Expert: Ivan Goldberg, M.D. - 7/23/2011

Question
QUESTION: I have been taking meds successfully in treatment of my bipolar disorder for over 5 years. I have had to go to the emergency 3 different times in the past several years for medical issues. I am totally normal and aware until they start treating me. Every single time I blackout and remember nothing that occurred. Once I was told later that I became violent and threatening to the doctor treating me but have no memory of it. What is causing this? I have always told the doctors in advance that I am bipolar. How can I start off fully aware and then blackout with no memory of what happened afterwards? I was still talking and walking but remember nothing. One thing that concerns me even more is that I have a surgery coming up on 7/25. It is a major surgery and I am afraid I am going to blackout and say something that could ultimate injury me even more. My surgeons have been made aware of this but my family can't even tell when it has happened in the past.

ANSWER: Hi Julie . . .

In my experience, behavior such as what you describe is not related to having bipolar disorder. I have seen such behavior in individuals with many psychiatric diagnoses. What they have in common is a history of having been neglected and/or abused early in their lives. I generally refer such individuals for psychotherapy to work out some of their old feelings.

Best regards . . .

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

QUESTION: Dr. Goldberg,

I would agree accept in my case no abuse happened and I have been under the care of a therapist as well as my Psychiatrist for years. So I am wondering if there is any possibility of some other drug interaction or reaction in brain chemicals that could cause this? I have read that in rare cases it could be caused by some type of seizure. I was seriously injured in a car accident and my neck was broken. But even under that stress I had no problems at all. This was before being diagnosed with Bipolar II.

Since being diagnosed, I have gone through outpatient surgery many times for pain relief where I was put into a twilight state and nothing happened.  However, I was recently admitted to the hospital for 3 days for tests and once again I have no memory past talking to the doctor about my breathing problems, and reminding him that I can't have ativan (which he used anyway)or penicillin. In that situation, I can only remember a friend (that saw this happen twice before# telling me I was asking the same questions multiple times, telling her to let the nurses know about my blackouts, and calling my Psychiatrist for help while I was still somewhat aware. I have no recall as to the conversation I had with my Psychiatrist or anything past that point. Later she told me that on the call I was extremely confused when trying to explain it was happening #blackout) again and at some point I just handed the phone to a nurse in the room. The Doctor told me later that she told the staff that I need a specific medication to stop what was going on but because she had no rights at the hospital they would not follow her orders. I remember at some point a doctor came in I guess to talk to me but I have no memory of anything else until I found my self packing to leave. I stayed very confused for several days after that. Since my surgery is coming up, I have discussed this with all my doctors but my concern is if my family can't tell I am unaware of what is happening, how can the doctors? Is there any other issue that could be causing this reaction?

ANSWER: Hi Julie . . .

You mention that you had a number of instances of episodes when being treated in ERs and hospitals. What is not clear to me if you received similar medications at the time of those hospital visits. Did you ever have such an episode at a hospital prior to being given any medication? What was the medication that your psychiatrist thought would stop your episode?

Best regards . . .

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

QUESTION: The first 2 visits to the ER were due to bipolar activity from lack of sleep and a medication mix up. However the 3rd visit was to run some cardio tests. On all 3 occasion I have no memory of what happened. On the 3rd visit I had actually gone into my GPs office because I was having breathing problems. This was not uncommon due to the time of year. I was totally calm during the visit but the doc was worried because my blood pressure was so high. She sent me to the hospital to make sure I wasn't having a heart attack. I went in to the ER told them that I had gone to see my GP because I was having problems breathing. The doctor immediately assumed I was having a bipolar episode and start to treat me with Ativan. I told him that I could not take ativan but he put it in my IV anyway. I was getting upset because he wasn't listening to what I was telling him. So he instructed the nurse to give me another shot of ativan and then a breathing treatment. Between all the ativan and the breathing treatments he did cause me to go manic. I am not longer telling doctors that I am bipolar unless there is a possibility that they need to administer steroids. From that point on I remember nothing. I would think that once the drugs he gave me went through my system I would come back to awareness but that never happened.

As to your question on medications I am on now. I had a cervical fusion performed while on my daily medication with no problems. I was aware of everything that was going on. That was back in 2008. These episodes have only been occurring in the last a couple of years.

I spoke with my Psychiatrist a few days ago about the surgery that is upcoming. She was hoping that is could be done using an epidural injection but that is not possible. I requested that my psychiatrist and surgeon speak to each other to figure out what to have available. My Psychiatrist has no privileges at this hospital so she will be relying on my surgeon if problems arise. My concern is still the same. No one can tell I am unaware of what is going on.

Thank you,

Julie

Answer
Julie . . .

What you describe has two major possible explanations:

1. It is a psychological reaction to the medical situation, If this were the case it would not be necessary for the ER staff to administer any medication.

2. It is a reaction to medications, most likely drugs in the same class as Ativan (lorazepam). Some people receiving these drugs go into a totally dissociated state and while they may seem OK, they have no memory of what has happened.

There may be other less likely explanations, but I suspect one (or both) of the explanations above would explain what has happened to you.

Best regards . . .

Ivan
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