar to those in bipolar
disorder.
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“Satisfied that I was suffering
from ADD, Dr. Titrate gave me samples of Ritalin.”
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Bipolar-II is frequently misdiagnosed as ADD or ADHD
(attention-deficit hyperactivity disorder).
Both conditions cause difficulties with distraction, hyperactivity,
inattention and impulsivity. An
important difference is that in ADD the difficulties begin before age 7,
are stable, and gradually improve with age.
In bipolar-II the difficulties usually begin around puberty, worsen
with age, and are cyclical and unpredictable rather than stable.
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“But I was dimly aware that the ADD medication was also doing
something else, something I didn’t like. I felt impatient, irritable,
explosively angry. I’d scream at my father for buying me the wrong
toothpaste.”
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People with bipolar-II often think and feel better after
starting stimulant medications, such as Ritalin or Adderall, which are used
to treat ADD. However, the harmful
effects of these medicines on mood can become apparent over time.
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“I took stimulants and finished all my homework, [then] I’d
smoke a joint with him in the evening. Smoking weed took me out of my usual
speedy state.”
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Ms. Lidz’s mood goes up and down. The
stimulant is an “upper” which helps the downs but causes an
irritable-up. To compensate, Ms. Lidz is now self-medicating with a common
“downer”, marijuana. Alcohol and benzodiazepines (e.g. ativan,
xanax, valium, klonopin) are also “downers”. Both the “uppers” and
“downers” are bad for mood in the long run because they are not
designed to treat the underlying problem (you might say that they
“cover it up” instead).
Two years later, she writes, “I stayed on
Adderall, but I stopped taking recreational drugs: Downers only brought me
down.”
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“… he dumped me over e-mail. I was devastated…I sobbed
and slapped my wrists against the tile floors… The next day,
I…decided to end my life.”
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Mood can be very unstable in bipolar-II. It can
plummet after the sudden loss of a relationship, in her case into agitated
self-harm and suicidal depths. This part of her story also explains why
people with bipolar-II are sometimes diagnosed as having borderline
personality disorder. “Frantic efforts to avoid abandonment”,
such as a suicide attempt after a break-up, are characteristic of
borderline personality. The
difference between bipolar-II and borderline personality is complex and is
described in more detail in an article
by Dr. Jim Phelps.
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“Strattera had no effect on me… Effexor seemed to have no
effect on me…”
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Everyone with bipolar-II is different, in part
because of the complex genetics that give rise to it in the brain.
Medications which are not designed for bipolar-II, such as these two, may
help some people, harm others, or simply do nothing at all. Effexor and Strattera may be
particularly dangerous in bipolar-II because they raise norepinephrine
levels, which can cause mood swings and aggression.
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“He put me on a heavy-duty antipsychotic called Zyprexa.”
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At this point, her doctor has suspected that she is
“a little bipolar.” It
was 2002, and lamictal had not been approved for bipolar disorder but the atypical antipsychotic
Zyprexa was. Ms. Lidz later tried two other atypicals – Geodon and
Abilify – and seems to have a poor response to this class of
medications. For other people with
bipolar-II the atypicals are very effective, particularly Seroquel.
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“I drank, drugged, and got the world’s most ridiculous
tattoo”
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Substance abuse occurs in up to 70% of people with
bipolar disorder. Although much of
this may be self-medicating the symptoms of mood, it leads to greater
problems in the long-term than it ever promised to help.
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“I couldn’t keep still in class or the library or even my
dorm room. I put off starting assignments until the last possible
moment… I skipped classes and disappeared from campus for days at a
time.”
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Bipolar-II is not an illness of the emotions, but
rather of the brain’s ability to manage and respond to emotions. This
management takes place in the frontal lobes (near the forehead), which are
also involved in prioritizing tasks and filtering impulses. In this quote, Ms. Lidz describes
problems in those areas.
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“To finish an art-history paper, I once stayed up 72 hours.”
