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Calmed by Ritalin: Questions about meds/DX


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Hi all,

It's been a while since I've posted here. I had a very interesting experience with Ritalin today that's prompted me to question a few things. But before I get to that, I'll lay out my history. This is kind of long, so you can skip down to my explicit questions, which I've marked with triple asterisks (***).

Current DX: Anxiety and Bipolar, NOS. For most of my life I've been highly anxious; in recent years there has been a more pronounced physical component (restless legs, general tension). I also have borderline-like traits (scared of feeling trapped) due to some bad stuff that happened when I was young. Finally, there are seasonal fluctuations in mood that have been getting more noticable over the last 5 years or so: winter lows and summertime increases in energy and agitation. Oh, and I generally feel very removed from my underlying emotions.

The Bipolar DX was largely arrived at empirically due to increased anxiety/agitation in response to a number of antidepressants (see below). My current therapist doesn't see any evidence of it and my only hypomanic-like episodes have been due to benzo tapering. (I did have a summer of partying in my early 20s that could have been hypomania or could have been about breaking free from some emotionally repressive relationships from childhood.)

An annotated med history is at the end if you want to read it, but currently, I'm on 15 mg of Valium and 800 mg of magnesium daily. I also take 2.5 mg of Prozac every other day. Prozac has been very helpful in terms of my mood, but I've also found myself feeling wound up both physically (heart palps and restless legs). This has been particularly strong as I tapered from 17.5 to 15 on the valium over the last couple of weeks -- I had to reduce the Prozac to compensate.

Dopamine:

Today, I tried some Ritalin (~5mg) that a friend had given me as an experiment. I was expecting to get hyped up, especially since I hadn't taken any valium yet. Instead the _opposite_ happened. I felt amazingly calm and collected. I also felt like my physical jitteriness subsided quite a bit. I didn't feel like I needed the benzo at all until this feeling wore off about 4 hours later.

*** My bipolar DX is questionable, but if it were true, would dopaminergics have the potential to be calming in the short-term but destabilizing over the long term? Or is it what you see up-front what you get?

*** Is my reaction to Ritalin indicative of anything? Possibly dopamine hypoactivity?

This would explain my extreme akathisia from very small doses of zyprexa and seroquel. It could also explain the initial akathisia from SSRI start-up and my difficulty with benzo tapering (high serotonin => transitorily low dopamine). Finally, increased dopamine is one of the common links between the smoking and the two treatments that have worked: Celexa+Wellbutrin and Tegretol+Klonopin. (The other common mechanisms are l-type calcium channel blockade and increases in GABA sensitivity due to allopregnanolone.)

*** What does this mean for treatment?

I would be worried about Ritalin due to its potential for habit-formation. The other option would be Wellbutrin agumentation. Here I'm the problem is that I really don't react well to norepinephrine, which WB seems to have relatively more action on. Are there any other non-stim dopaminergics that I'm forgetting about?

*** Could Ritalin or Wellbutrin worsen dopamine dysfunction in the long run?

Anyway, if you've read this far: thanks and I'd apreciate any ideas you might have. My pdoc is good, but I'm a really weird case.

Best,

cache-monkey

Meds and combos that have NOT worked:

> Wellbutrin alone - lift in mood, but increased agitation/anxiety (ag/anx) to the point of OCD-like behavior

> Serzone, Sezrone+BuSpar, Serzone+BuSpar+Xanax - no mood lift, increased ag/anx

> Cymbalta+Xanax - frank akathisia

> Lamictal+Xanax - increased anxiety and first/only panic attack

> Lithium+Klonopin - some lift in modd, but increased anxiety from Li+; had to d/c because of nephrogenic diabetes insipidus

> Depakote+Klonopin/Valium - horrible sleep, low mood and mental function, no real reduction in ag/anx and maybe it got worse

> Atypical neuroleptics+Klonopin - All gave akathisia at low doses (e.g. Zyprexa at 2.5 mg and Seroquel at anything above 25 mg)

> Lexapro+Klonopin - felt more tense

> Have also tried Trileptal, Keppra and Campral, all of which left me feeling down and had pain and/or itching as a side effect. Also, trying Lamictal again led to SJS-ish symptoms.

