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Old 08-28-2018, 07:56 PM #11
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Default Re: AP Switching: Aripiprozole to Quetiapine

hi. seroquel can be -densely- sedating. on the plus side, low potency tranquilizers (thorazine, seroquel, etc.) -might- carry a lower long term risk of TD than equivalent doses of moderate to high(er) potency drugs (Haldol, perphenazine, Abilify).

TD, EPS, akathisia, NMS, etc. can and do still happen on seroquel, of course. I have only rudimentary knowledge of this, but it seems that when a neuroleptic/tranquilizer is in the mix, more drugs=more problems. So...for instance...I take Abilify. When I briefly tried Depakote with Abilify, I had EPS and akathisia that persisted even -after- the Depakote was discontinued. True story. Lithium is, from what I've read+heard, even worse.

gabapentin might be worth looking into. old school shrinks--I had one once, she was actually fairly awesome--use sedatives (gabapentin, lyrica, benzodiazepines) to help keep the tranquilizer/neuroleptic dose a bit lower. They can also be used to ease tapering off of neuroleptics (and other psych drugs), although the benzodiazepines can have nasty effects after long term use, especially at higher doses (I think "high dose" is anything above the equivalent of 40mgs/valium daily, but I might be wrong about that).

I don't have major drug recommendations. Lamictal has been good to me, personally, but some people hate it, and others don't find it all that effective. Trileptal was kind of mind numbing and depressing, but it could have been the (excessively high) dose.

sorry about the situation. i hope this helps a bit.
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Old 08-29-2018, 08:52 AM #12
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Default Re: AP Switching: Aripiprozole to Quetiapine

As still_crazy mentioned, Seroquel can be extremely sedating. I can vouch for that; we have played with the dosage for a while to get it balanced between symptoms and sedation. That being said, it may work for him!

Extrapyramidial side effects (EPS) such as akathisia is another thing you'd want to avoid. Trust me, it sucks. I did not have it with Seroquel, but did experience it with Risperdal to some extent.

I definitely agree with still_crazy though. Maybe one of the obove mentioned things (gabapentin, Lyrica) could be of some assistance?
Lamicatal seemed to work for me, but I know that it can be unpleasant and they will (are obligated to) warn you of a possible skin reaction, which may sound scary, but a good doctor tapers up very slowly!
(in my case, increasing 25 mg every two weeks starting at 25 mg)

Hope you have found some clarity in these responses!
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Old 08-29-2018, 09:09 AM #13
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Default Re: AP Switching: Aripiprozole to Quetiapine

Quote:
Originally Posted by TicTacGo View Post
Of course I do not mind! I'll help where I can!

Quote:
"... Abilify is one of those neuroleptics (antipsychotic is a very outdated term) with mood stabilizing effects, but is activating. This means that unlike the more sedating ones, it actually gives some energy.
With that effect, it is often used in treatment of depressive-type episodes because of how it is able to lift the mood.

Quetiapine is a more sedating AP and therefore stands as one of the first line treatments of acute mania (along with olanzapine and risperidone) and should thus have a calming effect on agitation or other manic symptoms. ..."
DS had first been placed on Abilify about three years ago for "symptoms of irritability associated with Autism." It seemed to work well enough, as I recall. I know the worse parts of his irritability subsided to the point that both my wife and I took notice enough to make notations. The doctor we had at the time (who was also the first to officially diagnose an Autism Spectrum disorder) had planned from the outset to add a 'mood stabilizer' and had chosen Fluvoxamine Maleate. I recall him saying that the Aripiprozole could treat DS' agitation but it would not treat (or could worsen) his OCD . DS' mum and I had already started becoming suspicious regarding the effects of SSRIs but the doctor felt our son would benefit from it and that it would be safer/less side effects than the other antideps.


