#referral to scriptpharmacist

[scriptshrink]

I'm writing an apocalypse. Society essentially ends. One of my protagonists is bipolar (as I am). Part of his struggle for survival involves trying to get hold of medication. Personally, I am not sure how I'd do at world's end if I was also unmedicated. My personal experience does not really include extreme tragedy and threats to my survival. So the question: do people in life-threatening situations find that their illness sort of takes a backseat for a while, or do they make things worse?

(part 2) Would having bipolar disorder make my character more susceptible to PTSD or other issues? Would his learned coping skills or meds kind of insulate him? What are some withdrawal risks if he can’t get the meds?

The Scriptshrink consultants answer after the jump!

Charlie 

I’m gonna answer the questions about meds specifically because I have a lifetime of experience with them and I used to study pharmacology, but I’ll leave everything else out because it’s a bit of a tricky question for me to answer.

Theoretically, the medication could have somewhat of a “numbing” effect (common for mood stabilisers) which would make it less likely for PTSD to develop, but I don’t know if this is a thing that’s actually been studied. I know that my memories from when I was on my first medication are vague and distant, as I felt like there was somewhat of a disconnect between my feelings, thoughts and my actions - but I don’t know if this would be enough of a disconnect to stop PTSD from developing, should I have been exposed to anything traumatic in that time. Also, traumatic memories are processed differently from nontraumatic memories, so its a bit up in the air. 

 As for withdrawal, it depends on the medication, a few different classes of meds are used for bipolar and all have different side effects and withdrawal symptoms. It also depends on the dosage, whether the person is tapering or going cold turkey, and the individuals physiology. We’ll assume, given the scenario, it’s cold turkey. 

So, the common withdrawal symptoms from lithium include: anxiety, headaches, nausea and emotional dysregulation (very rapid, uncontrolled mood swings). Lithium is pretty forgiving in terms of withdrawal compared to other drugs, which I’ll get into. 

Anticonvulsant drugs (valproate, lamotrigine, carbamazepine etc.)  are a lot less forgiving in terms of withdrawal. Mild symptoms include tremors, irritability, dizziness and vertigo. I came off of a drug of this class and I was so dizzy I nearly fell, multiple times. This was at a fairly low dosage too. The main risk with discontinuing anticonvulsant medications is that it can cause seizures. It’s not super common, but it is a risk.

Finally - antipsychotics. These include aripiprazole (abilify), olanzapine (zyprexa) and quetiapine (seroquel) among loads more.  I’ve luckily not been through antipsychotic withdrawal but it’s apparently a special kind of hell. Symptoms like anxiety, depression, confusion and difficulty concentrating are common. Nausea, loss of appetite and diarrhea are also not unusual. It’s also possible for someone to develop psychosis, or at least start to hallucinate, when coming off of an antipsychotic even if they didn’t initially have psychosis. Sudden changes in the dosage of antipsychotics also increases the risk of neuroleptic malignant syndrome, which is really dangerous. 

As well as all these symptoms, there’s the most obvious thing - that the meds are being used to treat a disorder, and now he doesn’t have the meds. It’s common for someone to relapse (usually into mania) while going through withdrawal.

NaamahDarling

You have wiggle room. You can decide on the severity of his bipolar, how well he responds to medication, how well he handles adversity. I would totally believe it if a bipolar character melted down under life-threatening circumstances.  I would also totally believe it if they buckled down and handled it as long as there were consequences.I’ve had withdrawal from Seroquel and it was, indeed, a circle of hell. Tremors, severe insomnia, several episodes of depersonalization/ dissociation.  The worst was the random twitching every minute or so.  Hypnic jerks were terrible.  

Basically, if you WANT withdrawal to be a factor, it sure as heck can be.  You might also consult @scriptpharmacist​ for details on withdrawal from specific drugs.Immediate catastrophes absolutely can drive everything else to the back of your mind. It might be short term, though - days, a couple of weeks at most. And after that, as the acute stress fades, it starts to take its toll, and you can wind up worse than before, needing more intensive treatment. 

Even non-mentally-ill people react to life-threatening situations in different ways. Also, some react really well to, say, a medical emergency (broken leg, kidney stone) but not so much to a natural disaster (tornado, house fire, earthquake, etc.). So there’s a lot of variation within healthy populations.  And even totally healthy people may navigate a disaster and then, once the danger has passed, totally break down.  That’s normal, even for healthy folks, and mentally ill/bipolar folks are the same.How well your character handles pressure is more of a general character trait that you can decide on than one derived from whatever mental illnesses he might have.

Also, bipolar disorder is frequently comorbid (happening together) with a lot of other psych issues.  It would not be unusual at all for your character to have/be more susceptible to PTSD. 

Learned coping skills can help under pressure, but those take effort to deploy and as things become more stressful, coping strategies become harder to implement and may not work quite as well.  It’s rough even if you’re good at it. 

I have a procedure mapped out for panic attacks and even a severe attack is always going to be of limited duration.  Dealing with something like the bipolar depression is harder because it’s not limited in duration.  I have strategies, but it’s harder to take on something so large. 

