QUESTION:
Dear Dr. Heller,
After reading EVERYTHING on your wonderful website recently, I saw my psychiatrist on October 2, 2000 for a medication review. I have been seeing this Dr. since February of this year and had basically stayed on the same meds, which were: Effexor XR 300 mg. daily, Klonopin 0.5 mg bid, Trazodone 50--100 mg @ hs, and Valtrex 500 mg daily as suppressive therapy for genital herpes.
Following much discussion on my part regarding your theories of Dyslimbia and BPD, and much interruption and making light of your theories on his part, I finally got frustrated enough with him that I basically insisted on him trying at least some of the things you suggest. I expressed my absolute intolerance of the fact that I still can't handle the stress of going back to work (haven't been able to work for a year now as a nurse or anything else for that matter) and that I can't seem to cope with a darned thing even the slightest bit stressful. Constant thoughts of suicide never leave me for long. I experience extreme fatigue. I have mood swings that come and go without warning. I am currently experiencing severe emotional pain following the breakup of an 18 month relationship with yet another abusive man (even though I did the breaking up and knew I did the right thing because he was being emotionally abusive).
I did eventually persuade him (my Dr.) into tapering me off Effexor XR (37.5 mg daily) and beginning Prozac (starting with 10 mg daily x 7 days, then 20 mg daily thereafter). He also consented to giving me something for severe mood swings, so he went for Depakote even though I told him you preferred Tegretol because he said "Tegretol has some side effects that you don't want any part of!". I am taking 225 mg of the Depakote in the a.m. and 500 mg @ hs. He did agree also to get some labs done on me, which showed the following: ALT (SGPT) 21 IU/L......(reference range 5-45) AST (SGOT) 20 IU/L......( " " " ) Vitamin B12 244 PG/ML(reference range 250-900) Folate 6.8 NG/ML (reference range 4.0-20.0) TSH 1.30 uIU/ML (reference range .27-4.20)
The questions I have for you are: (1) Would you treat the slightly low B12, and if so, how? (2) Also, do you think my thyroid is ok? I do have a family history of hypothyroidism and goiters.
In one of your articles I remember a TSR test being mentioned, but unfortunately I know nothing about it. I had planned to fax you my records (approx. 20 pages from the office that I am currently being seen at), along with this email, as I think these might be helpful to you. I'm also trying to arrange a trip down to see you by staying with somebody I know in Boynton Beach to help with expenses. Unfortunately I got charged $25 today for 18 pages of records and have discovered that there are several things missing (my last two visits with the Psychiatrist among other things).
Here are the diagnoses in my chart that I got copies of today: Axis I - (1) Post Traumatic Stress Disorder, Childhood Onset. (2) Major Depressive Disorder, Recurrent, Severe. (3) Generalized Anxiety Disorder Axis II - Initially deferred, but later a diagnosis of Borderline Personality Disorder was established. Axis III - Generally good health - history of migraines. Axis IV - Past sexual abuse, past domestic abuse, psychiatric symptoms and sequelae. Axis V - Current GAF - 40. Highest GAF - past year - 50.
Also, is there any chance of getting a tape or anything of the Lecture and Recovery Workshop you will be doing on Nov. 9th? I would love to hear what you have to say, but know I can't get down there to Florida that quickly - I live near Des Moines, IA.
Thank you so very much for your time and attention to the above. I want you to know as an RN and as a patient, your contributions to mankind and the mental health field are "too wonderful for words."
ANSWER:
Thank you for your very kind words. I have a lecture from last year that was recorded,
and if you'll send a blank video tape with return postage we'll send it to you.
Regarding Tegretol versus Depakote - Tegretol's biggest problem is a one in 125,000
chance of severe bone marrow damage. Depakote is not a clean drug by any means - and can
cause tremors, weight gain, and severe pancreatitis. In my experience Tegretol is far
superior to Depakote in treating the BPD. Depakote has been shown to reduce anger in BPD
patients (which Prozac does also), but Tegretol has been shown to reduce the severity of
behavioral dyscontrol - a seriously important issue.
If you were my patient I would definitely treat the B12 as it is very low normal. My usual
recommendation is B12 3000ug daily x 1 month, 2000ug daily x 1 month, then 1000ug daily.
Regarding the thyroid, the only test you reported was the TSH. For most individuals with
the BPD and thyroid problems, the TSH is normal but the FTI (or T7) is low. My Newsletter on low thyroid will give you lots of information.
It's usually impractical to get TRH infusion or similar tests performed.
