Question: Dr. Jones
My son is 14 yrs. old and has been diagnosed with bipolar more depression than mania. ADHD and Anxiety. He is on 150 mg of Lamitical, and he is starting 36mg of Concerta, and is currently on 80mg. of Prozac. My son has severe social anxiety and performance anxiety. He is a select basketball player and baseball player. He has dropped all sports due to anxiety. The only thing he does now is ride bikes with his dad and works out at the gym. We are looking at also having to home school him due to his condition. He is very smart, talented in music and sports, but locked up with anxiety. Can you please help. We have also tried Xanax, Propanolol (for Physical symptoms) Nothing we have tried has helped the anxiety. Anxiety and panic attacks run in my family. Most of my family are taking Effexor XR. What do you think about my 14 year old son trying this medication. Please help!!
This anxiety is so crippling. Thanks so much for your help!

Answer from Dr. Jones:

Social Anxiety Disorder is the most common anxiety disorder, affecting 16% of people to some degree.  Most patients are somewhat comforted by knowing there is a strong genetic factor.  Studies of pregnant women monitoring the pulse of the fetus with a loud noise or acute stimulation show that those that will have a shy temperament have a much stronger reaction in terms of increased heart rate and their heart rate stays up much longer.  I have found that many people with social anxiety are also ADHD so that is common.  Also, being diagnosed with bipolar is not unusual because all three of these conditions involve the dopamine system of the brain. 

Stimulants are often helpful, although my experience has been that the Adderall Vyvanse, Dexedrine type of medications are often the best.  One of the reasons they are helpful and one of the paradoxical things we find is that stimulants decrease anxiety because they help us to think of one thing at a time and can help with more easily ignoring distractions.  Especially with Social Anxiety distractions come from all directions, mind, body, and other people  -  what if this?, what if they don’t like me?, what if I say the wrong thing?, and what if I draw a blank?.  They may feel their heart racing, or their throat gets tight, or they feel hot or flushed.  Any negative stimulation in the environment affects them.  There can be a thousand people in the room and if somebody yawns when they are talking, they think, “oh no, they think I’m boring”.  Or somebody laughs and they think they are laughing at them, which makes it very hard to stay on track and the anxiety keeps escalating. 

Propranolol is helpful for some types of symptoms as long as asthma is not a problem.  But it has to be the right dose for the individual.  It is especially good for racing heart, shaking muscles, quivering voice and tremor.  It is not particularly good for sweating and blushing but a lot of patients take it along with one of the tranquilizers at least for situational things like giving a talk or being in class if that’s what the problem is.  Xanax is good for anxiety but the tranquilizer that is most commonly effective for social anxiety is Klonopin, or clonazepam.  It is actually the most potent for panic.  Klonopin is also the only medication in that class that has an effect on serotonin which is the worry system and obsessing. It also reduces racing thoughts.  Plus it lasts longer so it does not have to be taken as often as Xanax.

In terms of your son, I have had a teenager do home schooling for a semester or so but the goal is always to get them back into the normal situation.  They just have to start desensitizing possibly in another environment.  One girl I treated wouldn’t go to school, but got a job during the summer as a hostess in a restaurant and because she was on medication it allowed her to tolerate that situation and it desensitized her to the point that she was able to go back to school.

The most important thing is you can’t get over social anxiety first and then start getting into social situations.  The only way to get over it is to be in the situations
but not having severe symptoms.  Forcing oneself or being forced into situations and having a horrible time, being embarrassed, feeling humiliated, and can’t wait until it’s over doesn’t help, it actually worsens the condition because it more strongly conditions the brain that the situation is bad news. 

The way to get over it is by being in social situations with minimal anxiety or at least less than before and having various techniques, including cognitive techniques to use.  But if you are overwhelmed with anxiety then it is pretty hard to use cognitive techniques. 

If the physical symptoms are severe then managing them is important and things like Propranolol are good, but you have to take the right dose.  So too much can cause additional physical symptoms and too little doesn’t control the symptoms.  For things like sweating, medications like Cardura or anticholinergics are more effective and for blushing sometimes Klonopin helps and sometimes Pindolol helps because it has the serotonin and beta blocking effect. 