I would kinda expect a character like yours to have some self-care stuff he’s found that he CAN do, and for those things to be VERY important to him.Trying to get meds even TODAY when they are can be harrowing. My Seroquel generic is HARD to get, but withdrawal from it is AWFUL, so I don’t have a choice. I HAVE to fight to get it. Finding my right generic Wellbutrin was so hard and I do well enough without it, that I just went off it because the stress of fighting to get it was so absolutely atrocious.  

So his meds would have to work WELL and have manageable discontinuation effects to make it worth trying that hard to get them.Readers who HAVE mental illnesses might appreciate a nod in the direction of “he’s tried other meds, and it didn’t work out, it’s THIS ONE that is SO HELPFUL he will PUNCH MUTANT ALLIGATORS to get it!” Trying several meds is common, and it’s also relatable and would be an easy detail to slip in. You don’t have to name them.Check also to see if it’s a drug you have to work up to a full dose of (like Lamictal), so you know whether it’s realistic to have him go right back to taking it like nothing happened.

Disclaimer 

[scriptshrink]

Does substance abuse change the way medicines affect the body? Specifically, an alcoholic on antidepressants and a pill-popper on antipsychotics. Does it change if the person stops abusing their substance or if they abuse their substance worse than usual? I SWEAR this is a writing question.

This is a question for @scriptpharmacist !

[scriptshrink]

Hello, hope you're well! :) Question about Brief Psychotic Disorder. Character is traumatized by having to face his abuser and his manipulation/mental abuse daily. Character is an addict, and, in the throes of the psychotic episode, relapses into abusing Xanax/Valium/Vicodin and the like to deal with the stress. Would that stop the psychotic episode, since it 'helps' him feel less anxious/scared/stressed and 'feel less' traumatized? Or is it not that simple?

From what I can tell, it’s really not that simple. These medications may help the character feel temporarily better and less stressed out, but it would not end their psychotic episode. You’d typically need antipsychotics for that.

However, because your character has brief psychotic disorder, not schizophreniform, schizophrenia, etc, it’s possible that by the time an antipsychotic could kick in, the psychosis could already have ended. Sometimes they can kick in within a few days; other times it can take 6 weeks for the effects to kick in (to qualify for a diagnosis of brief psychotic disorder, the episode can’t last more than 4 weeks).

Disclaimer - psychopharm is not my forte, at all - @scriptpharmacist may help you get a better answer.

[scriptshrink]

Guilty ask - A is married to B. B has an affair with C. BC decide to kill A. With C's knowledge, B poisons A. But they have miscalculated and instead of dying, A is so high that once he finds out about B's infidelity and the murder attempt, he kills B but doesn't remember it. In this story, C gets rid of B's body, and carts A back to his house. When A awakes the next day, he never suspects he's missing a day - is this possible? (He lives a solitary life, so no one points out any incongruity)

I’m not that knowledgeable about poisons / the effects of drugs - go say hi to @scriptpharmacist for that part!

But yes, it’s not unreasonable for him to never find out he’s missing a day if he doesn’t have a structured weekly routine, and isn’t the type to really keep track of days anyways.

[scriptshrink]

So I have a character that is going to be tortured and then have a drug addiction forced on her (as in they basically forced the drugs into her system and made her crave more as most addictions do). So I was wondering if you had any tips for how combining the ptsd from the torture and the withdrawal after effects would work. Help would be really appreciated and there's no rush on answering!

Heya! There’s a lot of different drugs that could be used, and each of them has different symptoms when going through withdrawal. Maybe head on over to @scriptpharmacist to narrow down what kind of drug you’d like to use, then come back to me when you know what one you’d like to use in particular!

[scriptshrink]

What would be the immediate effects of wellbutrin (if any)?

This is a question better suited for @scriptpharmacist!

[scriptshrink]

My character has bipolar disorder passed along from her mom's side of the family. Would it be plausible for symptoms to start showing up after a really traumatic event (like someone's death) when she's 13? Also, how would she be diagnosed and what medications/therapy would be prescribed, and what kind of side affects might they have? This blog is so helpful! Thank you so much!!!

While it can show up at any age, 13 is a little early on for bipolar disorder to show up (the average age is 25).  Not to say it’s not possible, but keep that in mind.

There are actually two different kinds of Bipolar disorder that you need to choose from in creating your character.  

Bipolar I - in this disorder, the manic symptoms are much more severe.  You don’t need to have had a depressive episode to be diagnosed with this.

Bipolar II - You can’t have had a full-blown manic episode - only a hypomanic one.  You need to have had a depressive episode to be diagnosed with this.

I’ll go more into the differences between them (and cyclothymia) in another post later on.

Medication can be extraordinarily helpful to a character with bipolar.  Lithium is the most famous one, but it comes with a whole bunch of nasty side effects. Other mood stabilizers include Depakote, Lamictal, and Tegretol.  A lot of the time, atypical antipsychotics are used too - even if the character is not psychotic.  I knew someone who took Risperidone and Clozapine, but I’m not really sure which of the others are helpful to someone with bipolar.  These come with a whole host of other side effects.

@scriptpharmacist, can you go into a bit more detail on these drugs and their side effects?

Therapy also helps a lot, but medication is the front line.

One of the interesting things to note about most medications for bipolar is that many people with bipolar have some trouble taking their medications consistently.  Mania feels really good, and oftentimes the side effects of medication really suck.