A patient asked if I would see husband who suffered from fibromyalgia. Her greater concern, however, was his anger and hatefulness.Their marriage, she told me, was in jeopardy.

Rick was 35 and employed in advertising. He had fibromyalgia for several years and none of his doctors had been able to help him. He was getting by with ibuprofen, but barely. He acknowleged that his anger and irritability was a problem but, strangely, it was present only in the morning. It usually dissipated by mid afternoon. His pain also. Another issue of concern to him was his slowness of thought and lack of mental focus. This also in the morning. By the afternoon he acquired great powers of concentration and creativity. His best work, indeed his only work, occurred between the hours of3 and 11 PM

His lack of mental focus was quite evident on a follow up visit. It occurred about 8AM and my patient’s inability to recall, comprehend, and relate meaningfully to me was startling. I suspected adult attention deficit disorder, but the temporal pattern, present in the morning and not in the afternoon, was most unusual. Nonetheless, most everything I see is unusual so I pursued my inquiries. He responded that he did indeed experience very vivid dreams that were¬† frightening to him. He ofter awoke from them anxious,angry, and, on occasion briefly paralyzed, unable to move or speak.

I have written before about the bipolar spectrum, a constellation of disorders including attention deficiency, narcolepsy ( vivid dreams and sleep paralysis), and mood shifting bipolar disorder. My young advertising executive had it in spades, and in a most unusual temporal pattern. Distracted and angry ( a common bipolar symptom) in the morning and energized and creative(bipolar mania???) in the evening.

I treated him first with the stimulant amphetamine (Adderall). His dreams became more pleasant and his morning inattentiveness abated somewhat but he remained painful and, he acknowleged, quite irritable in the mornings. I added the opiate methadone ( I have written much about the role of methadone in the painful bipolar) and his improvement was sudden and total. He told me on a recent visit that on one occasion he forgot to take his morning methadone dose and nearly got in a fight with a coworker. Realizing what was happening, he returned home to take his pills, the back to gainful morning work, mentally focused and without anger and pain ( also, I believe, a common bipolar symptom).