It is best to only change one medication at a time.  Lamictal is good for the depression associated with bipolar disorder.  200mg is the most typical dose.  Prozac is effective in terms of OCD or obsessing.  You wouldn’t want to take Prozac and Effexor together.  Effexor does have good studies for social anxiety disorder and covers a wider range of symptoms but you would have to transition it gradually, reducing the Prozac by 20mg each week so you would need to wait a week before starting the Effexor.  Then you would gradually taper off one while adding the other.

So the most important thing is your son can get over Social Anxiety Disorder. It’s common, it’s disabling and there are a lot of medications that can help by taking the right one or combination of medications at the right doses and then getting into the dreaded situations and desensitizing.  He will have to get to where he doesn’t avoid at all because any avoidance reinforces the symptoms.

Don’t give up! Persevere until you find the right medications at the right dose to help your son. Good luck in your efforts to help your son find a normal, healthy life.
Answer:

Dr. Jones
My son is 14 yrs. old and has been diagnosed with bipolar more depression
than mania. ADHD and Anxiety. He is on 150 mg of Lamitical, and he is
starting 36mg of Concerta, and is currently on 80mg. of Prozac. My son has
severe social anxiety and performance anxiety. He is a select basketball
player and baseball player. He has dropped all sports due to anxiety. The
only thing he does now is ride bikes with his dad and works out at the gym.
We are looking at also having to home school him due to his condition. He
is very smart, talented in music and sports, but locked up with anxiety. Can
you please help. We have also tried Xanax, Propanolol (for Physical
symptoms) Nothing we have tried has helped the anxiety. Anxiety and panic
attacks run in my family. Most of my family are taking Effexor XR. What do
you think my 14 year old son trying this medication. Please help!!
This anxiety is so crippling.

From Dr. Jones:
Social Anxiety Disorder is the most common anxiety disorder,
affecting 16% of people to some degree. Most patients are somewhat
comforted by knowing there is a strong genetic factor. Studies of pregnant
women monitoring the pulse of the fetus with a loud noise or acute
stimulation show that those that will have a shy temperament have a much
stronger reaction in terms of increased heart rate and their heart rate
stays up much longer. I have found that many people with social anxiety are
also ADHD so that is common. Also, being diagnosed with bipolar is not
unusual because all three of these conditions involve the dopamine system of
the brain. See social anxiety newsletter

Stimulants are often helpful, although my experience has been that the
Adderall Vyvanse, Dexedrine type of medications are often the best. One of
the reasons they are helpful and one of the paradoxical things we find is
that stimulants decrease anxiety because they help us to think of one thing
at a time and can help with more easily ignoring distractions. Especially
with Social Anxiety distractions come from all directions, mind, body, and
other people – what if this?, what if they don’t like me?, what if I say
the wrong thing?, and what if I draw a blank?. They may feel their heart
racing, or their throat gets tight, or they feel hot or flushed. Any
negative stimulation in the environment affects them. There can be a
thousand people in the room and if somebody yawns when they are talking,
they think, “oh no, they think I’m boring”. Or somebody laughs and they
think they are laughing at them, which makes it very hard to stay on track
and the anxiety keeps escalating.

Propranolol is helpful for some types of symptoms as long as asthma is not a
problem. But it has to be the right dose for the individual. It is
especially good for racing heart, shaking muscles, quivering voice and
tremor. It is not particularly good for sweating and blushing but a lot of
patients take it along with one of the tranquilizers at least for
situational things like giving a talk or being in class if that’s what the
problem is. Xanax is good for anxiety but the tranquilizer that is most
commonly effective for social anxiety is Klonopin, or clonazepam. It is
actually the most potent for panic. Klonopin is also the only medication in
that class that has an effect on serotonin which is the worry system and
obsessing. It also reduces racing thoughts. Plus it lasts longer so it does
not have to be taken as often as Xanax.

In terms of your son, I have had a teenager do home schooling for a semester
or so but the goal is always to get them back into the normal situation.
They just have to start desensitizing possibly in another environment. One
girl I treated wouldn’t go to school, but got a job during the summer as a
hostess in a restaurant and because she was on medication it allowed her to
tolerate that situation and it desensitized her to the point that she was
able to go back to school.

