Lamictal – a drug for DID?

“Although there are no medications that specifically treat dissociative identity disorder, [some drugs] may be prescribed to help control the …symptoms associated with it.” [Stephens]

Oh yeah? Check out Lamictal.

Review of some relevant brain changes with PTSD and DID

Currently, many types of drugs are used to treat the symptoms of PTSD and DID. But none are advertized to cure the disorder or act directly on the symptoms of dissociation. But some new research may be proving that wrong.

I presented research in a previous post, What’s going on in the brain with DID? Biological markers in DID, which explored changes in the brain caused by trauma and long term PTSD.

Hippocampal volume was found to be smaller in combat veterans and victims of child abuse. Post integration, individuals who had DID showed increases in hippocampal volume, suggesting that chronic dissociation is related to hippocampal volume. [Papernow] Since this brain structure has a major role in memory and learning, and communicates with the amygdala, where the traumatic emotional memories are stored, a decreased volume may suggest functional changes that cause triggering, flashbacks, amnesia and dissociation.

The reason for this decrease in volume is believed to be a change in neurotransmitters released over time after trauma. Trauma increases the levels of the excitatory neurotransmitter glutamate. However, in per presentation Relational Approach to the Neurobiology of PTSD and Dissociation, Papernow states that “organized perception” at the time of trauma requires a balance in the excitatory and inhibitory neurotransmitters. The long-term elevated levels of glutamate are hypothesized to cause the decrease in hippocampal volume, affecting memory and leading to a “distorted perception of self we see in DID patients.” [Papernow]

So, a theory is that a drug that can decrease or counter the elevated neurotransmitter glutamate could lead to a recovery of hippocampal volume (which is possible as suggested by the increase in volume observed in post-integrated DID patients). This in turn could lead to a more comprehensive perception of self and reduce the symptoms of dissociation.

A new drug for DID?

In steps Lamictal (lamotrigine). This drug is used primarily as a mood stabilizer for bipolar disorder, and as an anti-seizure medication for epilepsy. However, a growing number of clinicians are using the drug for DID patients because it’s main activity is to increase GABA, which is an inhibitory neurotransmitter which blocks glutamate. And see above, that nasty glutamate in high concentrations seems to be a bad guy for memory and dissocation.

Tada! So let’s go through that again.

long term trauma -> increased excitatory neurotransmitter glutamate -> decreased hippocampal volume -> memory problems and distorted perception of self.

Lamictal increases inhibitory neurotransmitter GABA, which blocks glutamate. This counteracts the original problem, and possibly leads to both a better perception of self and a larger hippocampal volume for improved memory processing and recall.

Another possible mode of action is hypothesized in animal studies and in vitro (in the lab, not in the body) studies that suggest that Lamictal “inhibits voltage-sensitive sodium channels,” as reported in the Mechanisms of Action in the package insert. [Lamictal: Clinical] Sodium channels are one of several channels in the membranes of neurons – they open and close depending on the voltage of the action potential (electrical signal) that travels down the axons of neurons. When this action potential reaches the end of the axon, it causes the release of neurotransmitters. These are the chemicals that neurons use to communicate with one another. Glutamate is one of the neurotransmitters released, and one of those implicated in the memory problems and dissociation. [Lamictal: Clinical] If Lamictal actually stabilizes the neuronal membranes (via reducing ability of sodium channels to open) and reduces the amount of glutamate released, these problems can be counteracted.

Cool!

Lamical safety and side effects

Okay, so how safe is Lamictal? Common side effects with LAMICTAL include dizziness, headache, blurred or double vision, lack of coordination, sleepiness, nausea, vomiting, insomnia, tremor, and rash. I experience dizziness and lack of coordination – not bad, but if I try to balance I can feel it, or sometimes I trip over my feet. I have trouble with balancing on one leg I exercise now! I do experience some nausea.

However, the bad side effect is the rash – as my meds doc said when he first suggested the drug for me, “It works for many people, but one of the side effects is death.” (Dark Humor: Medication that works well for “Many People”) Fortunately, at the first sign of rash, discontinuing the drug reverses the effects. I had a rash early on that scared me, but we slowed down the increase in dose and it went away.

Another frustrating aspect of the drug is that it takes so damn long for it to be effective. To avoid the rash problem, the initial dose is very low, and every two weeks it is increased a little. It takes about 2 months to get to a therapeutic dose…and during that time, you have no meds helping out. It was a pretty terrible time for me since I was crashing, severely depressed, and for a couple weeks, suicidal. To address THOSE issues, I was on Xanax. But I seem to be just getting the first positive effects at a dose of 150 mg and was able to stop the Xanax. So, fingers are crossed this med is good!

