Prep For psychiatrist Meeting Next Week

[Wonderful Family]

I'm trying to put together some notes for the psychiatrist meeting next week. What's anxiety, BiPolar (BP), ADHD, etc. I'm going to outline my thoughts here and maybe others can help me think through it. I'm wondering if we can figure out what the "problem" is, we might be able to help address the situation better or a different way. This is long; but I need to outline the details for myself

Basically, I'm trying desparately to come-up with other solutions (our psychiatrist is great at going through medication options and others) outside of Residential Treatment Center (RTC). I'm struggling because my difficult child is explosive, rude, and everything else - but has always "tried". Will yell at me at dinner because of whatever and tell me what he'd like to do me with the food I am making him eat, but eats some; this kid also lives with and accepts whatever we ask him to try for the BiPolar (BP) (e.g., he'll go to counselors and docs with little complaint, although he doesn't say much or actively work at them, asks for medications, etc).

We've had good stability (versus the wild man we had before), especially with the Lamictal. Upping the dose (we are now basically maxed-out at his weight) of Lamictal gives an immediate response in 24-48 hours - he's always much calmer; but soon settles back into what we think of as day-to-day functioning.

I've never gotten past the thought that we just stopped much of the poor behavior and the worst of the cyling/depression; but not much else. It seems as if he lives in constant "hypomanic" periods; but the cycling is minimal (we can track those to 4-6 weeks for the best and worst periods)? He can still pull himself out of it if it is something he really wants to do and control himself for periods of time; but we have to give him lots of time to decompress.

Symptoms:

• difficult child constantly complains of inability to focus, pay attention at school, he's spacey (all true), etc. He does have ADHD diagnosis'd as well. He can pay attention to things he wants such as his online game (plays with husband with lots of verbal outbursts, but still truly focused) for hours and hours on end.
• School complains of difficult child's ability (his case manager) of being able to do something one day, the next day not at all, or ability to "function" moment to moment, hour to hour, etc.
• Numerous complaints from difficult child concerning stomach pains, anxiety (stated differently), very obvious situations that are almost panic attacks.
• difficult child has always been a picky eater, but in mid-November he mentioned in the middle of a celebration dinner at his favorite place that he thought the food was "posioned". He has eaten very little since . . . this was just when his behavior started to get extremely poor again. Same night - difficult child wanted to know why he was so hyper and aggressive feeling at the same time. (Denied feeling this way the next day when I asked if he was feeling pretty energentic the next morning; but he was lying). I have not seen any other obvious mania since then; although he can easily go over the edge if we push and don't walk (which we always do).
• He has lack of motivation to do just about anything and is basically miserable. Failing school, but still going every day with a good attitude. Manages to get along with other kids at school; but only 1 "good" friend - the others all disappear within a few days after being around him a lot.
• Day starts with difficult child wanting a hug before he leaves for school; can't touch him afterwards. It's like he has all his nerves exposed within a few hours of being up.
• difficult child has said several times in the last year he is Obsessive Compulsive Disorder (OCD) (this was something they started talking about in private school; but it always seemed as if he was just messing around; but he did mention it once a few months back to psychiatrist who did not take it seriously).
• Other than one episode, no physical violence (although increasing talk about what he would "like" to do - big red flag).
• difficult child has asked 3 times in the last month if he will go back to seeing counselor again; when asked if he wants to, the answer is no. However, difficult child will not talk about ANYTHING and last counselor (excellent one) didn't feel he could help difficult child at this time.

The depression part is obvious.

If we go in next week talking just about the depression; that will be addressed. However, difficult child is of a very strong opinion that he is not depressed, just very irritable (and very anxious - my opinion). Is it possible the anxiety may be causing a good part of the problem and he really isn't depresed (hypomania/mixed state).

I am wondering how the anxiety or other bipolar/hypomanic symptoms play into this and appropriate medication treatment. I also know that Obsessive Compulsive Disorder (OCD) and anxiety travel together; same MI family (I think); but that they are also a component of BiPolar (BP).