To an extent, the doctor was correct. We didn't see any negative side effects for some time with the addition of Luvox to the treatment; however, a great deal of time was taken to get our son to get to therapeutically useful dosages to minimize any unwanted effects, but once he did reach close to maint. dosage, things began slipping. For some reason, I canna recall the specifics of it (I've probably written it in a journal) but whatever they were, they were disturbing enough to pull him off of everything, which we did under the doctor's scheduling. Fortunately, it was Summer and school was out, in case of negative withdrawal effects.


I don't recall our son experiencing side effects from the withdrawal of the meds. I do remember the PsyMD had said that we might need to return him to Abilify if the anger presented itself.


He was correct, the anger/hatefulness did return and DS was placed back on Abilify as the primary agent, along with guanfacine for what's probably a provisional tic disorder (it fluctuates, waxes, wanes, changes form and first manifested long before any psychotropic meds were introduced) and had been on it continuously 2 - 2 1/2 years. He'd had his last dose couple of weeks ago.


Forgive me, I'm sure all of that is relevant to something, but the reasons presently escape me.


In any advent, so he's placed on a 2nd gen AP with unique activating propertiesᵇ for the purpose of controlling agitation "associated with autism" - which it did.


Three years later, he returns with symptoms of agitation at levels equal or higher than when first placed on Abilify. Perseverance of limited interests now at dysfunctional levels. Inability to maintain limits (even those he has placed on himself), hypomaniacal-like (no such word )etc., etc.


Enter Seroquel. 2nd gen AP with sedative properties. He experiences heavy (but not unacceptable) levels of sedation.
Quote:
first line treatments of acute mania
. And it delivers. Hyper perseverance/mania does, in fact diminish; however, irritation and anger (he states he'd never experienced the likes of before) skyrocket.




"
Quote:
Abilify seemed to work. Odd enough. The only problem was the agitation it seemed to cause. it was from there that I was placed on quetiapine."
In my son's case, the Abilify did help control "irritability associated with Autism". Rather well. BUT, it did not control mania, if fact, in hindsight, we can see how it acerbated things on that end. But it warn't prescribed for that. The mania/biopolar symptoms ( though present) had not taken front and center yet. (DS has never rec a Bipolar dx, I use the term "bipolar" because its the closest term I can find that describes some of his features)


Quote:
(Seroquel)... should ... have a calming effect on agitation or other manic symptoms.
The Seroquel did have a marked effect on his mania symptoms, for which it was prescribed. It warn't Px'd for "irritability associated with Autism", though, which maybe is what has rebounded so badly.


Irritability, anger associated with AS must be quite different from that associated with BP and likewise responds quite differently. If that really is the case, I'm wondering if this has exposed the possibility he has both.


==========
We took our son to see the PsyMD, yesterday. She officially yanked the Seroquel, a decision which we wholly agree on and put him on Rispiridone - which you'd mentioned.


We did have one experience with it a number of years ago, when he was about 10 or 11. At the time, I really didn't know much at all (even less than I do now) about these medications, the differences between APs, ACs, SSRIs, what was for what or what symptoms to be on the lookout for.


Or to even be on the lookout for anything.


I just recalled my son behaving differently. He used to love to play with his action men, his little toy soldiers and their little vehicles, it brought him such joy. I noticed him not acting right. Couldn't put my finger on it, he just moved funny and he didn't want to play with his favourite things. One day, he was just sitting on the bottom of the staircase landing not doing anything, looking worried.


I asked him what was wrong and he started telling me about how when he moved, all his 'selves' would move before him and after him. He had 'before selves' and 'after selves'. Some would move in advance of him and some after, like images on a camera taken during multiple, high speed exposures and these 'selves' had memories of before life, different periods during his life and his 'after selves' had memories of after he died.


Then he said that it didn't bother him until his 'after-selves' began breaking order, when he was getting ready to get up and go up the flight of stairs, some of his after-selves had left him to go up first and it was worrying him.


