Overlooked: Vyvanse has many interesting features for ADHD treatment – but this challenge is often missed.
Take a quick look at this video, will only take a few minutes, – but can help find the Top of the Window with Vyvanse – the ‘forgiving amphetamine.’ I reviewed the Vyvanse titration process [duration DOE] this previous video, so do check that one out, but watch for this uncommon and subtle presentation previously described in this article on the Top of The Therapeutic Window.
Top of the Window – Heavy Nuance
Check out this thought: The top can look like the bottom with Vyvanse, more than the other stimulants, – because it’s so forgiving.
Please take a look and tell me what you think, it can be quite obvious and quite subtle at the same time.
The key points here, just to review and amplify:
- Onset of action was appropriate in time at first, about 30-45 min after taking it
- Increased dose caused apparent improvement, but later the effect onset comes around 10 AM, – 3 hr after taking it
- Intensity high for about 4-6hr then drops off early afternoon
- They don’t feel the ‘jittery’ side effect one experiences on too much Adderall, but they feel very irritable, anger easily and can become suddenly quite depressed
- Others are burdened by their emotional travails when they never had this intense emotionality previously
- They aren’t eating correctly – often no breakfast
- They aren’t sleeping adequately
- They can’t focus, and feel that they need more stimulants and antidepressants
- Some wag calls them bipolar, serious, and – it becomes the diagnosis de jur
- They distance themselves from their progress and regress in their program, smoke, drink, etc.
- They can become suicidal over their dismay at the regression.
- SPECT Imaging does not show signs of ‘diffuse cortical hyperperfusion’ – [euphemistically yet emphatically labeled 'Ring of Fire' by Amen - a designation frowned upon by experienced nuclear medicine folk]- but rather signs of diffuse cortical hypoperfusion.
- This same observation applies to Adderall XR and Adderall IR, but is much easier to recognize.
Yes you can stop it altogether, abruptly if the presentation is more acute – but I find that simply cutting the dose in half can create a foundation for a careful recalibration – taking more time.
Drop us a comment if you do think of some more features on this puzzle.
cp
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{ 30 comments… read them below or add one }
Fascinating article — it’s refreshing to see a doctor so engaged with science. (wow, that sounds odd — one would think all doctors are engaged with science!) Is the video for this article still accessible (I think it says that it’s been removed). Speaking very generally, do you think that “top of the window” side effects generally mirror the blood levels of the medication at any given time? For example, many doctors say that if side effects like overfocused intensity occur at 3-5 hours (i.e., when a med like Vyvanse is at it’s peak), it means the dose is too much, but if they occur after 6 hours, it’s really “rebound,” but it seems like you’re saying that it can follow another pattern such that when the dose is too high, the effects may actually seem normal until later in the day, and thus the dose may be mistaken as too low (or I may be misreading).
Because of how steady Vyvanse, I think this can make measuring DOE even harder in light of all this. How do you get your own patients to precisely measure DOE when Vyvanse can be so mysterious?
Joey,
Have been meaning to get another video up… the previous was a bit over the top on the abuse research, diminishing the potential for problems. Just have to get another one done, and will do so when I get back on track after the recent office changes. Lost my right hand woman to the entertainment industry [her life passion], hired another, she didn’t match, and have been training a great new woman, so much background noise at my shop.
You are reading it quite correctly. The hyperfocus is a problem just as you say. Excellent last question: can only be answered by precise measurement of objectives on the front end, see my paper on Precise Solutions, and my new book, which will be out late March early April for details. White paper, Precise Solutions for ADHD Meds is free here.
cp
thank you. but thanks the same is what Dr.Tisnado told me thank you agin.
hello im sorry this idatic question but i need a prfesional advice. also sorry for my inadicuqet spelling and grammer. Im 15 years old and i takeing 40 mg of vyvanse. my questiond is does caffine cut the effects of vyvanse. the curiuse thing is that 2 to3 mounths ago i went from 50 mg to 40 mg. These was so because i was felling very strange. first i toke estatera then retaline then aderal and finaly vyvance.the doses of the rest so wat is your oppinion.