The most important thing is you can’t get over social anxiety first and then
start getting into social situations. The only way to get over it is to be
in the situations
but not having severe symptoms. Forcing oneself or being forced into
situations and having a horrible time, being embarrassed, feeling
humiliated, and can’t wait until it’s over doesn’t help, it actually worsens
the condition because it more strongly conditions the brain that the
situation is bad news.

The way to get over it is by being in social situations with minimal anxiety
or at least less than before and having various techniques, including
cognitive techniques to use. But if you are overwhelmed with anxiety then
it is pretty hard to use cognitive techniques.

If the physical symptoms are severe then managing them is important and
things like Propranolol are good, but you have to take the right dose. So
too much can cause additional physical symptoms and too little doesn’t
control the symptoms. For things like sweating, medications like Cardura or
anticholinergics are more effective and for blushing sometimes Klonopin
helps and sometimes Pindolol helps because it has the serotonin and beta
blocking effect.

It is best to only change one medication at a time. Lamictal is good for
the depression associated with bipolar disorder. 200mg is the most typical
dose. Prozac is effective in terms of OCD or obsessing. You wouldn’t want
to take Prozac and Effexor together. Effexor does have good studies for
social anxiety disorder and covers a wider range of symptoms but you would
have to transition it gradually, reducing the Prozac by 20mg each week so
you would need to wait a week before starting the Effexor. Then you would
gradually taper off one while adding the other.

So the most important thing is your son can get over Social Anxiety
Disorder. It’s common, it’s disabling and there are a lot of medications
that can help by taking the right one or combination of medications at the
right doses and then getting into the dreaded situations and desensitizing.
He will have to get to where he doesn’t avoid at all because any avoidance
reinforces the symptoms.

Don’t give up! Persevere until you find the right medications at the right
dose to help your son. Good luck in your efforts to help your son find a
normal, healthy life.

What does it mean when stimulants stop working and/or start causing anxiety or moodiness?  Stimulants usually have a stronger effect when they are first started and then the dose has to be increased to achieve a good response.  Some patients will become tolerant to at least some of the stimulant effects and have to increase the dose gradually over time.  This is not a major problem as long as the total daily dose doesn’t exceed the maximum.

Dosing chart:

Your problem may just be an inadequate dosing issue.

The anxiety and moodiness that you are having may be a side-effect or a rebound effect depending on when it is occurring.  If your mood symptoms are at their worst between 3 1/2 to 5 hours of taking Vyvanse it is probably a side-effect.  If they are  occurring later it more likely is rebound and you need a second dose – probably around lunch time.  Rebound symptoms are more likely with Adderall XR than Vyvanse – short acting Adderall or Dexedrine tablets are even worse.

The majority of my patients have done better on and preferred Vyvanse.  There are some patients however who do better on Adderall XR, presumably because they need the added norepinephrine effect.  More patients on Adderall need to add Tenex, but it can also be helpful with Vyvanse.

Anxiety and moodiness starting after taking stimulants for a while can also be due to underlying genetics of mood disorder, especially bipolar.  Any significant family history of major mood disorder increases the risk.  Patients with ADHD and bipolar genetics do best on a combination of a mood stabilizer and a stimulant.

Depression runs in my family and I’ve been on the same medicine for a while with no episodes of depression.  About two weeks ago I woke up feeling not myself and contributed it to getting my period on top of coming down with a respiratory infection.  Still not feeling well after two weeks I think it might be depression because I feel tired, confused thinking, can’t focus, etc.  I’ve called my doctor and he told me to up my medicine 100mgs.  My question:  

Since I have not had an episode of depression in quite some time could it have been brought on by me not feeling well?

Dr. Jones’ reply:

I’m not sure what antidepressant you are on – but it was possibly Zoloft or Luvox since they can be increased by 100mg increments, but not SNRI’s (Effexor, Cymbalta) or other SSRI’s (Prozac, Celexa, Lexapro, Paxil).

