Expert: Ivan Goldberg, M.D. - 8/9/2008

Question
QUESTION: I am diagnosed BPII w/ rapid cycling and dually dx'd with Substance Abuse. I have a history of Self Injury during mania and deep long-term depressions.  I am currently taking Lamictal (400mg), Welbutrin (150 in summer, 300 in winter) Klonopin prn for anxiety and Seroquel 50mg for sleep issues.
All that being said, my swings have been much more moderated, but I have had 3 since the beginning of 2008. During each of these cycles, even when hypomanic, I am consumed with depressive and self-destructive thoughts, particullarly Self injury and inward rage. I will take risks like driving way to fast, and have feelings of "what's the point of keeping doing this" during those times. My mind races, I don't sleep, yet I have no motivation. My main fear is that while I do not intend Suicide, I fight the urge to do myself some lesser form of bodily harm.  I no longer know what to ask my doctor/therapist for help with.  Is this all part of the BP, or is something else going on that I should seek help with.

ANSWER: Hi Carolyn . . .

While I cannot give personal medical advice I can tell you when treating people with a history similar to yours there are a number of problems that must be addressed:

Ongoing substance abuse makes the successful treatment of a mood disorder impossible;

Lamictal dose should be regulated on the basis of both the blood level of the drug and clinical response. Too often blood levels are not obtained;

Psychotherapy must be part of the treatment;

People who SI should be involved in a DBT program in addition to whatever other sorts of psychotherapy they may be doing;

An attempt should be made to totally eliminate antidepressants (such as Wellbutrin) in people who rapidly cycle;

People who rapidly cycle often need two or three mood stabilizers to control the cycling process.

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: Thank you for your response. Believe me I understand about the substance abuse factor and have been clean over 5 years.
2 quick follow-ups:
What is DBT ?
Does this at all sound like mixed episodes, is that something I should bring up with my doctor.
Again thank you, and I will ask about the Blood levels on the Lamictal.

Answer
Hi . . .

DBT = Dialectical behavior Therapy. Although ut is promoted as a therapy for people with borderline personality disorder i think it should be a required coarse in high-school and it certainly is good for anyone with bipolar disorder.

The presence of negative thoughts about one's self or the future during a hypomanic episode are characteristic of mixed states,

Best regards . . .

Ivan
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