Javier,
Caffeine could cut the effectiveness of any of the stimulants by taking the person into a state of excess stimulation, thereby diminishing the effectiveness. I do recommend that you make sure you talk with your doc in detail about questions like this – if the doc knows the problem it is more likely to find a good solution.
cp
Dr Parker,
What is the effect of Vyvansse on Bipolar symptoms. As you know, I am once again trying to titrate up on Vyvansse and we started VERY slow at 40 mg divided in half to start. It is hard to tell what symptoms are Vyvansse but it seems like it aggravates cycling of moods during the day that resemble a worsening of my bipolar cycling of moods. Vyvansse seems much worse at this than the other stimulants that just give a high rise then a quick drop. I know this is normal for Vyvanse, but wonder the direct effect it has when added to the already cycling moods of bipolar, and if a more straightforward stimulant might be less complicated to moniter?
Also, it causes such a hyper focusing at first (I think this is where the OCD part of me kicks in) that makes it difficult to get anything but that one thing done, followed by a scattered, disorganized, forgettful feeling mentally which causes one to feel they need to see an ADD dloctor for meds!!
I know the goal is to get the dose high enough to put off the twilight zone feel until night, but I’m not sure all the rest of it is that great either. This might be because of the bipolar thing, and that’s why I was hoping you would shed light on the difference between Bipolar mood cycling and Vyvansse mood cycling, and how one would know the difference.
Thanks!!!
Lorre Hopkins
PS I know you well enough by now to expect you to say that treatment with Vyvannse should improve the symptoms of many who have a Bipolar diagnosis, because they are misdiagnosed. So I am only writing from the theory/assumption/viewpoint that the person truly is Bipolar and responding well to mood stabilzers, but also is AD(H)D.
Lorre,
You did a great job of tagging my theory and philosophy correctly, but you also know that I am, as I said below, always instructed by what is actually happening with you, with your perceptions. If it isn’t right, no matter what the expectation, it’s wrong. Mood disorder, an excitatory imbalance in the neurotransmitters can be significantly stimulated and aggravated by any stimulant, period. Looking forward to checking out the neurotransmitters, and suggest that you hold on Vyvanse until we have that conversation.
Don’t push it too long, we can discuss it later – and remember my oft stated other rule: If it isn’t working as predicted, and you had that great protein breakfast, then don’t take it. I don’t try to treat ‘on the label’ but the brain function. If the function is off with the med, then the function must be addressed and corrected whatever the diagnostic profile.
Talk soon,
cp
Dr. Parker,
I was perscribed to take a 50mg doseage of Vyvanse a little over 5 months ago and it has been nothing but beneficial to helping me maintain focus and has increased my memory retention ten fold. The issue I’m having is that I had to step up to a 70mg dose a few months back due to the 50′s wearing off in the middle of the day. I noticed that even though I am an occasional smoker that my cravings for a cigarette increased dramatically from day one. I started to notice that after a few months I started to feel depressed and would just have feelings of wanting to cry for no reason. I have a theory and I wanted to get your opinion on it as to why this is happening. I feel like the stimulant effect from the nicotene is causing me to hit the “top of the window” while being on the 70′s. I have lost about 20lbs. over the last six months as well due to me making a diet change and actually being able to stick with it on my mediciation, and not to mention the obvious metabolic increases that a stimulant brings. Could my now smaller size paired with the nicotene and the 70mg doseage be pushing me over the window? What about when being paired with caffeine? I drink about 3 cups of coffee in the morning and have a vitamin rich sugar free energy drink in the afternoons…but it has a high amount of caffeine in it as well. I suppose it’s a moot point as I desperately need to stop smoking for obvious reasons, but I want a professionals opinion as to why there would be such a “depressed” if you could call it that, feeling that seems to plauge me now when the Vyvanse is supposed to be working its best. Would the best remedy be to go a natural diet that completely cuts the caffeine to maximize the positive benefits of the Vyvanse without the terrible “sadness” that comes otherwise? Any help or guidance would be greatly appreciated!
Chad,
Yes to all of the above! I completely agree with your considerations, as every one of them may have some good ‘sea legs’ when sailing out tomorrow. Each of our suggestions is likely true, as you are confusing your various neurotransmitter receptors with your current self conjured brew.
Having said that I would suggest you look at this video which outlines the Dopamine/Serotonin seesaw and Cognitive Anxiety at CorePsych – a possible contributing factor to the depression side.