He had'nt been on Rispiridone for very long. He'd started mentioning coloured circles around lights and other visual oddities a bit before his experience on the staircase. I didn't know the significance of these effects at the time, but when he started talking about how beings that lived in between light rays were getting ready to come take care of him - I remembered something my grandmother had described she'd experienced when her heart had stopped for a good while in ICU - and no more Rispiridal!



I wondered in the Risperadone wasn't metabolizing into DMT by some strange process.

Have you ever heard of such?


He'd never experienced anything like that before or since.



So, he's on it now...


The doc said that he was a different person now, older, bigger...different metabolism, etc.



Okay, we'll see.









Long story, some obsessional personality traits had merged with the AS' tendency towards repetition after a traumatic illness from eating tainted strawberries - was mistaken for OCD for some time.


ᵇ You know, I'm sure I've read that Abilify was mood-lifting, non-sedating and so forth dozens of times, but it warnt till I read your "mood stabilizing effects, but is activating." that its dawned on me why our son went from shunning sports, absolutely hating physical training to become an obsessive weight lifter and gymnast! It was during the period he was taking Abilify!! It was energizing!



* One thing, TTT, if you don't mind - could you describe for me what an acute mainia episode would look like from my end. What it would feel like from the afflicted's point of view?


Take your time, no rush on it. But I think it would be very helpful in our case to get that perspective.

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Old 08-29-2018, 09:39 AM #14
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Default Re: AP Switching: Aripiprozole to Quetiapine

Quote:
Originally Posted by -jimi- View Post
He's not still on Luvox, right? Combining Luvox and Seroquel isn't recommended.


No, his last dose of Luvox was probably two years ago. He was taking that as a stabilizer during our first trial with Abilify.


Quote:
Originally Posted by -jimi- View Post
Also remember that a person with autism can be mega sensitive to medication. ...

You ain't kiddin!

Quote:
Originally Posted by -jimi- View Post
What is his worst problem that needs to be addressed?

That is a very, very good question and you'd think that we'd have an obvious, ready answer for it. Its taken a lot of time to ferret out things from one another. Almost like having to stain biological matter in a petri dish so that you can tell what belongs to this cell, what belongs to something else...


I'd say that getting his very intense anger under control is job 1. A close second is dealing with the white-knuckle, death-like grip he has with respects to his perseverant, limited interests (which change or rotate, rather). He is a smart kid but he doesn't study, won't have anything - I mean ANYTHING to do with that which does not inhabit the realm of hypomania and anything he does develop an interest in, regardless of how casual it begins, or useful or whatever, if he does become interested in it, it WILL become obsessional.


The first time his aunt saw him as an infant, I'll never forget - she said "He's going to be intense. Really, really intense."



Quote:
Originally Posted by still_crazy View Post
hi. seroquel can be -densely- sedating. on the plus side, low potency tranquilizers (thorazine, seroquel, etc.) -might- carry a lower long term risk of TD than equivalent doses of moderate to high(er) potency drugs (Haldol, perphenazine, Abilify).

TD, EPS, akathisia, NMS, etc. can and do still happen on seroquel, of course. I have only rudimentary knowledge of this, but it seems that when a neuroleptic/tranquilizer is in the mix, more drugs=more problems. So...for instance...I take Abilify. When I briefly tried Depakote with Abilify, I had EPS and akathisia that persisted even -after- the Depakote was discontinued. True story. Lithium is, from what I've read+heard, even worse.

gabapentin might be worth looking into. old school shrinks--I had one once, she was actually fairly awesome--use sedatives (gabapentin, lyrica, benzodiazepines) to help keep the tranquilizer/neuroleptic dose a bit lower. They can also be used to ease tapering off of neuroleptics (and other psych drugs), although the benzodiazepines can have nasty effects after long term use, especially at higher doses (I think "high dose" is anything above the equivalent of 40mgs/valium daily, but I might be wrong about that).