What's worked?

> Celexa+Wellbutrin - felt very good ... limited anxiety, but I did have impulsivity in terms of binge-drinking and procrastinating (but no more than the "normals" I was going to school with); I was was actually in touch with my emotions and could act on them. D/c'ed because I felt like my depression was gone

> Benzos - help calm me, but leave me feeling blue and flat

> Tegretol+Klonopin - reacted similarly to Celexa+Wellbutrin, but with greater gains in anxiety both psychic and physical. Had to d/c due to SJS-like reaction

> Magnesium - a little calming

> Smoking - rarely fails to calm and lift mood [edited for grammar]

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My god, your question is smarter than my answer could ever hope to be! ;) But the fact that ritalin calms you could be a really strong indication that ADD is your problem, right? I know distinguishing between forms of ADD and bipolar can be difficult. Has your pdoc considered that?

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... the fact that ritalin calms you could be a really strong indication that ADD is your problem, right? I know distinguishing between forms of ADD and bipolar can be difficult. Has your pdoc considered that?

Actually, my pdoc hasn't, largely because I hadn't really thought of this as ADD because I can get hyperfocused when I'm on a deadline. I'll bring it up with him next time I see him. Thanks for the suggestion.

I guess I'd been thinking of it more in relation to my physical jitteriness, which I didn't bring out enough in my windy post. The concern here is something like "tardive akathisia", which I don't understand so wellbut has something to do with the dopamine system.

Also, one thing that I forgot to mention is that I was on low-dose selegeline (also pro-dopamine) for a while and that made my mental and physical jitteriness worse, which makes my reaction to Ritalin all the more puzzling.

~cache-monkey

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Yes, you certainly haven't lacked analysis. ;)

My tdoc and I discussed Ritalin with respect to my (then) BPII treatment (now that I've had a manic episode I've now moved up the ladder to BPI). According to him, too much activity in the frontal lobes are signs of both ADD and BP II/NOS. The fact that you respond to WB is some indication that your dopamine system is involved in the equation. But how much WB you're on makes a huge difference in the response (because it is a partial dopamine agonist). This is highly non-linear shit, man.

I personally would worry more about the benzos than the ritalin for habit formation if it does in fact work that well for you. Do you dream a lot, e.g. when you're not on benzos? Also when you say smoking, do you mean nicotine or cannibis? When I used cannabis it did just as you describe.

Remember also -- good doctors don't treat diagnoses, they treat patients. Good luck and don't worry you'll have your minor in pharmacology in no time....if you don't already!

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Yes, you certainly haven't lacked analysis. ;)

Yeah, that's pretty much me. Serves me well professionally, but definitely bordering on OCD/hypochondria in the health domain.

But how much WB you're on makes a huge difference in the response (because it is a partial dopamine agonist). This is highly non-linear shit, man.

Had not heard any of this. Looked up the metabolism again and remembered that I'm genetically an intermediate CYP-2D6 metabolizer and probably phenotypically a poor metobolizer because I'm on Prozac. This means that the NE-favoring metabolite (hydroxybupropion) accumulates much more than in normal metabolizers. (Plus hydroxybup inhibits 2D6 itself, adding the the wacky phamacodynamics.) Maybe that's why I felt wound up on Wellbutrin mono-therapy.

I personally would worry more about the benzos than the ritalin for habit formation if it does in fact work that well for you. Do you dream a lot, e.g. when you're not on benzos? Also when you say smoking, do you mean nicotine or cannibis? When I used cannabis it did just as you describe.