Additionally, it is an easy speculation to suggest that your NT [neurotransmitter] dysfunction includes other heretofore not considered NT imbalances discussed in detail on the CorePsych Neuroscience page. Reading there will take you down many new paths that will very likely prove relevant.
cp
Dear Dr. Parker,
It has been 10 days since I sent the first email about my brother and our fear that the 70 mg dose of Vyvanse was causing severe restlessness, tremors and insomnia. We took your advice – skip two doses, start taking half and then go to a lower dose for an extended time. His doctor agreed and gave him a new Rx for 50 mg. The anxiousness stopped within days and the insomnia within a week.
Thank you so much for your guidance. We will monitor the 50 mg closely and decide whether any other titration is needed.
Unfortunately, days before I corresponded with you, his doctor thought the best way to treat the anxiousness was to switch him from Lexapro 20 mg to Pristiq, and had already begun that process. So, he is undergoing both medication transitions simultaneously. His doctor recommended the following course: Start taking Pristiq for 1 week with the Lexapro, cut the Lexapro in half for the second week along with the Pristiq, and then take the Pristiq only. He took his last dose of Lexapro a few days ago and is now feeling depressed, discouraged and hopeless to the point of crying. I know this can be withdrawal from the Lexapro, which he has been on for years. Would you recommend he go forward with the change to Pristiq, and, if so, do you think the course described above is not too abrupt? I have read horror stories of SSRI withdrawal and note that many people weaned off far more slowly. Does adding the Pristiq lessen the severity of withdrawing from Lexapro?
We seem to move from one issue to another because fine tuning medication is such a difficult process. Our doctor is fairly aggressive in prescribing, which is great when it’s a match, but scares me now that I see how long it can take to make up for going in the wrong direction. I just want to make sure that the change from Lexapro to Pristiq is not setting my brother up for weeks of possible withdrawal and/or side effects.
Thanks for the help you have given thus far. We are certainly becoming more literate about this crucial facet of treatment.
Sincerely,
Anne
Anne,
Slow and steady is always better with SSRI discontinuation – even if covered by another SSRI. Different receptors are covered differently by different SSRIs. I have found it necessary to slowly transition from Effexor XR to Pristiq even though they are apparently the same medication – in truth they are different as well.
cp
I can relate to all of these problems with Vyvannse. It’s biggest problem is that it is so subtle you don’t recognize the same feelings of being over medicated like on other drugs.
Lorre,
So true, just finished a post on the details including Anne’s note – We see these problems all too often, because Vyvanse is so forgiving.
cp
Dear Dr. Parker.
Your articles and videos have helped so much in navigating the crazy pathway to treating ADD. I serve as my 52 year old brother’s ADD coach. He was just diagnosed two years ago, after a lifetime of failed jobs, frustration, alcohol abuse and all the other common experiences of others in his situation. He was diagnosed with depression years ago and has been on Wellbutrin and Lexapro for years and continues to take both. He is also one of the nicest people in the world.
After reading about and realizing that he has classic symptoms of ADD, we found a psychiatrist with expertise who tried him on several stimulants, finally settling on Vyvanse. This made such a tremendous difference in his executive functioning, success at work and self esteem! The doctor started him on 30 mg and quickly switched to 70. At the time, the other doses were not yet available. He has been on 70 mg for a year and a half. The only negatives were that every once in a while, he would go through episodes of agitated, short-tempered, hyperfocused behavior – especially at work. These were very out of character for my mild-mannered brother and very short-lived. He would call me, incensed at how others at work weren’t doing their job, his boss was treating him like a peon, etc. His language and tone were very volatile and his perspective seemed irrational. Without exception, within 24 hours, he would be calm and rational and question why he had reacted with such ire.
These episodes happened sporadically, but increased this past February to the point that he was in jeopardy of losing his job. His boss, who is aware of my brother’s diagnosis and treatment (which includes behavior therapy) made it clear that he might have to let him go. At that point, it didn’t occur to his psychiatrist or me that this could be a toxic effect of the Vyvanse being above the top of the therapeutic window. The doctor suggested it was “shades” of bipolar that are sometimes seen with ADD. He prescribed Abilify, 10 mg daily. The agitation ceased shortly after, but within 6 weeks, my brother became so sedated that he was sleeping 15 hours a day and half-asleep the other hours. When we realized this was a side effect of the Abilify, the doctor took him off. The withdrawal was awful and included tremors, anxiety and sleep disruption.