I don't have major drug recommendations. Lamictal has been good to me, personally, but some people hate it, and others don't find it all that effective. Trileptal was kind of mind numbing and depressing, but it could have been the (excessively high) dose.

sorry about the situation. i hope this helps a bit.
It does help, SCrazy! I've a couple of questions for you, as well, but I'll have to hold 'em till I get back.


Cheers!
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Old 08-29-2018, 04:26 PM #15
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Default Re: AP Switching: Aripiprozole to Quetiapine

Quote:
Originally Posted by still_crazy View Post
...


TD, EPS, akathisia, NMS, etc. can and do still happen on seroquel, of course. I have only rudimentary knowledge of this, but it seems that when a neuroleptic/tranquilizer is in the mix, more drugs=more problems. So...for instance...I take Abilify. When I briefly tried Depakote with Abilify, I had EPS and akathisia that persisted even -after- the Depakote was discontinued. True story. Lithium is, from what I've read+heard, even worse.

Well, the Seroquel was taken out of the picture and in its place, Rispiridone - though it stands to reason that many of the (possible) side effects will still be the same.


Quote:
Originally Posted by still_crazy View Post
gabapentin might be worth looking into. old school shrinks--I had one once, she was actually fairly awesome--use sedatives (gabapentin, lyrica, benzodiazepines) to help keep the tranquilizer/neuroleptic dose a bit lower. They can also be used to ease tapering off of neuroleptics (and other psych drugs), although the benzodiazepines can have nasty effects after long term use, especially at higher doses (I think "high dose" is anything above the equivalent of 40mgs/valium daily, but I might be wrong about that).

I'll have to look it up but I take it that a 'sedative' is not the same thing as a 'tranquilizer' - which would be a good thing, as we were thinking we'd have to rule out all tranquilizers/sedatives on account of how he reacted to the sedation/tranquilizing properties of Seroquel.


I'd mentioned gabapentin to his PsyMD but she ruled it out immediately, stating something about it not being suitable for AS conditions and mentioned some sort of side effect that I didn't catch.





Quote:
Originally Posted by TicTacGo View Post
As still_crazy mentioned, Seroquel can be extremely sedating. I can vouch for that; we have played with the dosage for a while to get it balanced between symptoms and sedation. That being said, it may work for him!

Extrapyramidial side effects (EPS) such as akathisia is another thing you'd want to avoid. Trust me, it sucks. I did not have it with Seroquel, but did experience it with Risperdal to some extent.


Right, we'd thought we'd seen possible signs (tremors, muscle weakness/rigidity) with the Seroquel near the end of his first trial run.


As he's on Rispiridone now, with the same possibility on the horizon, when it comes to observing symptoms and being so many of the symptoms of EPS, TD, Akathisia, NMS, etc overlap, at least in the initial stages - what exactly do you look for and when exactly do you say 'might need to mention to doc' and when do you say 'we're stopping right now!'?


Obviously high fever, delirium, scary numbers from vital signs, etc - (and images of cartoon cats emerging out of the light to perform your last rites, of course) but its unlikely a person will start out with full fledged symptoms, though I've heard with NMS, once it gets going, it develops really fast and as you said, you want to avoid getting to that but neither do you want to yank a potentially helpful med over symptoms that will resolve over time.

Quote:
Originally Posted by TicTacGo View Post
...
Lamicatal seemed to work for me, but I know that it can be unpleasant and they will (are obligated to) warn you of a possible skin reaction, which may sound scary, but a good doctor tapers up very slowly!
(in my case, increasing 25 mg every two weeks starting at 25 mg)

...

Yes, the dreaded and very disturbing photos of Stevens-Johnson Syndrome sufferers.



We actually had our son tested for a gene that supposedly signifies if one is likely to be highly susceptible to developing it (his mum being of Asian descent) but I've really not looked into how dependable the test is with respects to determining the likelihood a given medication will cause it.


