Tegretol

Tegretol is the additional medication Rajid prescribes for Emma while investigating whether bipolar disorder explains her changing mood and other symptoms. Intended to reinforce the mood-stabilizing effect of lithium and potentially work within days, it instead becomes associated with a severe physical reaction and an emergency visit. Its brief place in Emma’s treatment captures the uncertainty of the PAAZ’s diagnostic process: the drug is offered before the diagnosis is settled, produces consequences before its benefit can be assessed, and is stopped just as another treatment is being considered.

Prescription and intended use

Rajid proposes adding Tegretol, identified as carbamazepine, to the lithium Emma is already taking. He explains that the combination is commonly used to strengthen lithium’s mood-stabilizing effect and may work quickly at her existing lithium dose. When Emma asks how soon she might notice a result, he estimates that she could see the first effect in about three days. He also discusses side effects and risks, presenting the prescription as a treatment trial rather than a guaranteed answer.

The anticipated speed of the medication matters to Emma for practical reasons. While Rajid explains the proposal, she calculates that if treatment starts that evening, they might know by Friday whether it works; she could then leave the hospital on Saturday and return to the office on Tuesday. Her calculation turns an abstract treatment timeline into a hoped-for route back to work and ordinary life. The promise of a quick result also sits uneasily beside Rajid’s uncertainty: he wants to see whether bipolar disorder might account for her symptoms, and asks what would happen if that diagnosis proved wrong.

Rajid proposes discussing Emma’s condition with Sergei, who knows her well, and combining his observations with the mood forms and what staff see on the ward. He wants Emma to continue filling in those forms and to meet again at the end of the week. When she says she feels fitter, more stable, and more balanced, he asks whether she will give up her pills. His question makes clear that feeling better does not, in his view, settle whether treatment is needed. Emma objects that she has often thought about death, had reported those thoughts to Doctor Visser, Lars, and Sergei, and had not been admitted then; she cannot understand why making plans during a good day led to an admission within hours. Tegretol enters a situation already shaped by competing interpretations of what counts as danger and what counts as improvement.

Taking the medication

The new treatment is made tangible in the medication strips Gwen places before Emma. One contains the familiar lithium; the other, Tegretol, is new. Gwen asks Emma to check that both are correct, then watches as she takes them with water. Emma experiences the combination as a contradiction: she is in hospital because she feared taking too many pills, yet she is now being given another one. The familiar taste of lithium brings back anger and despair, while the new prescription intensifies her fear of diagnosis, medication, and side effects.

Gwen remembers that Emma found medication difficult during an earlier admission and reassures her that staff can monitor her. She also explains that Rajid has thoroughly reviewed Emma’s file and expresses confidence in his judgment. But Emma cannot simply take that reassurance as proof that the day is going well. She describes her mood as flickering and the light as gone, as though she has lost the instructions for how to understand what is happening. The empty blister strips become a small, concrete record of treatment taken, even as the meaning of that treatment remains unsettled.

Adverse reaction and discontinuation

Within days of starting Tegretol, Emma tells Dimitri Kaminski that she is experiencing side effects. She describes her head as dull even while her thoughts seem to spark, a strange combination that leaves her unable to work normally on the forms Rajid has asked her to complete. When Dimitri suggests that she might return to puzzling, she says she is not far enough into feeling unwell for that and is occupied with her paperwork. He notices the pencil in his hand, which she has apparently been using without realizing it, and suggests a break outside. In the garden, Emma identifies the problem simply as the side effects of Tegretol. The drug has interrupted the ordinary task of filling in the forms meant to clarify her moods.

The reaction leads Emma to the Spoedeisende Hulp. There she explains that she is taking lithium and temazepam and began Tegretol a few days earlier; she says the problem started then. The clinician notes the timing, agrees that there is no reason to keep her there, and advises her to stop taking the medication. The assessment is based on the close sequence between starting Tegretol and becoming unwell, rather than on a confirmed long-term diagnosis. Emma returns to the ward facing the consequence: stopping this medication means waiting to begin another, staying at the PAAZ through the weekend instead of being with Sergei, and missing the return-to-work timetable she had imagined.

At a later conversation, Rajid acknowledges that Emma seemed agitated and connects this to her pronounced physical reaction to Tegretol and an elevated heart rate, which could also have made her feel driven or restless. He does not treat the medication episode as proof that her broader symptoms have been explained. Instead, he wants to wait until the effects have fully disappeared before starting Depakine, which he says can work with lithium against manic periods, including delusions and hallucinations. In the meantime, the mood forms are intended to help establish how often Emma’s episodes occur and whether there are triggers.

Treatment, uncertainty, and meaning

Tegretol’s place in the story is brief, but the treatment episode exposes a mismatch between the speed Emma hopes for and the pace of clinical uncertainty. She imagines three days as the interval between taking a pill and reclaiming work; in practice, the same interval leads into a reaction, an emergency assessment, and a delay before the next proposed medication. The drug’s promised quick action is therefore reversed: instead of accelerating discharge, it prolongs Emma’s stay and disrupts her plans.

The prescription also sharpens Emma’s conflict with the emerging bipolar explanation. She is asked to try medication while the diagnosis is still being assessed, and she worries about what it would mean if she were not bipolar after all. At the same time, she insists that she does not see the problem Rajid sees in her behavior and contrasts her long-reported thoughts of death with the swift response to a day when she felt well and made plans. Tegretol is thus not simply a treatment object in the narrative. Its addition, administration, side effects, and withdrawal make visible the gap between Emma’s reading of her own experience and the clinical team’s effort to manage risk and identify a pattern.