it was suggested that resident doctor #4 send me home with topamax (topiramate), a prescription anticonvulsant which is notorious for its weight loss properties. in doing so, we could investigate any benefit as a mood stabilizer, and also test out a theory that anorexia nervosa has truly adapted the way i respond to cues of hunger and appetite.
if one considers my severely underweight body and knows how this psychiatrist refers to my anorexia as impressive, then one understands that this was an out of place request. interestingly enough, my doctor trusts me and trusts his theory-- and after our conversation, wrote out the prescription.
the eating disorder has an influence and desire for hunger which is clear without confirmation, but resident doctor #4 keeps soft balling me with the idea of approaching a meal plan with the help of the antipsychotic zyprexa (olanzapine).
i am not interested.
a joke suggests patients gain weight from merely queueing at the pharmacy to fill their prescriptions for zyprexa. not only does the medicine offer substantial sedation, but from reviews posted online, it has managed to stimulate a variety of appetites. unfortunately, these opinions simplify the pharmaceutical experience and suggest it "made me gain weight" or "made me ravenously hungry." zyprexa is thought to manipulate glucogenesis but does not, on its own, increase caloric intake or force people to swallow additional food. many of those who had posted reviews were angry with their related weight gains and did not reveal information relevant to brightened mood, which could justify appetite. instead, they focused on how the drug "made" them powerless in the face of carbohydrates. it "made" them bend to insatiable hunger. they were blind to any participation on their part.
so, there i stood in resident doctor #4's office, feeling nervously unstructured-- therefore desperate to try to lose weight with topamax -- and he proceeded to pitch the topic of zyprexa again.
uh, no.
now, why would he focus on zyprexa when i have not been diagnosed with a psychotic illness? in the case of anorexia nervosa, using traditional ssri antidepressant medications are virtually useless prior to body weight restoration. after carrying around an underweight body for the majority of my life, i neither have intention of ever aspiring to a normal weight, nor the desire to stress shrunken vital organs with any additional mass. i need to find a way to nourish my brain, but mostly reject the notion that those with long term anorexia should return and maintain their normal weight. it doesn't make sense to nearly double my weight and then expect to live any longer than i would now.
---
low weight anorectic patients lack sufficient central 5-HT available for the release and reuptake-inhibition of ssri antidepressants. this explains why the 'zoloft, prozac, paxil' branch of the psychotropic family tree offers grief rather than a reduction in symptoms. the essential amino acid precursor (l-tryptophan) availability (which i lack) is required to continue 5-HT-synthesis. the side effects from those particular ssri medicines routinely trumped any elevated mood.
zyprexa shows potential in the treatment of anorexia because it functions differently. zyprexa does not depend on l-tryptophan, bypasses the presynaptic apparatus altogether, and acts via postsynaptic 5-HT2-antagonism. for me to endure a trial of zyprexa would be very exciting for resident doctor #4 because 'it will work immediately and i will experience something much different than normal' or it will not.
---
how could i accept a prescription for a medicine which lists carbohydrate cravings (read: the potential for substantial weight gain) in its list of adverse effects? even my invalid friend chuck is scared for me to try it out. the stress standing behind the mere thoughts of taking zyprexa would kill me, even if nothing noticeable was changing with my body. i lack faith i will tolerate even minute amounts of that medicine without immediately expanding into a gigantic, swelling fuss. perhaps, anorexia is delusional-- i believe my weight would increase from that pill even if adhering to a complete water fast.
why do this? why potentially invite more food and physical hell when the objective is to alleviate it? AND let's add considerations related to the anti-obsessional qualities of zyprexa, and acknowledge complaints over altered glucose metabolism. unless 'aspects of the problem i would like to leave behind' are rooted in obsession, the odds of a successful trial are definitely in resident doctor #4's favor.
in the case of anorexia nervosa, accepting medication with a side effect of weight gain and edema stirs up the possibility of a profound weight loss. for me, to note that a tremendous gain in weight is expected will summon my rigidity. consider how i may instead unexpectedly drop pounds due to the intense fear of this pill. this is resident doctor #4's biggest concern-- that i finally let him experiment with zyprexa, reluctantly, and *lose a lot of weight* in the process.