I've been on benzos for about 2 1/2 years. At this point I've pretty much habituated, as has become apparent as I've tried to titrate. I also smoke tobacco. (The effects aren't always immediate. Sometimes it's about keeping my blood level above a certain point.) Here there's an issue of dependence, as well. So I'm a little leery of getting involved with a third habit-forming substance.

Anyway, thanks for your input. I'll make sure to talk explicitly with my pdoc about this at our next meeting. We'd left off last time talking about Lyrica last time, so he might want to try that route first. (It might be good for the anxiety and restless body issues...?)

Best,

cache-monkey

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Dopamine:

Today, I tried some Ritalin (~5mg) that a friend had given me as an experiment. I was expecting to get hyped up, especially since I hadn't taken any valium yet. Instead the _opposite_ happened. I felt amazingly calm and collected. I also felt like my physical jitteriness subsided quite a bit. I didn't feel like I needed the benzo at all until this feeling wore off about 4 hours later.

Ritalin really is not strictly dopaminergic, although we've had a couple of posters claiming otherwise after reading abstracts on HedWeb. Aside from stimulating the release of both noradrenaline and dopamine and inhibiting the reuptake of both for a while, it also inhibits serotonin reuptake a bit.

I would be worried about Ritalin due to its potential for habit-formation. The other option would be Wellbutrin agumentation. Here I'm the problem is that I really don't react well to norepinephrine, which WB seems to have relatively more action on.

The meds with a strong NA effect that you've been on were Selegiline, Cymbalta, Wellbutrin, and Ritalin. The MAOI didn't work out, and it was the most pro-dopaminergic of everything you've tried. Cymbalta is a stronger SRI than NARI - and you've had a lot of trouble on the SSRIs and neuroleptics. But the two most noradrenergic you did fairly well on (with other stuff in your system)

However, I wouldn't recommend dropping everything for Vivactil.

Are there any other non-stim dopaminergics that I'm forgetting about?

Mostly anti-Parkinsons' drugs. Amineptine isn't available. Elavil might have an effect, but it might be drowned out by other effects and side-effects.

Could Ritalin or Wellbutrin worsen dopamine dysfunction in the long run?

In theory it might, but the effects might run the other way instead in the absence of abuse. It's worth looking for studies on the subject.

Anyway, if you've read this far: thanks and I'd appreciate any ideas you might have. My pdoc is good, but I'm a really weird case.

What's worked?

> Celexa+Wellbutrin - felt very good ... limited anxiety, but I did have impulsivity in terms of binge-drinking and procrastinating (but no more than the "normals" I was going to school with); I was was actually in touch with my emotions and could act on them. D/c'ed because I felt like my depression was gone

If the combination worked that well and you were calmed down without sedation by Ritalin, why not try it again, augmenting with low-dose Ritalin? At least if it's over-stimulating, the Ritalin can be dropped.

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The meds with a strong NA effect that you've been on were Selegiline, Cymbalta, Wellbutrin, and Ritalin. The MAOI didn't work out, and it was the most pro-dopaminergic of everything you've tried. Cymbalta is a stronger SRI than NARI - and you've had a lot of trouble on the SSRIs and neuroleptics. But the two most noradrenergic you did fairly well on (with other stuff in your system)

Hmm. I agree that Cymbalta's binding profile makes it about 10 times more potent blocker of serotonin transport than norepinephrine transport. But I happened to run across this study a number of years ago. It indicates that in the prefrontal cortex, Cymbalta just juices the NE relative to 5-HT and DA (600% vs. 110% and 60% increase in extracellular levels). The study also indicates that BuSpar (on which my anxiety, especially the physical component, skyrocketed) boosts NE and DA, but lowers 5-HT (160%, 100%, -50% resp.). I think this is what I was basing my assessment on, as well as an increase in anxiety on Remeron . But then the study in question was a rat study, and the common NE mechanism between BuSpar and Remeron is alpha-2 blockade, which might be an entirely different animal than direct autoreceptor inhibition. So maybe I bring up a pure NE reuptake blocker like Strattera.

