Understanding Chronic Pain

Trichotillomania, Pain, Bipolarity and the Curious Effects of Polypharmacy

A young mother came to me with 5 years of low back pain and depression. She had been under psychiatric care and had been given, first Wellbutrin, which made her depression worse, and then Cymbalta, which made her feel "weird." She was also on Elavil (amitriptyline) for treatment of her recurrent migraine.

On interview, she acknolwedged that she did have periodic feelings of being highly energized and sometimes panicky, wanting to get out of the house and run. During these intervals she would feel irritable and be subject to mind racing. She could occasionally diminish these symptoms by taking a Benadryl pill. She told me that during these anxious and irritable spells she would talk rapidly and often feel "mean."

I always look for clues to bipolar disease in those who suffer chronic pain, and this young lady was giving me several of them. The longstanding depression, the periodic mind racing, anxious high energy and mean interludes were certainly compatible with that disorder, as was her history of adverse reactions to conventional antidepressant therapy.

As the visitor will certainly note, I am very attracted to the association of narcolepsy with chronic pain and bipolarity, but this lady denied any real symptoms of that disease. I elected to treat her with clonazepam to help her ongoing disordered sleep, and also Methadone, hopefully for both analgesia and mood stabilization. On her return, she told me that within hours of starting Methadone at the low dose of 5 mg daily, she could feel her pain diminishing. More importantly, within a few days she realized that her mood was better. She was no longer having shifts and had gone several days without the intervals of irritability, anxiety, and meanness, and she had been having those with great frequency. She reported that she was, however, still troubled by periodic attacks of overwhelming fatigue. This was an issue that I had not explored initially, but which in my opinion is a common symptom of bipolar disease. I added the simulant Adderall (amphetamine).

On her return 2 weeks later, she told me excitedly that with the Adderall her fatigue had much diminished and that her mood was progressively better. Satisfied with her progress, I scheduled a return  appointment 2 months away.

She returned to report continued improvement, telling me that the "mean" spells had gone away and that "I'm in control. I don't say things now that I shouldn't." She also told me that her migraine, which had remained a bother in spite of several years of therapy with Elavil (amitriptyline), was also much better. She did comment, however, that her back pain continued to be a problem and that she was beginning to hurt all over her body, an unexpected development in one who was doing so well in other regards. I told her she could increase her Methadone up to a maximum of 30 mg every 8 hours.

On her next visit, she reported that the Methadone was quite ineffective, and that her pain was becoming progressively severe, this in spite of mood having been both lifted and stabilized, her sleep restored, her migraines diminished, and her fatigue almost gone.

This, I assure the reader, is a most atypical and unusual clinical scenario. I have written when the right drug(s) kicks in, everything gets better.

But sometimes it takes lots of drugs. I added oxycodone in the form of Percocet, which is a combination of Tylenol and oxycodone. It is an excellent opioid analgesic, and I had no problem at all adding it on top of Methadone. Much had been accomplished already, but there was no reason for not trying more pharmacy. 

She returned to report almost total relief of pain with Percocet. She told me she felt better than she had in 5 years, and mentioned in passing that her many-year compulsion or habit, as she called it, to pick at her scalp hair had totally gone away. She had, she said, so frequently picked at her scalp, scratching and collecting hairs, that it was excoriated to an extent that it was embarrassing for her to go to the hair stylist because her attention was always called to the curious excoriations on the scalp. The scientific name for compulsive hair pulling is trichotillomania, and with therapy (admittedly directed to other problems), that strange disorder was cured, as were her back pain, migraine, fatigue, and bipolar disease.

When the right drugs kick in, everything gets better. 

Last Updated: Apr 30, 06:58 AM

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Obsessive Compulsive Disorder, Migraine, and Narcolepsy Anger, Narcolepsy, Bipolar Disease, Attention Deficit Disorder, and Pain