i am screaming inside to start sawing apart many problems being held in a no-win suspension, but also don't want to venture from the zone of my own familiar hell. that's right-- i am about ready to face uncomfortable changes with my eating disorder, but on the other hand, this hell is tolerable. this life is what i know. i am scared of the different hell that any change will bring, even if it is only a minor or temporary discomfort. how would one rock the boat only sharply to the left, without having it overcompensate when it rebounds to the right? right now, i can only see 'worse' replacing 'bad' and nothing positive. well, that is one for him: i don't know what 'different, but not hellish' feels like.
long story short, resident doctor #4 is confident that medications with both 'appetite suppressant' or 'increased appetite' side effects will not influence the way my eating disorder functions. i should neither lose weight with an appetite suppressant, nor gain if my appetite is driven. he wrote the topamax prescription for a one month supply-- not only trusting me with what i think is a huge potential for weight loss -- but he has signed for three additional refills.
now consider the negative voice of anorexia and how it will never let me win. the voice gnarls sentiments of 'how fat must i appear to him' to score this topamax prescription. my body must not be a skeleton. i must not be extreme. the anorexia wanted it, but is simultaneously mortified. it must not be offering my body enough peril if i can access a potentially damaging 'weight loss' medicine. "you must be so fat, and if you aren't, your doctor apparently understands that you do have a pound or two of leeway. you aren't thin enough to warrant the strongest sentiment of 'you have absolutely NO weight to lose.'" in the opposite spectrum, any medicine known for its weight gaining properties would grant an appalled opinion from anorexia, too. anorexia nervosa used to be one dimensional, one sided. now it's offended by anything that approaches it.
consider how resident doctor #4 sees me regularly, and that familiarity affords us a security. this prescription is not a grand error, rather, it is an indication of trust. i should mention that we avoided discussing the subject of weight gains and losses from these medicines related to mechanisms outside of appetite. in his experience (which trumps the voices of 5 million whining mental patients who post their experiences online)... patients who have gained weight on zyprexa have radically increased their daily calories, but swear their eating has not changed. they mention eating a second dinner later in the evening, and about adding a pint of ben & jerry's at bedtime, but swear they "aren't really eating differently."
why didn't i press him to write out a prescription for amphetamine salts or another stimulant? neither of us would want me to take a medicine which lowers the seizure threshold. this topamax will not hurt me alone-- it is a tool which should only work in relation to weight loss for those who live with uncomplicated eating or with ordinary dieting scenarios. he may be right-- it may not work. ***then again, my opinion is that he has more faith in the way he can convince me topamax will not work.*** i believe his confidence is merely a front. if this is the case, i am right and zyprexa will 'kill me.'
so, there it is:
resident doctor #4 states he honestly doubts i will automatically lose weight on topamax even though it is common and occasionally dramatic side effect.
AND should this medicine prove not to render a reduction in weight or any type of physical experience, it will only strengthen his argument for an upcoming trial of zyprexa. or, at least it strengthens an argument toward trusting his decisions.
the real answer is that if he trusts me with just about the worst thing in the world, which would be these pills, then i can do more than spit on his prescriptive suggestions.
but... regardless of everything written, philosophy is not fact. i know i will lose weight on topamax and gain considerably on zyprexa. if this topamax offers even a slightly positive experience for anorexia, a future trial of zyprexa hasn't a chance in hell.
[update november 2008] i am currently trying zyprexa and, instead of hunger, it launched me straight into the rigid state of anorexia. i have been losing weight the entire time. i started with 2.5mg for two weeks and felt slightly tired. this dose was upped to 5mg and the only thing that happened was anorexia's grip got tighter. resident doctor #4 increased it to 10mg, divided over the course of the day. i felt zoned out on the 10mg, but definitely increased the grit. right now i am taking a very large dose (15mg divided twice a day with ativan, which honestly should knock out a large animal) and am dealing with insomnia. my eating disorder is really hypervigilant. it's like i can't rest because i am waiting for something to happen. in a way, this illustrates a level of my fear, and how i will not let down my guard, but zyprexa does not seem to touch the 'obstinate-ness' of anorexia whatsoever. after so many years of worrying about this medication, it's almost a disappointment. the expectation was to wake up the day after the first pill and feel the freedoms that i did not want available to me-- and then fail at fending them off.
there have been no carbohydrate cravings to ignore, no profoundly elevated mood, and as for the anti-obsessional properties-- i feel slightly more obsessed with using anorexia's philosophy as a structure for other avenues in life (restricted finances, restricting emotions and information from other people, hyper-competitiveness, etc...). it's binding me up with unrelenting ocd, rather than loosening up ritualistic behaviors.