Thanks so much!
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Old 08-29-2018, 04:51 PM #16
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Default Re: AP Switching: Aripiprozole to Quetiapine

I have read the latest posts to get up-to-date with everything.

Firstly, the Abilify suddenly causing irritability -might- be because he has further developed. From what I read, I assume he is in his pubescent years? The hormones may be a part of why the Abilify is now possibly exasperating the irritability.

The doctor did say that Abilify should help the irritability, but not the OCD- there isn't great evidence that antipsychotic tranquilizers are of much use. Again, the only one sometimes used for OCD (perhaps in the case of sensitivity to SSRIs) is risperidone.

In terms of the Seroquel: that sedating effect if a bugger. I know all too well how one can wake up and hardly be able to stand. That is something some doctors may try and manage, while others, as his did, will remove it.

I have never heard of such experiences happening on Risperdal. While some psychology articles mention onset of psychosis on Risperdal, it is not a common thing.
If any such thing reoccurs, then it is likely the Risperdal. if not, then one could look into other causes of those peculiar things he had described.

[I'll do the description of mania separately!]
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Old 08-29-2018, 05:02 PM #17
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Default Re: AP Switching: Aripiprozole to Quetiapine

Mania:

In the case of classic mania, an onlooker may notice:

- Increased energy (more than usual)
- Excessive talking (more than usual) or a need to keep on talking. (pressured speech)
- Flight of ideas/racing thoughts (if sufferer expresses them verbally)
- Distractability
- Increased goal-directed activity (almost like hyperfocusing on one thing, except it'll be jumbled with all the great ideas they have)
- Impulsive behaviors
* Psychosis in severe cases

The difference between hypomania and mania is,
1) How debilitating it is
2) Whether or not there is psychosis
3) Whether hospitalization is necessary to contain it.

The sufferer (in the classic case), would feel euphoric and as though they can tackle tasks with all this energy; they may even feel very confident.

In the agitated mania, they usually feel dysphoric with this high level of energy, but of the unpleasant kind. I see at as a pressure cooker, as it feels as though you are unable to get rid of this awful energy.

Hope this helps.
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Old 08-30-2018, 02:03 AM #18
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Default Re: AP Switching: Aripiprozole to Quetiapine

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Originally Posted by TicTacGo View Post
Mania:

...

The sufferer (in the classic case), would feel euphoric and as though they can tackle tasks with all this energy; they may even feel very confident.

In the agitated mania, they usually feel dysphoric with this high level of energy, but of the unpleasant kind. I see at as a pressure cooker, as it feels as though you are unable to get rid of this awful energy.

Hope this helps.

Would further attempts to physically release the pressure produce more dysphoria? More agitation?


I remember numerous times my son (16) would become euphoric about something - a gymnastics routine that he was finally able to do, for example, he would keep doing it over and over and the euphoria would take on an impatient, nervous tone and of course, the lactic acid is building up in what has to be increasingly fatigued muscles, so naturally, his form is deteriorating - which is winding him up all the more - but he won't let go.


We'll hear him stomping up the stairs, after 2 hours of very intense physical activity (the routines require a lot of energy to pull off one, successfully) cursing, sweating, very angry - you know where this goes...


Like a madness takes over him.


It could be anything - going to a sushi restaurant, whatever - everything takes on this intensity that is completely out of proportion. There is nothing else in the world at that moment but THAT.



Our lives are exhausted by it. All we can do is manage his intensity about something.


When its about anything or anyone else other than whats on his mind he becomes extremely lethargic, his eyes are glazed, he looks so tired, like he hasn't slept in weeks and has the capacity to argue for literally hours, will waste hours arguing about doing something or participating in something that would've taken 20 minutes.



Does this sound like Bipolar in your opinion?


Thanks again for all your feedback and responses.
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Old 08-30-2018, 08:12 AM #19
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Default Re: AP Switching: Aripiprozole to Quetiapine

Ah, I understand what you mean.