It has now been 3 1/2 weeks since we stopped the Abilify, and my brother continues to report “anxiety” which appears to be gaining in severity, as well as continued sleep disruption and some difficulty processing thoughts. Today, he described the feelings as “going 100 miles and hour”, “jumping out of my skin”, and “about to explode”. When he lays down to rest, he can’t stop his thoughts.
After reading many of your articles and watching your videos, I am beginning to believe that too much Vyvanse was the culprit all along. He was agitated; treated with a sedative (antipsychotic) that masked the agitation; and now that the sedative is gone, the agitation is returning because the Vyvanse remains the same. He does not seem outwardly angry just continually nervous and restless. The symptoms are not evident when he first wakes up and ease toward late afternoon and evening – which corresponds with when the Vyvanse is active in his system.
Could you please give your opinion? I would like to ask the doctor to lower the Vyvanse dose to see if it would relieve the agitation. If you agree this is a wise course, how low would you start and how would you titrate upward? I have read people’s blogs that claim lowering from 70 to 60 relieved symptoms. Should the doctor start at 30 again, or maybe 50?
Any advice you can give would be a blessing. It has been a long course, with a lot of twists and turns. My brother, like so many others has shown tremendous courage and perseverance, and was just beginning to experience some success and peace, but the events of the past few months are eroding his confidence and he is feeling helpless, as am I.
Thank you so much,
Anne
Anne -
This is such a classic situation, and so well written/reported in this comment that it deserves it’s own blog post. I will comment on it there, but to cut to the chase here – I often go down to 1/2 of the dose in a situation like this [knowing only these variables, and not knowing about other key issues such as breakfast and transit time]. I’m on the conservative side, but don’t think you have to go all the way back to 30mg. My recommendation, because he is having so much trouble: just stop the med for a day or two and expect rebound. Then start back at about 40, and watch the DOE, – specific DOE timing will set the titration perfectly.
My take with this limited info: it’s not the Vyvanse, you’re right, it’s the dose. Need to go more slowly in the first place. Easier on Monday morning looking at the game tapes!
cp
Hi, my son is 7 and has been taking Vyvanse for 3 months now. We were amazed at the effectiveness from the very beginning. He started on 20mg and we noticed a huge difference the first day. However, his teacher noticed that it was only lasting until right after lunch. After about 2 weeks, his doctor raised it to 30mg and the DOE was extended until about 3 p.m. Again, after about 2 weeks, his dosage was raised to 40 mg which is where he is now. With 40 mg, we seemed to have reached the right dosage. His last month of school was great, his “noises” totally disappeared, his focus has been amazing, his emotional outbursts have been greatly reduced as well as other “annoying” behaviors, his self-esteem has been improving, he doesn’t aggravate his sister as much – I could go on and on about the improvements. I only have a few complaints. He has a little trouble going to sleep at night, but he had that issue before the medication! The DOE has never been 12 hours and never gets us through the difficult evening hours. It’s almost like But, it’s still better than it was. Also, his appetite has really been affected. Initially he ate well for breakfast and dinner but just didin’t want to eat anything in between. He has lost about 10 lbs., which in his case, is not a bad thing because he was about 10 lbs. above what he should be for his age/height. I talked to his doctor about all of these concerns at his last f/u visit. She suggested Melatonin for the sleep issue which has helped some. Regarding the DOE, she said he is probably a fast metabolizer and, since he’s doing so well otherwise on the 40 mg, suggested we see how he does during the summer and readdress it once school starts. And, about his appetite, she suggested that we give him a high protein Boost in the middle of the day if he doesn’t want to eat. About a week ago, however, things just seemed to change. It’s almost like the medication just stopped working. All of his “annoying” behaviors have returned, he is extremely emotional, angers easily, calls himself “stupid” and an “idiot” all the time, annoys his sister constantly, and doesn’t seem a focused as he was. And his appepite has gotten worse – now he really doesn’t want to eat breakfast. I make him a smoothie every morning and he will drink that. This morning I got him to eat a Kashi high protein bar. I”ve read alot of your articles on E-zine about the DOE and the “window” and I’m really having trouble deciding if 40 mg is still too low or if maybe we’ve gone over. Any thought you have would be greatly appreciated. Also, what are your thoughts on Melatonin to help him sleep? We’re only giving him 1 mg. And one last question – could his not eating be sabotoging the effects of the Vyvanse? Thanks in advance for your help!