[update: topamax] each time testing out topamax, two pounds have been lost during the first week-- all dehydration. routinely, three days after stopping, i suddenly have noticeable stretch marks due to the rebound hydration. unfortunately, this rebound weight gain equals more than the two pounds initially lost, and also takes several weeks (!) to balance out. **people in my life who are scared to talk to me about weight, hesitantly express concern that overnight, my ankles have considerable edema.**
the suppression of appetite from topamax did not alter nightly food rituals, therefore it did not manipulate or facilitate a change in eating disorder routine. the lack of enjoyment or interest in food may have increased the magnitude of my b/p behavior. what i mean is, the flatness from topamax may have inspired the b/p to last longer because taste was altered and "food was a little boring." b/p behavior has a rush and elements of excitement before its dissociation (or it wouldn't perpetuate so long).
about adverse effects:
hair loss: supplementing with biotin, zinc, and selenium did not stop a frightening level of shedding. after a few weeks, i switched from topamax to zonegran. (topamax had stabilized my mood. zonegran is a similar class of medicine.) the side effects on zonegran were much worse. after merely two capsules of zonegran, for weeks afterward i experienced violent outbursts of anger. i would wake up with fists clenched so tightly that my short fingernails broke the skin of my palms. my teeth shifted during the night from clenching and grinding. the worst part was feeling little pinging on my scalp-- actually feeling each individual hair loosen and fall about 20 minutes after swallowing a pill.
the topamax may have stabilized anxiety and mood, however, ordinary life which was important didn't hold value. for example, i will not allow parking tickets. they are unnecessary and basically a fine for being lazy. while on topamax, i received 10 parking tickets and also thought nothing of allowing them to go unpaid. by the time the topamax funk cleared, some of those parking violations had doubled, while others had tripled in cost. perhaps, topamax offered too much of an anxiety free experience, though i wouldn't have believed it at the time. i didn't feel free from anxiety.
currently, it has been six months since testing these two pills-- my vision has definitely been damaged (compromised by eye floaters, flashes, "picket fences" or vision trailing when dehydrated, nearsighted vision is impossible, near angle glaucoma perhaps?) and my hair is still falling out. the hair loss has slowed, but it not stopped in total.
if one considers my severely underweight body and knows how this psychiatrist refers to my anorexia as impressive, then one understands that this was an out of place request. interestingly enough, my doctor trusts me and trusts his theory-- and after our conversation, wrote out the prescription.
the eating disorder has an influence and desire for hunger which is clear without confirmation, but resident doctor #4 keeps soft balling me with the idea of approaching a meal plan with the help of the antipsychotic zyprexa (olanzapine).
i am not interested.
a joke suggests patients gain weight from merely queueing at the pharmacy to fill their prescriptions for zyprexa. not only does the medicine offer substantial sedation, but from reviews posted online, it has managed to stimulate a variety of appetites. unfortunately, these opinions simplify the pharmaceutical experience and suggest it "made me gain weight" or "made me ravenously hungry." zyprexa is thought to manipulate glucogenesis but does not, on its own, increase caloric intake or force people to swallow additional food. many of those who had posted reviews were angry with their related weight gains and did not reveal information relevant to brightened mood, which could justify appetite. instead, they focused on how the drug "made" them powerless in the face of carbohydrates. it "made" them bend to insatiable hunger. they were blind to any participation on their part.
so, there i stood in resident doctor #4's office, feeling nervously unstructured-- therefore desperate to try to lose weight with topamax -- and he proceeded to pitch the topic of zyprexa again.
uh, no.
now, why would he focus on zyprexa when i have not been diagnosed with a psychotic illness? in the case of anorexia nervosa, using traditional ssri antidepressant medications are virtually useless prior to body weight restoration. after carrying around an underweight body for the majority of my life, i neither have intention of ever aspiring to a normal weight, nor the desire to stress shrunken vital organs with any additional mass. i need to find a way to nourish my brain, but mostly reject the notion that those with long term anorexia should return and maintain their normal weight. it doesn't make sense to nearly double my weight and then expect to live any longer than i would now.