If the combination worked that well and you were calmed down without sedation by Ritalin, why not try it again, augmenting with low-dose Ritalin? At least if it's over-stimulating, the Ritalin can be dropped.

Well here's the thing that I realized later in the day. It was amazingly calming while I was on it, but after it wore off I felt worse; especially the restless body business. Makes me wonder if maybe there really might be some sort of tardive akathisia. Again, maybe an argument for Strattera (+low-dose SSRI?)

In any case, I do apreciate your input.

Thanks,

cache-monkey

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If the combination worked that well and you were calmed down without sedation by Ritalin, why not try it again, augmenting with low-dose Ritalin? At least if it's over-stimulating, the Ritalin can be dropped.

Well here's the thing that I realized later in the day. It was amazingly calming while I was on it, but after it wore off I felt worse; especially the restless body business. Makes me wonder if maybe there really might be some sort of tardive akathisia. Again, maybe an argument for Strattera (+low-dose SSRI?)

That sounds similar to the cholinergic rebound from diphenhydramine - if I take that stuff too late in the day I might as well have RLS for all the trouble I'll have getting to sleep. It sucks, but there are days when Adderall just isn't a strong enough decongestant...

So it would make sense if the increased dopamine release just puts you in deficit once the Ritalin wears off. That would be a good argument for trying a noradrenergic like Strattera or even one of the TCAs instead of a stimulant. Waaaayyyyy off label, but I'd wonder if amantadine wouldn't help out on the dopamine front without screwing things up worse for you.

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Ever tried Requip??

Thanks for the suggestion. I actually did try that briefly, but only at a very low dose per my pdoc's directions (lowest dose in the starter pack). I don't remember what else I was on along with it, but I do remember getting "augmentation". I.e. as the Requip wore off, I felt physically worse than worse. Blargh ... more weight on the "my dopamine system is royally fucked" hypothesis. I wish there was a real dopamine system stabilizer.

~cache-monkey

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Actually, my pdoc hasn't, largely because I hadn't really thought of this as ADD because I can get hyperfocused when I'm on a deadline. I'll bring it up with him next time I see him. Thanks for the suggestion.

I'm surprised your pdoc used this to discard an ADD dx as it is a common feature of childhood ADD. Paradoxically, children with ADD can become extremely focused on activities that are of interest to them.

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Well here's the thing that I realized later in the day. It was amazingly calming while I was on it, but after it wore off I felt worse; especially the restless body business.

I agree with null0trooper on this one - sounds like the "crash" that can follow Ritalin use. My son experienced this with Ritalin, severely with Rubifen, and to a very minor extent with Concerta. The "restless body business" sounds familiar too - my son has physical "tics" and restlessness combined with verbal outbursts when unmedicated. Again, this symptom can be consistent with ADD.

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Dreamer-

Thanks for the input. So ADD could definitely be in the mix. The worry with meds is that the physical restessness gets worse in the long run with meds. I'm wondering what your son's experience has been. I.e. did it seem that when the meds wore off (or when/if he tapered them) that his tics/restlessness were worse than before starting?

~cache-monkey

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Dreamer-

Thanks for the input. So ADD could definitely be in the mix. The worry with meds is that the physical restessness gets worse in the long run with meds. I'm wondering what your son's experience has been. I.e. did it seem that when the meds wore off (or when/if he tapered them) that his tics/restlessness were worse than before starting?

~cache-monkey

I can't dx you, but it sounds like a possiblity that it would be helpful to chat with your p/tdoc about. The Ritalin made his tics/etc worse when he withdrew, Rubifen brought back his rages (could last hours), Concerta wears off and he has tics/etc when it does but they are relatively mild. He hasn't gone "med free" because he is a danger to himself and others when he is not medicated (years of behavioural therapy have reduced but not eliminated this).

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