Medical Literature

QUESTION:

Dear Dr. Heller,

My 24 year old daughter is mentally retarded. she is on Tegretol, Paxil, and Loxapine she has calmed down some. she was placed in a group home yesterday and she became violent. is there anything that I can do to help her/ or something that can be done for her?

ANSWER:

Assuming she has the BPD, the medications are a good choice. It’s very, very difficult working with these mental health diagnoses in someone who is mentally retarded. Making diagnoses is also very difficult. I often recommend that my screening test be taken by both biological parents to look for clues regarding the child’s diagnoses. Attention deficit disorder needs to be looked at as well, because impulsive anger can worsen her condition. The atypical antipsychotics, especially Clozaril, Risperdal and Seroquel may be of significant use as well. I have generally found that high normal blood levels are needed for Tegretol to have it’s maximum effectiveness.

QUESTION:

Dear Dr. Heller,

Will you tell me, is it possible to have (and recall later) hallucinations during an epileptic fit?

Thank you.

ANSWER:

Yes, particularly if the seizures are in the brain’s limbic system or “complex partial seizures”.  This is especially true for those suffering from the BPD.

QUESTION:

Dear Dr. Heller,

I got Haldol 2mgs from my psychiatrist for dissociation and dysphoria.  Now I hear from my therapist (4th year resident) that something awful can happen to me unless I take something called Cogentin with it.  I thought that only if you’re on Haldol every day could something bad happen, but he said that even for one dose I can get something called torte- (I don’t remember the rest of the word but he did a demonstration where his body was twisted and his tongue sticking out).  Now I am afraid to take Haldol because my medical Doctor did not prescribe the antidote to be taken with it.  Although I am on Wellbutrin and 10mgs of Prozac every day, I am suicidally depressed.

ANSWER:

Your therapist’s immaturity is showing.  It was an extremely inappropriate thing to say.  Your psychiatrist did the right thing, and clearly has your best interests at heart.  I commend your psychiatrist for giving you as needed medications to stop dissociation and dysphoria (anxiety, rage, depression and despair). Everything in life (and especially with medicine) is balancing risks against the benefits.  It’s dangerous to drive a car, but the benefits usually outweigh the risks.  When you turn on the hot water, the pipes could explode.  It’s highly unlikely, but it could happen.  You perceive the benefits as outweighing the risks. Rarely does Haldol cause a side effect called a “dystonic reaction”.  This is a temporary imbalance in dopamine in a separate part of the brain that are called the basal ganglia.  Dopamine blockers like Haldol cause a relative imbalance with another neurotransmitter called acetylcholine.  It can be blocked with a medicine like Benadryl or Cogentin.  Since it rarely happens, using Cogentin or Benadryl whenever you take the Haldol is only necessary when the individual gets a reaction at a specific dose.  This side effect is often dose related.  The dysphoria instruction sheet I use for my patients explains this. Long term daily use – particularly in the elderly – can cause a serious neuromuscular disorder called tardive dyskinesia.  The risk is small but real.  The risk of suicide or self-destruction from not treating dissociation and dysphoria (anxiety, rage, depression and despair) are also very real.  What I do with my patients is add Tegretol when they need lots of Haldol.  Here is the medication sheet I give to my patients.

QUESTION:

Dear Dr. Heller:

I am presently taking Prozac 60 mg with good effect.  On occasion I suffer from severe “dysphoria” which I treat with Zyprexa PRN.  Taking Zyprexa only as needed is helpful and kicks a dysphoric spell somewhat quickly. 

I see in your other articles that you recommend Haldol on a PRN basis.  Is there a difference?  Is Haldol superior to Zyprexa in BPD?  I, myself am not worried about the weight gain of Zyprexa.  Aside from that side-effect, is there any major differences with these two drugs?  I know Haldol is a typical and Zyprexa is an atypical antipsychotic.  Also, how about Risperdal?  Is this comparable or better in any measures?

ANSWER:

First I want to say how thrilled I am that you’re taking an antipsychotic medication on an as needed or “prn” basis.  It’s a crucial part of successfully treating the BPD.

Zyprexa can work that way, although it usually takes 60-180 minutes to work.  The weight gain is a huge problem, as is expense.  Many people complain they don’t “have any feelings” while taking it, and it tends to make patients very groggy.

Risperdal is great on an as needed basis.  When an SSRI (particularly Prozac) is in the system and a severe crisis develops, Risperdal – usually at 3mg – has no equal in this regard.  Side effects are a problem at this dose and I warn patients they may be groggy and non-functional for a day or more.  Interestingly Risperdal is rarely effective on an as-needed basis if taken daily.

Haldol is a typical antipsychotic, which means cumulative dose is more likely to cause a problem with tardive dyskinesia than Risperdal or Zyprexa (weight gain from these two medications can cause diabetes and resultant heart disease, arthritis, high blood pressure and stroke – these medical complications need to be taken into account.)  Haldol in low doses has been shown in the literature to work on an as needed basis for transient (or temporary) psychosis.  Side effects are rarely a problem and the individual is usually able to return to work or family life in 5-10 minutes with the dysphoria (anxiety, rage, depression and despair) gone and without impairment.