---
low weight anorectic patients lack sufficient central 5-HT available for the release and reuptake-inhibition of ssri antidepressants. this explains why the 'zoloft, prozac, paxil' branch of the psychotropic family tree offers grief rather than a reduction in symptoms. the essential amino acid precursor (l-tryptophan) availability (which i lack) is required to continue 5-HT-synthesis. the side effects from those particular ssri medicines routinely trumped any elevated mood.
zyprexa shows potential in the treatment of anorexia because it functions differently. zyprexa does not depend on l-tryptophan, bypasses the presynaptic apparatus altogether, and acts via postsynaptic 5-HT2-antagonism. for me to endure a trial of zyprexa would be very exciting for resident doctor #4 because 'it will work immediately and i will experience something much different than normal' or it will not.
---
how could i accept a prescription for a medicine which lists carbohydrate cravings (read: the potential for substantial weight gain) in its list of adverse effects? even my invalid friend chuck is scared for me to try it out. the stress standing behind the mere thoughts of taking zyprexa would kill me, even if nothing noticeable was changing with my body. i lack faith i will tolerate even minute amounts of that medicine without immediately expanding into a gigantic, swelling fuss. perhaps, anorexia is delusional-- i believe my weight would increase from that pill even if adhering to a complete water fast.
why do this? why potentially invite more food and physical hell when the objective is to alleviate it? AND let's add considerations related to the anti-obsessional qualities of zyprexa, and acknowledge complaints over altered glucose metabolism. unless 'aspects of the problem i would like to leave behind' are rooted in obsession, the odds of a successful trial are definitely in resident doctor #4's favor.
in the case of anorexia nervosa, accepting medication with a side effect of weight gain and edema stirs up the possibility of a profound weight loss. for me, to note that a tremendous gain in weight is expected will summon my rigidity. consider how i may instead unexpectedly drop pounds due to the intense fear of this pill. this is resident doctor #4's biggest concern-- that i finally let him experiment with zyprexa, reluctantly, and *lose a lot of weight* in the process.
i am screaming inside to start sawing apart many problems being held in a no-win suspension, but also don't want to venture from the zone of my own familiar hell. that's right-- i am about ready to face uncomfortable changes with my eating disorder, but on the other hand, this hell is tolerable. this life is what i know. i am scared of the different hell that any change will bring, even if it is only a minor or temporary discomfort. how would one rock the boat only sharply to the left, without having it overcompensate when it rebounds to the right? right now, i can only see 'worse' replacing 'bad' and nothing positive. well, that is one for him: i don't know what 'different, but not hellish' feels like.
long story short, resident doctor #4 is confident that medications with both 'appetite suppressant' or 'increased appetite' side effects will not influence the way my eating disorder functions. i should neither lose weight with an appetite suppressant, nor gain if my appetite is driven. he wrote the topamax prescription for a one month supply-- not only trusting me with what i think is a huge potential for weight loss -- but he has signed for three additional refills.
now consider the negative voice of anorexia and how it will never let me win. the voice gnarls sentiments of 'how fat must i appear to him' to score this topamax prescription. my body must not be a skeleton. i must not be extreme. the anorexia wanted it, but is simultaneously mortified. it must not be offering my body enough peril if i can access a potentially damaging 'weight loss' medicine. "you must be so fat, and if you aren't, your doctor apparently understands that you do have a pound or two of leeway. you aren't thin enough to warrant the strongest sentiment of 'you have absolutely NO weight to lose.'" in the opposite spectrum, any medicine known for its weight gaining properties would grant an appalled opinion from anorexia, too. anorexia nervosa used to be one dimensional, one sided. now it's offended by anything that approaches it.
consider how resident doctor #4 sees me regularly, and that familiarity affords us a security. this prescription is not a grand error, rather, it is an indication of trust. i should mention that we avoided discussing the subject of weight gains and losses from these medicines related to mechanisms outside of appetite. in his experience (which trumps the voices of 5 million whining mental patients who post their experiences online)... patients who have gained weight on zyprexa have radically increased their daily calories, but swear their eating has not changed. they mention eating a second dinner later in the evening, and about adding a pint of ben & jerry's at bedtime, but swear they "aren't really eating differently."
why didn't i press him to write out a prescription for amphetamine salts or another stimulant? neither of us would want me to take a medicine which lowers the seizure threshold. this topamax will not hurt me alone-- it is a tool which should only work in relation to weight loss for those who live with uncomplicated eating or with ordinary dieting scenarios. he may be right-- it may not work. ***then again, my opinion is that he has more faith in the way he can convince me topamax will not work.*** i believe his confidence is merely a front. if this is the case, i am right and zyprexa will 'kill me.'
so, there it is:
resident doctor #4 states he honestly doubts i will automatically lose weight on topamax even though it is common and occasionally dramatic side effect.
