Medical Literature

QUESTION:

Dear Dr. Heller,

My fiancé has a passive aggressive personality disorder that is affecting our life, his work and every aspect of his life.  He wants to get help for this and we have seen a therapist, but with little results as she was unfamiliar with this disorder.  He would be willing to meet with Dr. Heller or anyone he could refer.  He lives part-time in Los Angeles, CA and Georgia, close to Atlanta.  Any help would be appreciated.

 

ANSWER:

The passive aggressive disorder hasn’t been fully explained yet.  I believe it’s a decision that’s made as a child that permeates all aspects of their life.  The decision is “I’ll get even with you, I’ll stay mad at you the rest of my life.”  Taken from that context, the passive aggressive disorder at least makes sense.  The individual copes with fear, pain, and powerlessness by acting automatically in a passive aggressive manner.  There are two things that need to be done to overcome the passive aggressive disorder: 1) All the diagnoses must be successfully treated that contribute to anger like the BPD and depression, and, 2) The individual needs to forgive and move on.  There are many wonderful sources for letting go of fear and anger, some more spiritual.  I like “Happiness is a Choice” by Barry Neil Kaufman as a good first choice, and listening to Zig Ziglar’s tape series.  I have many individuals with the passive aggressive disorder who are doing very well.  They have to learn a new way of life and how to be happy.  If he’s willing to do whatever it takes to accomplish those goals he can do very well.  If he is unwilling to do so, the passive aggressive pattern will likely persist and you will eventually become it’s victim as well.

Can You Give Me A Medical Description For This Disease?

QUESTION:

Dear Dr. Heller,

I understand that it can take on many forms.  I tried to get a definition from the Internet.  With all the sites I found, one needs to be a physician to log on.  I may have epilepsy and am unable to drive to the library to research this topic.  Any reply would be most appreciated.

 

ANSWER:

There’s no “smoking gun” proof yet, but many studies show EEG (brain wave) abnormalities that worsen during dysphoric spells.  Because the abnormally functioning areas are deep in the brain we cannot yet “prove” the biological basis for this disorder yet.  Both from the limited EEG data especially combined with physical finding and patient symptoms, a seizure disorder in the brain’s trapped or cornered animal area is likely to blame. I think Dr. Norden was on to something when he wrote about the actual physical overheating of the brain.  I strongly suspect a seizure like phenomenon occurs in the brain’s limbic system, causing an overheating in the rage and dysphoria (anxiety, rage, depression and despair) sections.  The response to medications gives some important clues.

 

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QUESTION:

Dear Dr. Heller,

UNDERSTANDING THE DISEASE TO BE EPISODIC IS IT SUCH THAT: 1.  MANIA CAN LAST FOR A FEW DAYS AND THE DEPRESSION FOLLOW IN ABOUT THAT SAME TIME FRAME?  2.  OR IS IT SEVERAL MONTHS IN LENGTH (PERHAPS) EVEN SEASONAL BEFORE IT CHANGES BACK 3.  CAN STRESS TRIGGER THE CHANGE?  4.  HOW LONG DOES THE EPISODE LAST BEFORE IT CHANGES TO THE OTHER?

THANK YOU.

ANSWER:

1)    By definition hypomanic needs to last 4 days, mania 7 days.  One can have a “mixed episode” where both mania/hypomania and depression have been present at least 4 times in a week.  There are probably some who do not fit that definition, and the combination of BPD and bipolar can be very confusing at times. 2)    The peak incidence of mania is spring and fall, and seasonal winter depression is also quite common.  3)    Stress can trigger the change, and it can happen without stress as well.  4)    There is no predicting how long the episode will last before it changes to the other.

QUESTION:

Dr. Heller,

I’m 19 years old & have been in & out of therapy since I was 6.  I was diagnosed bipolar last year.  I don’t know if my diagnoses was correct or not…the meds made me worse…so far I’ve tried Wellbutrin, Prozac, Neurontin, lithium, Depakote, Luvox, and Zyprexa…I had an especially bad reaction to Wellbutrin, I became very angry and even threatened my brother with a steak knife…some of the other meds I was taking in combination, so I don’t know what did it, but they forced me into a manic episode..so I went off all the meds, now I have no health insurance so I don’t even go to therapy.  I also think I have obsessive compulsive disorder or obsessive compulsive personality disorder, and borderline personality disorder after reading the guideline.  I’ve also been told I have an eating disorder, and I scored very high on a test for ADHD.  AHHHHH so anyway, can I really have all these things at once?  And what kind of non meds treatment is available?  IM tired of all this, but all the pills made me worse, so I’m trying to find ways to get better without pills.  I would really appreciate it if you could e-mail me back with any info you could give me, thanks.

 

ANSWER:

The first thing I’d recommend is to look at the screening test I use for my patients, and then review the diagnostic criteria.  The first FAQ answer should help you as well.  It’s found in the ask the doctor section.

QUESTION:

Dear Dr. Heller,

I was looking for interactions with Paxil and came across your Website. I read somewhere that people taking Paxil medication should not ingest caffeine or even green tea or other caffeinated tea because it interferes with Paxil’s effectiveness. Do you know if this is true?

Thanks for all your time and effort!!!!

ANSWER:

Many individuals with the generalized anxiety disorder have a tough time with Paxil. They also have a difficult time with other SSRI’s like Prozac and Zoloft, and with stimulants such as Ritalin and caffeine.

It’s more of an individual issue. Abruptly quitting coffee intake can cause headaches, fatigue, memory problems, and confusion. Many people comment – “I’m useless until I’ve had my first cup of coffee” – which I believe explains this concept well. I don’t recommend avoiding caffeine – but I’d be careful to avoid high doses. One to two cups of coffee per day are plenty. Green tea and soft drinks such as cola and “Mountain Dew” have lots of caffeine.