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The ability to run on high energy despite lack of
sleep is characteristic of bipolar-II.
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“[after starting lexapro for anxiety] I did not get any less
anxious. I spent day after gloomy day in bed, feeling dizzy and nauseous
and paranoid, getting stomachaches, driving my friends crazy, and wanting to kill myself. I became more and more
unstable: sometimes moored to my bed, sometimes restlessly ricocheting
around campus. I had a couple of scary panic attacks—each followed by
sudden eerie moments of composure and lucidity. I became terrified of being
alone.”
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This is a good description of a mixed state –
when mania (or hypomania) overlaps with depression. People can feel “tired and
wired” at the same time. Most of all, mixed states carry terrible
anxiety. Often the person does not know what they are anxious about, but
has a free-floating sense of dread that sometimes rises to a panic.
Paranoid sensations that people have bad intentions towards you are
common. It can feel like
you’re living in a horror movie.
Rather than treating her anxiety, lexapro has made
it worse because antidepressants like this can cause mixed states.
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“Convinced that my classmates hated me, I tried to slice my wrists
with broken glass… When I finally got home, I threw a huge
tantrum.”
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Bipolar-II can cause people to be overly certain, or
stubborn, in their convictions. The belief that other people hate you often
develops during mood swings. Here
she is so convinced of this belief that she nearly takes her life over
it.
During a “tantrum”, the body is agitated
and revved up while the emotions are down. When the “ups” and
“downs” of bipolar affect different parts of a person at the
same time it is called a mixed state.
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“I had a brief honeymoon [from the mood swings]. Now, in addition
to a large dose of Lexapro, Dr. Titrate prescribed the mood stabilizer
Lamictal and, for focus, Provigil, a non-stimulant used to keep
narcoleptics awake.”
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Her first real signs of improvement occur when
Lamictal is added, but the benefits do not last because she is also on
medications that can destabilize mood (lexapro and provigil). When she develops panic attacks, two
other antidepressants – Cymbalta and Wellbutrin – are
tried. Antidepressants would be a
good option if her panic attacks are due to panic disorder, but in her case
she is panicking because of rapid shifts in her mood.
This is a very unfortunate problem. Antidepressants have been widely studied
for Anxiety Disorders. People with
bipolar-II often have high anxiety (one study found they have more anxiety
than people with non-bipolar depression), but their anxiety may worsen with
antidepressants because it is not due to an Anxiety Disorder.
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“When first started [Lexapro], about 2 hours later felt insane
amount of energy, was zooming, felt very speedy. Then shortly after that
same day I crashed and couldn’t get out of bed” …
“I had euphoria/irritability like never before”
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Here she quotes other people who have experienced
similar problems on antidepressants.
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“This is so typical of the so-called treatment bipolar II patients
receive,” the therapist said. “The disorder is usually only
diagnosed after everything else is ruled out.”
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Psychiatric diagnosis is never 100% accurate but, as
her therapist points out, the process can be improved by ruling out bipolar
disorder before treating other conditions. In fact, the DSM (the diagnostic
manual) guides psychiatrists to do just that, and recently the Food and
Drug Administration (FDA) advised doctors to rule out bipolar disorder
before starting antidepressants and related medications.
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“I’ve got a new therapist, who specializes in dialectical
behavior therapy. She locks in on what I need to change and what I
don’t, then works for those targeted changes. The only medication I’m on now is Lamictal, the mood
stabilizer.”
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After simplifying her
medications, her mood has finally stabilized. It is truly a case of
“less is more.” She has
also started a form of therapy which is designed for people with mood
swings (described in the self-help book “Don’t Let Your Emotions Run Your
Life”).
Ms. Lidz’s mood problems overtook her life between the
ages of 16-21. Imagine missing out
on those years and the maturity one gains through them. Therapy can help people regain what was
lost during a mood episode as well as prevent mood swings from returning.
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-Chris
Aiken, M.D.
Updated 3/9/7
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