AND should this medicine prove not to render a reduction in weight or any type of physical experience, it will only strengthen his argument for an upcoming trial of zyprexa. or, at least it strengthens an argument toward trusting his decisions.
the real answer is that if he trusts me with just about the worst thing in the world, which would be these pills, then i can do more than spit on his prescriptive suggestions.
but... regardless of everything written, philosophy is not fact. i know i will lose weight on topamax and gain considerably on zyprexa. if this topamax offers even a slightly positive experience for anorexia, a future trial of zyprexa hasn't a chance in hell.
[update november 2008] i am currently trying zyprexa and, instead of hunger, it launched me straight into the rigid state of anorexia. i have been losing weight the entire time. i started with 2.5mg for two weeks and felt slightly tired. this dose was upped to 5mg and the only thing that happened was anorexia's grip got tighter. resident doctor #4 increased it to 10mg, divided over the course of the day. i felt zoned out on the 10mg, but definitely increased the grit. right now i am taking a very large dose (15mg divided twice a day with ativan, which honestly should knock out a large animal) and am dealing with insomnia. my eating disorder is really hypervigilant. it's like i can't rest because i am waiting for something to happen. in a way, this illustrates a level of my fear, and how i will not let down my guard, but zyprexa does not seem to touch the 'obstinate-ness' of anorexia whatsoever. after so many years of worrying about this medication, it's almost a disappointment. the expectation was to wake up the day after the first pill and feel the freedoms that i did not want available to me-- and then fail at fending them off.
there have been no carbohydrate cravings to ignore, no profoundly elevated mood, and as for the anti-obsessional properties-- i feel slightly more obsessed with using anorexia's philosophy as a structure for other avenues in life (restricted finances, restricting emotions and information from other people, hyper-competitiveness, etc...). it's binding me up with unrelenting ocd, rather than loosening up ritualistic behaviors.
[update: topamax] each time testing out topamax, two pounds have been lost during the first week-- all dehydration. routinely, three days after stopping, i suddenly have noticeable stretch marks due to the rebound hydration. unfortunately, this rebound weight gain equals more than the two pounds initially lost, and also takes several weeks (!) to balance out. **people in my life who are scared to talk to me about weight, hesitantly express concern that overnight, my ankles have considerable edema.**
the suppression of appetite from topamax did not alter nightly food rituals, therefore it did not manipulate or facilitate a change in eating disorder routine. the lack of enjoyment or interest in food may have increased the magnitude of my b/p behavior. what i mean is, the flatness from topamax may have inspired the b/p to last longer because taste was altered and "food was a little boring." b/p behavior has a rush and elements of excitement before its dissociation (or it wouldn't perpetuate so long).
about adverse effects:
hair loss: supplementing with biotin, zinc, and selenium did not stop a frightening level of shedding. after a few weeks, i switched from topamax to zonegran. (topamax had stabilized my mood. zonegran is a similar class of medicine.) the side effects on zonegran were much worse. after merely two capsules of zonegran, for weeks afterward i experienced violent outbursts of anger. i would wake up with fists clenched so tightly that my short fingernails broke the skin of my palms. my teeth shifted during the night from clenching and grinding. the worst part was feeling little pinging on my scalp-- actually feeling each individual hair loosen and fall about 20 minutes after swallowing a pill.
the topamax may have stabilized anxiety and mood, however, ordinary life which was important didn't hold value. for example, i will not allow parking tickets. they are unnecessary and basically a fine for being lazy. while on topamax, i received 10 parking tickets and also thought nothing of allowing them to go unpaid. by the time the topamax funk cleared, some of those parking violations had doubled, while others had tripled in cost. perhaps, topamax offered too much of an anxiety free experience, though i wouldn't have believed it at the time. i didn't feel free from anxiety.
currently, it has been six months since testing these two pills-- my vision has definitely been damaged (compromised by eye floaters, flashes, "picket fences" or vision trailing when dehydrated, nearsighted vision is impossible, near angle glaucoma perhaps?) and my hair is still falling out. the hair loss has slowed, but it not stopped in total.