Women with a family history and or prior history of depression who respond to an SSRI or SNRI can have return of symptoms if their serotonin level is reduced (as it is premenstrually, post partum, or during perimenopause).  Being ill can also contribute to relapse by disrupting sleep or normal thyroid function.

Previous studies have shown that:  "the dose that gets you well keeps you well", but even then the relapse rates are:  20% of patients have recurrence within 3 years,  50% relapse if the dose is lowered, or 80% relapse if medication is stopped.

Recurrent depression not only causes distress and possible short term impairment, it can also increase your vulnerability to future episodes and decrease your responsiveness to treatment.

There are several things that can help prevent recurrence:

1. Good sleep - 7-8 hours every night (Lunesta, Ambien provide normal sleep)
2. Physical activity – daily vigorous activity for at least 30 minutes (a 2 mile walk or equivalent)
3. Omega 3 fatty acids - take twice daily.  (I trust Cooper brand the most)
4. Bright light daily 
5. Thyroid - make sure thyroid levels are good  www.askdrjones.com/ 
6. Cognitive behavioral therapy - if needed
7. Other medications - other medications may help such as alprazolam, atypicals, stimulants
8.  L Methylfolate - (Deplin,  Cerefolin, or Cerefolin NAC)  - these contain a form of folic acid that gets into the brain cells.  Deplin was recently approved by the FDA as an add-on treatment for depression.  Cerefolin also contains B12 and Cerefolin NAC has a third ingredient that increases glutathione (a powerful brain cell antioxidant).  These medications not only can improve mood, but improve cognition and energy.  Caution:  taking Deplin if your B12 level is low can be harmful.  It is safer to either check your B12 levels or take Cerefolin. 

I don’t use Risperdal because of the increased risk of neurological side-effects, and increased prolactin interfering with hormones, including estrogen.  Lexapro is good for anxiety, obsessiveness, and depression, especially sadness, but if your daughter is manic depressed/bipolar the Lexapro can make her more emotionally unstable.  Effexor XR is a broader spectrum medication with potential advantages but would also destabilize if she is bipolar.

How thorough was her examination?  What family history is there for anxiety, depression, or bipolar?

If your daughter needs a mood stabilizer or something to "glue" her thoughts I have had the best luck with Abilify or Seroquel. www.askdrjones.com/2005/02/14/ranking-the-mood-stabilizers/

Age fifteen is such a critical time developmentally so you need an experienced clinician and you need to be seeing some improvement.

Geodon is a medication with a lot of issues so that it is not one of my first choices.  It is a good antimanic mood stabilizer if taken in higher doses (120-160mg).  At lower doses it can destabilize mood.  It is not an anti-anxiety medication.  It usually requires twice daily dosing and wears off fast if doses are missed and if not taken with food.  It only has a 50% absorption.  It is relatively benign from the standpoint of weight gain and metabolic syndrome.  It is not acutely effective for insomnia.  Dosing is more complicated because it is in capsules. 

Abilify is in tablets that can be easily broken in half at the 2.5 and 10mg doses,  has the longest duration of this class, and can be started low and slowly increased.  www.askdrjones.com/2005/02/14/ranking-the-mood-stabilizers/  Both medications are pricey.

Serious adverse rashes can occur with Lamictil but it is rare.  Most reactions are mild – they go away when the Lamictal is stopped and many people tolerate Lamictal okay when it is restarted.  If a week or more goes by before skin clears you have to start back at 25mg or even lower.

Severe reactions are rare but can include anything above the neck such as swollen lymph nodes,  lesions in the mucous membranes in the mouth, or under the eyelids.  Then it is not considered safe to try taking it again.

I can’t tell how severe your reaction was but on the face is worrisome and "vasculitis" doesn’t sound good.  You should probably discuss this reaction with a dermatologist before trying Lamictal again.    

Depakene even in the best form, Depakote ER, can have adverse effects on hormones – it would be one of my last choices.  Lamictal is the best tolerated mood stabilizer if it doesn’t cause a serious rash (very uncommon).    The main problem with Lamictal is that it has to  be built up slowly so it would need to be overlapped with Depakote or something else.  In general for most patients Lamictal is a much better medication.