And a personal note

I would also like to add one more thing. I was on an SSRI and went off it because of two particularly annoying side effects. The “certain sexual side effects” were especially frustrating because one of the things that HAD NOT been screwed up with my trauma history was my sex life…sex is great and I love it. But not being able to reach orgasm? Very bad.

The other issue with SSRIs was weight gain. I found myself compulsively eating when I was not hungry. Prowling the pantry not really aware that I was shoving food in my mouth. In about 2 months, I gained 7 pounds I am now working off.

So, I’ll trade coordination problems and nausea for great sex and no weight gain any time!

References

Lamictal: Clinical Pharmacology, TxList, accessed from http://www.rxlist.com/cgi/generic/lamotrigine_cp.htm

Papernow P. (2004). A Summary of Amy Banks, M.D.’s October 2, 2004 Presentation, Relational Approach to the Neurobiology of PTSD and Dissociation: Can medications enhance therapeutic effectiveness?, accessed from http://www.nesttd.org/Amy%20Bank%20Summary.htm

Stephens, L. (2005). Dissociative Identity Disorder (Multiple Personality Disorder), Psychology Today, accessed from http://psychologytoday.com/conditions/did.html

13 Comments»

  englishrain wrote @

Best of luck with the Lamictal. After going through nasty side effects with all the atypical antipsychotics, we landed on Lamictal as the only med that’s made me feel more stable with no side effects. The nausea went away in about month for me. Hope you have the same positive results.

  emilylonelygirl wrote @

englishbrain

I am just starting to get the good effects of the drug and I really hope they stay! The nausea is less this week, although I did throw up in the middle of a training session at the gym last week! (Yes, I made it to the bathroom on time!) :-)

Thanks for writing!

  Jae wrote @

Hi emily. I have been on Lamictal for around 5 years or more.After being on all sorts of meds ranging through from Lithium, benzo’s.anti psychotic sand many more, I have found Lamictal to be the one that worked best for me with the least side effects. I get the loss of concentration and occasional nausea, light headed. I find these things can improve if i eat properly get the sleep i need things that generally keep most people in check. I also used Tegretol at one stage along side with the Lamictal that worked well when thing got a bit crazy,some people have weight gain with that and after long term use some hair loss, sounds great haaa. Short term was ok. I have just discovered your blog and am finding it very good. I find it on Dr Frerichs site. So thanks for posting it on there. I’m out the other side of my journey with all my parts integrated (i hate that word) Still things to sort always is in life but things are so different-for the good. Go well and I’ll keep reading. Cheers Jae

  emilylonelygirl wrote @

Hi Jae

Thanks for the info on Lamictal – I am happy to hear that someone else also had a good experience, since there is not a lot of info on Lamictal being used off label for DID.

Wow – integration and stuff for the good – that is great! Good luck with it. Yeah, “integration” has such a funny sterile sound to it. Like throwing all the stuff in a bowl and mixing it up :-)

Hey – I just thought of something…from Star Trek, maybe we are just doing a big ole “Mind Meld”!

Take care
Em

  Laurie wrote @

I have been on Lamictal for almost two months. After several years of trying various SSRI’s, this is the first time I have felt somewhat better. I feel stable at least, but still have a great deal of anxiety (klonopin) and depression still hits now and then (for which the doctor will augment a SSRI). No real side affects (save a loss of appetite). Only on 50 mg/day. Will be interesting to see what happens when the doctor increases the dosage.

  emilylonelygirl wrote @

Hi Laurie

The SSRI’s worked but the side effects were bad. And I am finally feeling a LOT better on the Lamictal, but only after I was up to 150 mg. The meds doc says if I stay as good as I am not, 150 mg will be my regular dose. Fingers crossed!

Let me know how it goes!

Best of Luck
Em

  davidrochester wrote @

My therapist tried me on a hypotherapeutic dose of a drug called naltrexone, which is usually used in high doses for treatment of opiate addiction, but in small doses stops the brain’s ability to dissociate. It can therefore be useful for controlling flashbacks, and also useful when alters “retreat” at crucial points during therapy. The great thing about it is that the half-life is extremely short — about six hours, so any side effects are also short-lived, and the side effects themselves are mostly related to the inability to dissociate, such as increased discomfort in the body — not pain, but discomfort being in the body.

I chose not to continue the drug treatment, for personal reasons, but I can say that it was effective, and there were no physically detrimental side effects.

  emilylonelygirl wrote @

Hmmm. I looked it up – they talked about removing the “rush” from self injury. Could be a similar thing?

Please explain what you mean by “when alters retreat at crucial points during therapy.”

It sounds like naltrexone reduces ability to dissociate…but if you don’t want an alter to do way…. ?