Tracey,
Great note, very typical, but still not quite enough info:
1. Sleep can be causing the regression and sleep does need attention and melatonin in dose of 1-5mg is reasonable
2. Solid breakfast must come before meds not after for the appetite issue and the Boost sounds helpful but insufficient,
3. When side effect appear too much even with the DOE appearing in the right range I fall back one click especially in the summer, and recalibrate.
4. The neurotransmitter measurement on Useful References here has become the absolute next step for acquiring the next amount of necessary evidence. Like anything else in medicine it isn’t 100%, but it is inexpensive and can direct some of the next steps.
5. I always look at mood and ‘serotonin derivatives’ with unhappiness and crashing in the PM the most frequent drop in affect – and that will need to be discussed with your doc for some slight regulation there, or if you do the NeuroScience that will be easier with their precursors.
Some Ideas to discuss with your doc,
Dr. Parker,
I am pretty sure I’m beyond the effective window and was hoping you could elaborate further on how best to handle trying to reset my brain and body. Of course, my current state of mind has me doubting how taking less will actually help matters.
Also, I know Vyvanse is designed for once-a-day dosage, but I am curious to hear your take on, for example, splitting the contents of a 70mg pill and taking the first half in the morning and second half mid-afternoon.
Thanks for this invaluable resource. I look forward to your responses.
James,
Hasty reply but hopefully helpful:
1. Two times a day dosing can be helpful, but have to watch for the problem of insomnia and the second dose needs careful watching for DOE.
2. If your are on ‘too much’ then titrate [adjust] that single dose downward – each 10 mg decrease will decrease the DOE about 2 hr depending on your specific metabolic variables.
3. Often the second dose plan works well if taken before 11AM.
4. Second dose usually helpful with GI disturbance in AM [in spite of that highly recommended protein breakfast] – or with a push to get more than 14 hr… remember that 8hr is what the sleep experts say is needed for brain defrag.
cp
Hi,
I started on Vyvanse 50 mgs three weeks ago after taking Adderral xr 30mgs for over a year. It was much better than Adderral, but my concentration was not great, so my doc upped the dose to 70mgs yesterday.
I also started taking Pristiq instead of Lexapro for depression/anxiety. The problem I am having is that the Pristiq is causing severe fatigue. I am taking it at bedtime, but I am lethargic all day. Should I cut the 50mg tab in half?? Or, will this side effect go away?
I am very fascinated with the different responses I have gotten from all the SNRI’s. Wellbutrin was very activating, but made me mean, Cymbalta made my bloodpressure spike to the point that I could feel it, and now Pristiq makes me feel like I have taken a benzo.
Any suggestions?
Christine
Christine:
Two changes simultaneously might load your system. You are on my personal favorite combo, but they aren’t for everybody. Pristiq will likely be coming out with a 25 mg sometime in the future because some folks do metabolize it more slowly, and fatigue is less common as a side effect.
Without knowing you, and in the context of review with your doc: I have cut the Pristiq in half and have seen excellent results with the slower, lower dosage, and can’t find a specific reason not to do that except the time release delivery system may be compromised a bit. Every single time I have cut it in half we ultimately went to the 50 mg.
Sometimes going from 50-70 on the Vyvanse creates a side effect, – depending on the DOE and other dial-in factors you might need to do 60mg for awhile as you are near threshold for both and thus more likely to go out the top of the window.
Lower, slower and breakfast all help most of the time.
cp
The first week on Vyvanse, everything was so clear and seemed so right, it’s hard to explain, but my brain was with me all the time. I wasn’t off daydreaming. I had never felt that good, but then it went away after a week. So, we raised the dose, but that never seemed to work again. I’m on 70 mg, I was on 30 mg that first week, so I assumed when it stopped working it was because I needed to work my way up to the appropriate dose. So, we worked up, I think there was only one or two steps in between, up to 70mg where, I am now. My dr stopped, because he says this is the highest dose, and my symptoms are just as bad as they are off the medication.