If she is on birth control pills – which is not recommended for women with mood disorders – Lamictal doses need to be higher.  The NuvaRing is the best form of birth control in my opinion if needed.  

LAMICTAL (lamotrigine)

LAMICTAL (lamotrigine) is formally classified as an anticonvulsant drug.  However, it has been used for many years for migraines and pain.  It is also effective for treating bipolar depression.

WARNING: STOP THE MEDICATION IMMEDIATELY IF A RASH APPEARS.

Lamictal comes in scored tablets of 25, 100, 150, and 200mg. It is most cost effective to buy the larger sizes and cut them in half.

The dose may need to be increased to a total of 250-400mg.

SIDE EFFECTS

If significant side effects occur (e.g. dizziness on 25mg), the dose may be reduced even further. 

To decrease side effects (especially risk of rash) take each dose for 2 weeks.

What do we know about the cause of postpartum psychosis?

Hormones, especially estrogen, have a significant effect on mood. Estrogen raises serotonin. When estrogen drops precipitously, as it does premenstrually, postpartum, and at the onset of menopause – the brain serotonin levels drop. In women who are sensitive to low serotonin (because of genetics or previous episodes of significant depression) dropping the level will bring on symptoms of depression.

This principle can be demonstrated experimentally. By giving someone a drink of amino acid (from which tryptophan has been removed) the level of brain serotonin will temporarily go down. This is because tryptophan is the amino acid the brain uses to make serotonin. Only people with a vulnerability to becoming clinically depressed will show a depressive response to the serotonin level drop. This phenomenon contributes to premenstrual depression and menopausal (especially perimenopausal) depression.

Think about how dramatically hormone levels drop after child birth. This is why postpartum blues (brief symptoms of mild depression) is extremely common. The postpartum period is the highest risk period for full blown clinical depression.

Post partum psychosis is an extreme form of mood disorder in which underlying genetic vulnerability causes not only depression but a psychotic state. This fortunately only occurs in 1 out of 1000 births.

Psychosis is often confused with delirium. Delirium is a state of severe confusion and disorientation that can be brought on by toxins, severe infections, and many other causes. Every area of functioning is impaired. Psychosis means there is a distortion between conscious reality and external reality.

The most common symptoms of psychosis are hallucinations (seeing things or hearing things that aren’t there) or delusions (beliefs that aren’t true). A person can have one serious delusion that can affect their behavior but can be totally normal in other areas of functioning.

A woman who has had one postpartum psychosis is at a very high risk in any future pregnancies. It was for this reason that Andrea Yates was advised not to have any more children. So why did she and her husband ignore this? I don’t presume to know all the factors that they took into account. But I know she was never diagnosed as bipolar.  And they were never adequately educated about the physiology and medical science that we do have about what causes postpartum depression and psychosis.

Another factor in the Yate’s decision to continue to have children was their faith. They relied more on spiritual experience and counseling with their minister than medical advice. Unfortunately they had come under the influence of an extremist minister, and their medical advice was inadequate and not convincing.

Can they be faulted for not realizing all of this?  I think not. It is not unusual for a person of strong faith to at times feel caught between science on the one side and their faith on the other.

Many centuries ago St. Augustine showed more wisdom in this matter than many of our current experts. He said in effect science and religion aren’t in opposition. They are both ways of looking at and understanding one truth. When science and religion don’t agree we need to discourse and study so that the disagreement can be resolved – without feeling like you have to choose one or the other. Of course not all supposed science is valid and not all ministerial counsel can be trusted. Extremism of any type is dangerous.

Question: Can a series of major stress over a period of 3-4 years cause a person to become bipolar?

– Pat P.
Answer: If one has genetic predisposition, then a series of stressors can turn on the genes and induce depression, hypomania or both (mixed or dysphoric mania). Non-genetic personality factors and availability of social support also play a a significant role. In the absence of genetic predisposition, it takes a lot more stress overload to induce symptoms.
It’s analogous to the situation of high sodium diet and high blood pressure. It’s the combination of genetic predisposition plus high sodium that leads to hypertension, whereas neither alone do it.
For more info, see the blog on Jane Pauley and the overview of Bipolar Disorder.