Comments/thoughts. I'm of the mindset that another mood stabilizer might be in order, perhaps? Best way to communicate my thoughts about constant hypomania (if others agree that this is the right description) as a constant state?

 

[gcvmom]

I agree that another MS is probably in order. But which one is for the psychiatrist to advise you.

I also agree that his anxiety is likely the reason for the irritability. I'd be concerned about the "poison" paranoia. I think that might also tie in with the anxious/mixed state.

Rather than labeling his state as hypomanic, I think you'd be better to just describe factually what you're observing in his behavior. He does X, he does Y, he does Z. When all the parts are revealed, the psychiatrist should be able to draw the right conclusion. Perhaps, in the interest of time you can fax your concerns a day or two ahead of the appointment so that the psychiatrist has a chance to read over the list. It may help move the appointment in the right direction.

 

[smallworld]

When was Zoloft added? Zoloft is VERY activating for a kid with a mood disorder. While it can seem to help in some areas, it can also hurt in others. I'd take a close look at it to see if it's destabilizing your son.

Lamictal is not dosed by weight, but rather by clinical response. My daughter A weighs all of 77 pounds, and both her neuro and psychiatrist say we can go up to 400 mg if we need to as long as her gait and balance are not affected. Our neuro gives her brief neurological tests every 3 months in his office to make sure she's OK (she's only up to 250 mg and stable so we're no where near 400 mg, but my son J was at 400 mg until his Residential Treatment Center (RTC) began to wean him down recently).

When was Intuniv added? Do you think it's helping or hurting? There have been a lot of mixed reports on parent message boards about its effectiveness, particularly in the aggressive, agitation and hyperactivity departments.

Geodon is not considered one of the better atypical antipsychotics for tamping down manic or anxiety symptoms. Risperdal, Zyprexa and Seroquel are considered more effective in clinical trials. Zyprexa has been shown in a few clinical studies to be helpful for eating disorders. It helped my younger daughter with her severe choking phobia and distorted thinking about eating at age 8 (she was so phobic that she wouldn't eat at all). It's something you might want to consider for your son.

Wellbutrin is considered to be the AD least likely to cause mania in kids with BiPolar (BP) (because it doesn't boost Serotonin the way SSRIs do). It is also helpful for ADHD symptoms. Wellbutrin has helped my son tremendously. Again, something to consider for your difficult child.

One more thought: medications will not solve all the problems. These kids need intensive therapeutic interventions as well. Sometimes that means a 24/7 program. You may need to be open to that down the road.

Good luck.

 

[tictoc]

I'm also wondering about the Zoloft. difficult child had his first identifiable hypomanic period after taking Zoloft for two days (12.5 mg/day). It took a week for him to come down.

I think you have layed out your concerns very well and very clearly and I hope you will get good results at your appointment.

 

[TerryJ2]

Great responses here. I can't add anything except support.

 

[Wonderful Family]

Thanks for the comments and feedback.

difficult child has been on Zoloft for about 6 months; seemed to be the one piece that started helping earlier this fall; but what we are seeing now is similar to the way difficult child always was (this fall was a period in which was the best he'd had).

difficult child is now off the Intuniv - it didn't make a difference one way or the other (tried for about 6 weeks); he's been on/off Tenex for years with no reaction - good or bad. He's also been on Wellbutrin, and didn't seem to be a major problem; but no benefit either. We took it off when he wasn't making any changes. difficult child has historically not been able to really tolerate stimulants at all; and the AD's don't make much of a difference. The zoloft was added very carefully so that we could watch for any changes.

husband mentioned last night that perhaps it was time to look into next steps (first time he's done this; he's been really opposed to Residential Treatment Center (RTC), I just don't want to do it). I've got some information from last year when we were seeing similar results so I'll start there. I just can't imagine sending him away, really. He's a good kid, just can't function well.