Expert: Ivan Goldberg, M.D. - 6/8/2009

Question
Hi, I really need help in obtaining a second opinion in my recent diagnosis which I have been unsuccessfully been able to get and possibly a validation for my reasons for getting a second opinion. To start out I was diagnosed as bipolar 1 last year about a month before my 32nd birthday. I was seeing a psychiatrist for what I thought was an anxiety disorder at the recommendation of my wife. She begged me to go as my anger outbursts, although episodic and not regular would come in waves where I would be irritable for anywhere from a week to 3 weeks then nothing or a little depressed and worried for months at a time. At first I was taking celexa which actually made me feel more depressed and then had Wellbutrin added into the mix (wellbutrin did nothing). After talking with my psychiatrist for several months she had said that this sounds like it may be ADHD since I started having symptoms way back when I was 7 years old (I pulled my hair out in the second grade impulsively and was screened for ADHD every year to no avail since my grades were exceptional). She started me on vyvanse. at 30mg I started having palpitations and as the day went on hallucinations (rabbits in my backyard that weren't there and smoke). I called my psychiatrist and didn't get a response so I ignored the visual disturbances. The next day I saw 2-legged green goat-like creatures in my front yard. At this point I stopped taking all meds and dried myself out for a month. Went back to the same dr and started back on vyvanse by itself. After a few days I became rather incompetent as if I had ADHD symptoms, I became very paranoid and a little delusional thinking people could read my mind. I became very quiet and withdrawn even though inside my mind I was very active. I felt very guilty and that I had done society some great harm. I told my wife something wasn't right and she disagreed saying my moods were much better and I didn't have outbursts anymore. At least externally. At this point I felt it was my anxiety was worse so again I talked to the dr. She prescribed me cymbalta. Now I normally will think of a song in my head but just one at a time. After just a few days (3) on 60mg it was like listening to several radio stations at once. I started hearing really corny rhyming going on in my head, metal on metal sounds and also a commentary as to what I was doing. My mood had improved drastically, I cared about nothing. I went to work when I felt like it and functioned off of 2-3 hours of sleep per night. Apparently after a few days on cymbalta my wife had called my psychiatrist regarding an episode that happened the night before where I accused her of trying to kill me. My psychiatrist called me the next day and told me to immediately stop all medications. I did and a week later went in to see her. I felt great and denied any issues at this point. About a week later I started having horrible auditory hallucinations. I had a voice in my head that was telling me how horrible I was and that I should kill myself. I would also occasionally see things that weren't there and my paranoia was overwhelming. I had weird thoughts that weren't mine as though they were pushed into my head by an external force (like Europeans were putting cyanide into beer and my city water also had the same problem. At this point I also started to smell an ammonia smell which occurred when I got angry. What is weird is I was aware most of the time that this stuff wasn't real. It was like having a really bizarre dream that didn't make sense but you go along with it just cause it seems right at that particular time. I called my doc and described my symptoms. She strongly suggested hospitalization and prescribed my Abilify 10mg, I was then diagnosed with bipolar 1 mixed with psychotic features. My wife also tried to persuade me to go into the hospital which I declined. After a few days the hallucinations were manageable but still present and I could work around them although I had a horrible side effect Akithisa and Dystonia. The doc then told me to try Benadryl and if that didn't work it is probably mania and she would increase my dose to 20mg. Well the Benadryl didn't help and at 20mg the Akathisa/dystonia was horrible. She then prescribed me 2mg of cegentin which didn't help either. She increased that to 6mg which helped but the side-effects of the cogentin were horrible as well (anxiety, confusion, getting lost, very blurry vision). I complained and she attempted to transition me to depakote. I started off OK still taking abilify alongside of it, until I reached the so called "therapeutic dose" which immediately caused me to have serious suicidal thoughts. She put me on prozac at the time (she tried to increase my depakote but I protested). Prozac didn't help and I convinced her to take me off the abilify. At this point I was frustrated and very angry thinking all of this crap was caused by her and suggested a misdiagnosis since my symptoms weren't that bad before seeing her. We also talked about me smelling ammonia and various other things. She said that these were Olfactory hallucinations and are rare with mental disorders and usually mean something neurological. She referred me to a neurologist to rule out anything there and for a second opinion. I talked with the neuro and gave him this whole story. He did his examination and ruled out any kind of seizure and pretty much the possibility of a tumor saying that "he agrees with my psychiatrist". Apparently my psychiatrist is very well known in the Atlanta area and all doctors just agree with her diagnosis. He offered to do an MRI but said he thinks it would most likely return negative results. After finding out it costs $500 with my insurance and that I shouldn't get one anyway (I have a BB in my left sinus cavity) I declined on the MRI. So back to my pdoc. After several months taking abilify (back to 10mg) I started becoming very lazy and unmotivated I didn't even want to go to the bathroom as it required work I complained again. She switched me to risperdal which worked better along with klonopin for my anxiety. This worked but made me very sleepy at 4mg and was cut down to 2mg. Still sleepy and the klonopin was taken away. After a month I slipped into a very bad apathetic depression. I begged to come off meds and eventually got my way. I went to see a psychologist for a 3rd opinion and the response I got was similar to the neurologist. Yes I know your psychiatrist and I agree with her. I was also told to go back on my meds. I am sorry but major depression and severe Akithisa are not acceptable side-effects for me. I was told since I had suicidal thoughts on depakote that any AED such as Lamicatal would also cause them. I was not put on lithium cause I had blood in my urine and was checked by a uro that said I had chronic kidney stones. She also said lithium may not help since I cycle rapidly and have mixed episodes. I have been off meds since late March and although I haven't been 100% stable I have been OK without any major episodes. Do I have a good argument for wanting a second opinion? Also, why are depakote and lithium dosed in a one-size fits all fashion? I mean they basically determine your dose by figuring out what dosage will kill you then back it off a little bit. What if I would respond to a dose lower than the so called "therapeutic dose"?

Not sure if I missed anything but my grandfather was also eventually diagnosed as BP1 with Psychotic features and was discharged from the Navy during WWII when he was in the pacific theater. My family history along with the fact that the mania didn't go away when cymbalta was removed (got worse actually and caused psychosis) was her basis in arriving at my diagnosis.

I would have no problem taking meds if the helped and didn't make me mentally worse. I can handle normal side-effects like Nausea, weight gain, hair loss, sexual side effects, etc but the ones I had sucked far worse than begin crazy. Another reason I would like a rediagnosis is because I am an engineer and in these tough economic times I may have to get a job with a government contractor that would require a security clearance. It is difficult to get with a mental illness such as bipolar especially if you don't take meds.

Also had my thyroid TSH levels checked which were OK. Is there anything else it could be medically related?

Answer
Hi Kevin . . .

Your situation certainly sounds complex and while I suspect the final diagnosis very well may end up as bipolar disorder it is far from certain that that is all that is going on.

Drug toxicity, and/or some neurological problem may also have contributed to the clinical picture you describe.

I think that a sleep-deprived EEG and MRI should be done prior to your seeing a psychiatrist for a second (or is it third) opinion. Preferably you should see someone from a community other than Atlanta so that too much emphasis is not put on the opinion of your original psychiatrist.

A list of psychiatrists to whom you might turn for such a second opinion may be found at:
http://www.psycom.net/depression.central.psychiatrists.html

Best regards . . .

Ivan
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