QUESTION:

Dear Dr. Heller,

Thank you so much for kindly replying to my last e-mail.  Since contacting you I have already visited my doctor and have been started on Prozac.  Although this has certainly made a difference to my dysphoric spells and depression, I have become hyperactive and very anxious.  Since discovering your site a few weeks ago I have read every question and answer you have given, spending hours and hours sifting through all the information on your wonderful site.  I have read several times that when side effects of anxiety and a feeling of being unable to ‘switch off’ occur, then the GAD is almost always present.  After looking at the criteria I am quite sure that this applies to me too.

I read that you recommend BuSpar and I went to my doctor to request this drug, which he did honor me with.  However I have taken this a few times and each time I felt extremely nauseous and was convinced I was going to vomit (although I did not).  I also had very disturbed sleep with nightmares and woke up several times completely cold and clammy and drenched in sweat.  I could not bear to be uncovered and then once covered I felt too hot almost instantly.  Rather than making me feel more calm – I felt very agitated and unwell.  I have looked up the side effects of BuSpar on several different sites and these effects seem to fit well with some of the ones described.  Is this something that is common?  Will these effects likely be temporary?  Are they a sign of something dangerous?

I read that if someone is sensitive to Prozac you recommend that BuSpar be taken first to allow the person to be able to tolerate the Prozac.  Does this mean that I should discontinue use of the Prozac and take the BuSpar on its own first and then resume use of the Prozac after a short period of time?

Also I am currently taking Neurontin for temporal lobe epilepsy and I see that you say Neurontin can sometimes mimic ADHD.  I have been on Neurontin since March of this year and I have found it almost impossible for me to work properly ever since.  I am self employed and my partner thankfully has taken over most of the duties that I am now unable to do.  For example, I cannot seem to concentrate or keep my mind occupied for very long and I feel that my skin picking and emotional outbursts (particularly anger and aggression) have got worse since taking Neurontin.  I find it almost impossible to pick up the phone, and part of my job is ‘cold calling’, which I had absolutely no problem with before but now I feel too scared and anxious to do it.  I don’t know why this is, but it is a major part of my job.

My doctor, although fairly open to new ideas has allowed me to have the Prozac, Haldol and BuSpar but when I said that I would like to try coming off the Neurontin and trying perhaps Topamax again once I have settled on these new medications, he said he didn’t think that it was a good idea as the fits are fairly well controlled, which coincidentally has only occurred since taking the Prozac along with the Neurontin!  In fact I have not had a Grand Mal or an Absent Seizure since beginning the Prozac a month ago – that is the longest I have gone in a long while!  He also said that he was only going to let me have Haldol and BuSpar temporarily for a couple of weeks until I feel better, then he will withdraw them as he is concerned about the amount of medications I am currently taking.

I printed out lots of FAQ’s and information from your site as I had wanted to go armed with facts to assist me but he barely glanced at it.  Would it be wise in your opinion to change from Neurontin to something like Depakote or Topamax?  My weight is a big concern and I know that Topamax can produce weight loss in some patients and the opposite can be said of Depakote.  Incidentally I have lost 7 pounds since starting Prozac and I really don’t wish to reverse this effect!  I have tried Topamax once before but only for a few days and had a pretty bad reaction to it – but I wonder if this is what would be different now I am on the Prozac?

So to recap what I wish to know are answers to the following: Do I need to discontinue use of Prozac temporarily and meanwhile take BuSpar to be able to tolerate Prozac?  Is there an alternative to BuSpar that you would recommend?  And do you consider the side effects I have experienced to be consistent with BuSpar or could this indicate another disorder such as ADHD, possibly due to taking Neurontin?  Would you recommend changing me from my current anticonvulsant, i.e.  Neurontin, to something else?  If so, would I be able to tolerate the Topamax now that I am on Prozac?  If the Neurontin has ’caused’ ADHD I understand that this would only be as long as I am taking Neurontin, but is there something else I could take to counteract this, perhaps Ritalin, or would you think it wiser to cease the Neurontin altogether?

I am going to see a different doctor within my practice next week to see whether I can find another doctor who is willing to investigate this on my behalf.  If I have no joy then I will continue seeking an alternative doctor until I find one who will take me seriously.  Like you say, you have to want to get better and it is down to the individual to take control of their recovery.  I must tell you Dr. Heller that you have truly inspired me and I am more determined than ever to get better since finding your site.  I deserve a better quality of life and I am determined that it shall be mine.  I only discovered your site by ‘accident’ but I truly believe that some angel was guiding me to find your site.  Thank you so much for your wonderful work.

Yours truly.

 

ANSWER:

BuSpar lowers the serotonin receptor #1, reducing the worry and mind constantly going, seen in those with the GAD.  When BuSpar also increases anxiety it’s usually due to an elevated serotonin receptor #2 – which is commonly associated with post traumatic stress disorder.  Remeron is the key medication here.  It can be taken for a few months to block that elevated 5HT-2 receptor, and allows for BuSpar and Prozac to be taken.  It can have short term side effects – particularly grogginess, but it’s worth it.  I usually recommend 30mg daily. Sometimes stopping Prozac is necessary to allow BuSpar to work.  BuSpar and Remeron can be taken together.  Once BuSpar and Remeron are working, there should be no problem with either Prozac or Ritalin (if AD(H)D is present).  After treating those with the BPD for 13 years I’m still convinced that Tegretol is the “mood stabilizer” of choice.  It works the best.  I’ve never seen Neurontin work for the BPD.  Depakote is a reasonable alternative, but it’s not as consistently effective.  Topamax has caused lots of side effects.