I ask because I have found a great fear of many to participate in therapy. Also, it is partly me not letting down the wall for that to happen. Does this sound like your experience?

  davidrochester wrote @

Hi —

Yes, what it does [to clarify - the discussion here is about naltrexone, not lamictal - Emily], on a very basic level, is it limits the brain’s ability to produce endogenous opiates — which are serotonin and endorphins, both of which contribute hugely to the “numbing” effect of dissociative disorders. This is also why SSRI drugs can be highly counterintuitive to treat dissociative patients, even when they are severely depressed; the medication actually increases the brain’s capacity to dissociate, and so while the depression might or might not ease, the numbing almost always gets worse.

Anyway, yes, the drug dials down the brain’s ability to dissociate. Some therapists treating DID patients have them take it an hour before a session, to increase dialogue among alters during the session. Because the drug has such a short half-life, it can be used in this way, and also used periodically to gain “access” to alters who are unwilling to communicate, or who are hard to find.

My experience in therapy has been that as we approach something difficult, my ability to communicate internally starts to shut down. Sometimes, alters of whom I was very functionally aware suddenly “disappear” on me. The naltrexone does not cause integration, nor does it therapeutically help DID, except insofar as it makes barriers more translucent, and brings everyone closer together. It doesn’t force anyone to talk, but it does sometimes make it easier for the host to figure out where everyone is.

For people with severe PTSD, it reduces or eliminates flashbacks, night terrors, etc. It can also be very effective for anxiety, etc. that is related to flashbacks an alter is having, but which are not experienced by the host as “classic” flashbacks.

Again, the amazing benefit of this drug is the fact that it has no physical side effects, and even if it did, the half-life is so short that they would wear off very quickly. The drug has to be taken three or four times a day, because it doesn’t stay in the bloodstream very long. The main side effect I noticed was strictly psychological, and not everyone has it; I suffer from anhedonia most of the time anyway, and the naltrexone exacerbated that, which makes perfect sense, since it’s an endorphin blocker. If my brain worked anywhere near normally to begin with, that would not have happened, and it doesn’t happen to most people who use naltrexone for dissociation therapy.

The therapeutic dose for DID/PTSD is very small … between two and six mg, three or four times daily. The normal therapeutic dose is around 100 mg. You have to have it specially made up at a compounding pharmacy. Hypotherapeutic doses of naltrexone are also being used for relapsing-remitting MS, with great success … but in both cases, it can be tough to find a prescribing psychiatrist or doctor who will think outside the box.

  emilylonelygirl wrote @

Davidrochester wrote

Ohhhh, I was confused. When you said it stops the brain’s ability to dissociate, I took that to mean “no dissociation equals no presence of alters.” After all, didn’t dissociation CAUSE all the alters in the first place?!?

But what you mean is that reduced dissociation puts us all more firmly in the room rather than out into space. I misunderstood the concept – thanks for clarifying.

Also – I like this idea a lot….

It doesn’t force anyone to talk, but it does sometimes make it easier for the host to figure out where everyone is.

Yeah, a big problem around here, since the host-come-lately is the clueless one often in denial. Sure would be nicer to have more concrete input when I need it rather than looking for subtle clues and analyzing dreams.

And I can see where this would be useful. Sometimes I have something important to say and then suddenly it is gone and I am shocked back into “reality”. I hate that, and it makes me feel a little embarrassed. Especially now in the beginning of therapy (again) when I am so self-conscious and scared all over again.

I did a little search for it’s effects with dissociation, and some evidence goes back to 1995 – wow. And low dose naltrexone for a variety of diseases and conditions, like MS as you mention, but also ALS, AIDS, immune system disorders like rheumatoid arthritis, various cancers. That list makes me a little suspicious (snake oil salesman) but there seems to be evidence for some of them.

Here is a quick reference I found – not necessarily a “good” reference, but some info if someone wants to wander around: Low Dose Naltrexone Homepage

Thanks for the recommendation – my meds doc is pretty outside-the-box; after all, he is the one who suggested Lamictal in the first place. If I think I need it, I will have the name in my back pocket.

Thank you

Emily

  davidrochester wrote @

You’re welcome!

  Grace wrote @

I have been on lamictal for a year and a half and I honestly think it has helped me tremendiously. I had been on an SSRI and experienced the same side-effects you mention above.
I was suicidal when my PDOC put me on it and it has helped (but not eliminated) the flashbacks and dissociation. I take 300mg/day.
~ Grace

  Emily’s Camigwen wrote @

Hi Grace – I am very happy to hear that Lamictal is helping you. I never got to 300mg – I think only to about 250 but we had to back it down due to side effects. We’ve been playing with it to balance the side effects with the dissociation/flashbacks but it’s not perfect. I am having job interviews, and the problems with garbled words, not being able to say the word I need, etc., wouldn’t make a good impression. And the clumsiness walking around in a suit and heels … not good! Good luck with it!


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