Well I'd say (and some articles back me up) that if these symptoms (goal orientated activity, hyper-focus, agitation) have been constant since symptoms of AS first appeared, it may not be mania you are seeing.
Like I said, the depressive episodes may be more clear-cut. (though a bipolar diagnosis needs only a manic episode to be present AND is not better explained by another disorder- one of them being a disorder with prominent irritability)

If the shift in behavior was sudden and not present at time of AS symptoms, then it may be a manic episode you described.

That being said, it is possible for someone with AS to be bipolar. It is probably just diagnosed later when it is easier to really nitpick (or split hairs) as to which symptom accounts for which disorder.

In my opinion, I feel that the hyper-focus on whatever grabs his attention at the time (exercise, sushi restaurant etc.) sounds more like symptoms associated with AS. I may be wrong. In my case, the drive to complete a certain activity is usually met with confidence and almost a 'superpower' feeling; in other words, as though I can do anything.
When I become agitated, restless and have that energy, I feel more the urge to release the energy by whatever means neccessary
That is where it'd be tricky- one could say he had that drive for a specific task is because of drive, or you could say it is because that repeated activity was releasing (or soothing) that energy in some way (even to his own detriment). One could even argue a bit of both.

So even if I really stick to my own opinion without saying "I am on the fence because a professional would be able to differentiate", I am still on the fence because the symptoms overlap so much that he would perhaps be diagnosed with BP later on. Professionals sometimes see lack of need to analyze everything in great detail to separate something so close in nature.
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Old 08-31-2018, 12:40 AM #20
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Default Re: AP Switching: Aripiprozole to Quetiapine

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Originally Posted by TicTacGo View Post
Ah, I understand what you mean.
Well I'd say (and some articles back me up) that if these symptoms (goal orientated activity, hyper-focus, agitation) have been constant since symptoms of AS first appeared, it may not be mania you are seeing.
Yes, indeed they have been constant from the beginning. In fact, the perseverance and agitation that surrounded it were the only clear-cut symptoms (of AS) in the beginning (around age 4). That and what just seemed to be a built in inclination to oppose.


Quote:
If the shift in behavior was sudden and not present at time of AS symptoms, then it may be a manic episode you described.
No, there was no sudden shift in behaviour. The behaviour was always there, there was just more of it as he grew.
...
Quote:
In my opinion, I feel that the hyper-focus on whatever grabs his attention at the time (exercise, sushi restaurant etc.) sounds more like symptoms associated with AS.

In my case, the drive to complete a certain activity is usually met with confidence and almost a 'superpower' feeling; in other words, as though I can do anything.
I see, I see what you are getting at.
Quote:

When I become agitated, restless and have that energy, I feel more the urge to release the energy by whatever means neccessary
I see!! Therein lies the difference. He won't release the energy via any means available, as you would, for him, it has to be that and only that specific thing.

That'd also explain why he is so rigid. Rigid and inflexible with respects to the means. That's a hallmark of the Autism Spectrum but not so with Bipolar Disorder, is that correct? It may be present but its not a defining characteristic, right?


Quote:

That is where it'd be tricky- one could say he had that drive for a specific task is because of drive, or you could say it is because

that repeated activity was releasing (or soothing) that energy in some way (even to his own detriment).
In other words...a form of stimming?
-------------------------------------------------------------------------
Crackers! you broke this down nicely, didn't you? I've never managed to get my head around the difference btwn a Bipolar Manic Episode and its AS equivalent. I knew the written criteria but was unable to interpret some of DS' behaviours within the given parametres.


Thank you kindly for clearing much of this up. You've pretty well confirmed what the doctors have been saying (AS) but your explanatory methods puts some meat on those dry bones




Quote:
Professionals sometimes see lack of need to analyze everything
"Lack of need" means the doctors haven't been able to file a claim for it ... yet
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