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Dual Diagnosis


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My sister recently almost died after an attempted suicide that followed several days of non-stop cocaine use.  She was involuntarily committed and is now required to go to substance abuse treatment and get mental health care. 

She has several diagnosis that are all contributing to her "self-medicating" with drugs and alcohol.  Now that she had this overdose obviously she won't be given controlled substances at least not for awhile. 

She has:

OCD

Trichtollimania (pulling out her own hair)

Social Anxiety Disorder

Generalized Anxiety Disorder

ADHD

Insomnia

Depression

I also think she dissociates some.

Any suggestions on a good combo?  She wants Wellbutrin added in to counter the sexual side effects, but other than that she's open to suggestions.  Right now she is on:

Luvox (300 mg)

Trazodone (for sleep)

Risperdal (1 mg)

She was previously on Lexapro and it worked great for the hair pulling, which Luvox hasn't helped with, but it had too many sexual side effects so she went off of it.

I was thinking something like:

Cymbalta or Effexor or Lexapro

Wellbutrin

Trazodone

Strattera

Rispderal

I've heard Risperdal can be helpful for anxiety as well as mood swings.  But can Wellbutrin be taken with Strattera?  Her doctor had her on Wellbutrin and Adderall at one time and it sent her through the roof...

Thank you!

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I'd be catious treating with strattera now.  Let's see how much she calms down just being off the cocaine.  I would treat the OCD/Depression before the ADHD. 

Luvox is THE med for OCD.  Hopefully it will work.  But you have to give SSRIs time....like 2 months.  Going on and off them quickly is a bad idea.  Also, never assume just because one med of a class gives you sexual side effects that all will.

My guess 1) Wellbutrin, 2) Cymbalta, 3) Effexor, 4) adding another atypical AP like Geodon, 5) Strattera

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What's she's on now is a good start for the worst of her symptoms.  If she find the Risp too mind numbing, seroquel might be a better bet. 

I've been dxed with everything she has except I have a bit of Tourette's instead of the trich.  I also let coke and crack take over my life for a while, so I can guess where she is right now.  I have horrid ADD but can't take anything for it unless I'm also on something to keep the ADD meds from making my anxiety/OCD/Tourette's worse.

It's going to take some time for her brain to recover from the coke use.  Until then, it will be hard to gage the effect of any dopamagenic (sp?) agent. 

A medication that is commonly used to treat drug cravings, tourettes (which may or may not be related to trich), anxiety, insomnia and some ADD symptoms is clonidine.  Its sibling drug Tenex is often useful is many of the same circumstances.  They are sometimes used to treat oppositional defiant disorder and "explosive rage disorder" in children.  Both are hypertension medications that are used off-label for psychiatric purposes.  Tenex has the advantage of being less sedating so it's easier for some people to take during the day. It is not recommended for anyone who is a strong suicide risk as it's fairly easy to kill yourself with it.  I'm guessing that her pdoc is going with risp. rather than one of the milder APs because it's the one most likely to help with the trich.  Using clonidine for that would let her take Geodon or Seroquel for the OCD and anxiety.

As long as possible bi-polar isn't a factor, high dose SSRIs really are the best place to start for OCD.  Really high.  Often higher than the recommended max on the PI sheet.  If her pdoc doesn't want to go there and would rather futz around with combining low doses of this and that, find a new one. 

Wellbutrin has the potential to make many of her symptoms worse.  Strattera is the next logical place to go.  Some women have found it to have an aphrodisiac effect.  Without drugs, she's likely looking to sex for something, anything, to feel good for a while.  Unless she's really serious about staying clean, it would be all too easy to decide to do a couple bumps of coke just to be able to get horny.   

Contrary to what some of the the 12-steppers at addiction treatment places say, people who abuse stimulants are not likely to abuse benzos.  If she's miserable there would be nothing wrong with her taking some klonopin every now and then when things get unbearable.  If needed pdocs can instruct pharmacies to only dispense a week's worth of medication at a time or someone else could hold the bottle for her.  For horrid anxiety, there is still nothing that works better.

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Thanks velvet... great suggestions.  Clonidine was actually one she was thinking of asking for.  I'm not sure though what type of combination you were suggesting.  Would you keep the Luvox with Clonidine and Risperdal and Strattera?  Her Luvox is at too low a dose for now to help.  Well, and plus she disappeared with her crackhead boyfriend last night so who knows what is going to happen :-(

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