This is my 4th medicine change, I was on this first, when we got up to 70 mg, with no noticeable improvement, he took me off of this and tried, that barrel shaped one, that can’t be crushed, I can’t remember the name off-hand. That didn’t make me feel any better, then we tried Adderal XR and again no change. At this point he said those were my only options and to give up at this point, so I asked to go back on Vyvanse, and I tell him it works OK, so he doesn’t take me off of it and leave me with nothing, as he was going to do before and I thought I could play with the dosing on my own, to see if I can get it to work again. I want that week back, that week of feeling clear headed and coherent. Of knowing what was going on around me and understanding people when they talk to me.
Daisy-
Without a few more details this sounds at first like you were right: a good example of too much too fast – too rapid a titration, not leaving about 1-2 weeks near the top dose before increasing to the next, and, as you point out, no appropriate slow steps in between. With adults I rarely go faster than 10 mg increase every 1-2 weeks, watching carefully for that expected 2 hr increase in DOE in the PM with that carefully adjusted dose – and I fully admit I am very conservative. The only problem with that process in my office is the patient’s becoming impatient, as I rarely create a drug excess with that protocol.
Many docs feel the same way yours does, as they stay only with the package insert. He is simply following the ‘insert rules’ as Vyvanse is a controlled product, and just as I have almost no experience writing for antibiotics – and simply won’t write for them – he is simply doing a good job following guidelines.
My possible contribution to this conundrum is a mix of common sense and experience over the time that Vyvanse has been out – with a dose of clear science about the CYP 450 genetic polymorphisms of 2D6 [see the many posts here].
1. Common sense: Adults already often go over 30 mg Adderall XR [roughly = 70 mg Vyvanse] regularly – and can be titrated based upon watching carefully for the DOE as outlined in this post. If your medical person goes very slowly they will not have a problem, and I don’t recommend that you ‘play with the dose’ – even tho your doc may not be working with you at this moment – do stay tuned with your medical team with your actions, or you very likely will loose [justifiably so] their medical support.
2. Experience: I do go up past 70 mg in dose at times, and have heard whilst in CA last week that some have not only gone up to 400mg, but have recommended simply ‘going to the top’ without careful titration, a practice I completely dismiss as dangerous. I always steer completely away from an answer to the question of ‘just what is your top dose?’ because that discussion drives practitioners away from the essential practice of careful titration into cookie cutter medicine – a point with which I am completely philosophically at odds… don’t get me started!
3. The genetics: about 1.5% of folks are 2D6 [the AMP pathway] ultra rapid metabolizers as reported in many books such as Drug Interactions in Clinical Practice leaving practitioners with a challenging few that just don’t get right on average doses, as they burn up the effectiveness just too fast. These individuals are often unhappy and disappointed, often with long unsuccessful trials of meds. For these folks only someone completely comfortable with those higher [notice I didn't say 'highest'] doses of medications [using the predictable, careful titration strategies outlined in multiple posts here at CorePsychBlog and at http://www.squidoo.com/vyvnase is recommended.
Best bet: talk these issues over with your doc, and see if he is comfortable with a little increase – if not perhaps they can suggest someone more experienced in your community to walk carefully down that path with you. Do shoot for the 12 hr DOE as noted frequently in these blog posts.
Interesting and common problem – just talked to some of the docs in CA last week about this very issue – thanks for sharing it with our readers.
cp
Dr Parker,
I think I might need to cut back-5,6,and 7 are a big problem for me. I am an emotional basket case in the evenings, my husband can’t figure out what’s wrong with me, and my family is scratching their head. My moods don’t even make sense to me. After listening to your video I think I have all of the symptoms listed above. I’m glad I took the time to read your blog and will discuss this with you soon.
If you are out the top, do keep me posted and let’s talk this week after you have reduced the dose-
cp
Clearest explanation to date…I got all the others, but this one was super user friendly!
Thanks Deb!
cp
Dr. Parker, do you believe Dissociative Identity Disorder is a valid medical diagnosis. Do you have any information from your study and research of mental health that you can forward. My wife’s therapist has asked me to research what DID is about. Thank you. r/Ken Martin
Kenneth
Much on the Internet about DID, often associated with specific trauma in the past and PTSD – and can be associated with chronic stress from years of cognitive anxiety.
cp
I do believe that this is what’s wrong with my husband. Especially key points #4,7 & 8.