Posted by Cairo on October 5, 2003, at 18:43:02
I would really appreciate some advice regarding my 15 y/o daughter. She has been diagnosed with mixed ADD/ADHD, LD, language disorder, and very recently with Fibromyalgia. A neuropsych consult showed "primary" attention deficit with executive function difficulties. She was labelled selectively mute as a young child, though this may have been compounded by a language delay/auditory processing deficits. She always had good eye contact and wanted to be with kids. Psychostimulants have always helped her attention, though different ones carry different baggage - Adderall causes too flat an affect, Dexedrine caused SEVERE rebound, didn't get enough of a peak effect with Ritalin LA, she's a fast metabolizer of plain Ritalin with some rebound. She is currently on Concerta with kicker doses of Ritalin. Cylert was never tried. All of the above cause varying degrees of social withdrawal. She's always had mood issues even without the psychostims, usually showing as afternoon irritability when she was younger. A trial of Prozac about 4-5 years ago for mild moodiness didn't show much of an improvement. Imipramine was also tried, but it didn't do much for attention and caused tachycardia.
Two years ago she started developing FMS symptoms. A bout with mono 1 year ago made everything worse: increasing anxiety, social avoidance, and brain fog. We tried a 6 week trial of Strattera recently because of the psychostim side effects. At low doses there was a tiny improvement in attention and mood, but as we increased the Strattera dose because of the need to improve attention, we noticed a marked increase in social avoidance and depressive symptoms - extreme lethargy, refusal to go to school, increased fatigue, and a noticeable increase in lack of motivation. The higher dose didn't improve attention much. So now she's back on the former dose of Concerta plus Ritalin. She stopped refusing to go to school, anxiety improved somewhat, but she is still anxious which keeps her at the periphery of the group, but unable to join in. Her attention is now only so so and she just seems out of it most of the time. She has been seeing a Psychologist weekly for CBT for two years.
I suspect that some of her symptoms are due to progressive FMS/HPA axis hypofunction. She looks like atypical depression (thanks to JB Becker for his link to George Chrousos' article on major depression versus atypical depression and Chronic Fatigue/FMS) which is unmasked by the psychostims. Our Psychiatrist gave us a prescription for Paxil which we are waiting to fill after a sleep study is completed next week to rule out sleep apnea, restless legs or other sleep disorder (which I suspect would be secondary to HPA axis dysfunction anyway).
She has so much going on and carries a bad set of genetic baggage from both sides of the family: FMS, OCD, ADHD, schizophrenia, anxiety, not to mention all the other diseases such as heart, Parkinson's, dementia, etc. She is genetically one vulnerable young lady. BTW, a workup by a Rheumatologist rules out thyroid, immune dysfunction, Lyme's, Lupus, and the usual workup for FMS.
My questions are as follows:
1. With so much going on, where is a good place to start? Treat the atypical depression or start with a drug for anxiety?
2) What does the side effect of social withdrawal with psychostimulants and Strattera tell us about her neurotransmitter dysfunction? Did we give Strattera enough of a trial period or should we just forget it as it didn't help attention that much anyway?
3) Given her attention difficulties and lack of motivation and anxiety/social phobia, what place do drugs that increase dopamine have other than the psychostims?
4) Because of the FMS symptoms (muscle aches and tightness, Raynaud's like symptoms, orthostatic intolerance, etc.) and the role of HPA axis hypofunction, would we be better off starting her off with a tricyclic, wait for aprepitant to be released later this month to give it a whirl, or try the Paxil? And if an SSRI, any suggestions as to which might be a better first choice? What about Effexor?
5) Would ordering cortisol levels be indicated? Is salivary cortisol commonly done?I know that because of her complexity, I should just forget the questions and take her to an expert somewhere. Our local Pdocs don't seem to see the big picture and look at all her problems as being compartmentalized; one just wants to give her something for anxiety, another give her something for sleep. I mention CRH and HPA axis hypofunction and their eyes glaze over. WHAT ARE YOUR VOTES FOR THE BEST PLACE TO TAKE HER - any expert, any place? I would appreciate discussion regarding my questions, though.
I also have FMS/atypical, but that is another post. I just completed a sleep study which showed I have 200 arousals per night (and that's on a sleep med), so thank you for any help you can give this TIRED mom.
Cairo
poster:Cairo
thread:265767
URL: http://www.dr-bob.org/babble/20031004/msgs/265767.html