![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 4 to 28 of 53. Go back in thread:
Posted by Rick on July 1, 2001, at 12:16:26
In reply to Giving up, posted by Joe Schmoe on July 1, 2001, at 10:12:15
Before settling on Xanax, did you try Klonopin/Rivitrol? I also take a few other very helpful meds for my non-depressive Social Phobia, but the Klonopin is inarguably the linchpin of my treatment. My other meds are the icing on the cake, they nicely complement the effects of the Klonopin.
As long as it's taken daily, in the right dosage (taking too much is as bad as not taking enough), and on the right schedule, Klonopin works SOOOOOO much better for me than Xanax did and feels so natural (i.e., I don't notice it at all physically). In research Klonopin demonstrated a much more robust response than Xanax (of course, that doesn't mean it holds true for evereybody). In fact, the treatment response rate for Klonopin was greater than that seen for any other medication ever placebo-tested for social phobia.
BTW, how long did you take Serzone, and how much did you take? That's one of my other meds (the combo might be overly sedating for me if I hadn't added low-dose Provigil, too), but it took a full twelve weeks before the Serzone started kicking in. With Serzone I think a lot of Social Phobics and their docs end up rejecting what could have been a big help just because they don't realize it can take quite awhile -- and a minimum 400 mg -- to kick in for this disorder. In the larger of the two open studies of nefazodone (Serzone) for social phobia, treatment benefit took by far its biggest leap between weeks 8 and 12! (With Klonopin, response tends to start up pretty quick.)
I know the meds merry-go-round can be damn discouraging, but don't give up! I don't know if you're recounting your full med history here, but I went through tons of other meds before hitting on the combo that has worked so well for me over the last 12 months. That said, I think cognitive work can help a lot, too.
Rick
> Well, after suffering for years from social anxiety I decided to give the latest drugs a try, but now I am getting off this merry-go-round. Serzone was worthless and made me feel stoned and tired all the time, and now Paxil, after only a week, has made me unable to have an orgasm. I don't think these drugs are ready for prime time. I guess I will check back in again in another ten years. Maybe by then they will have something that works. In the meantime I will just continue to muddle through on Inderal and Xanax like I have been for the past ten years.
>
> Since I have only been on Paxil a week I am hoping I can quit it cold turkey. I just want this stuff out of my system. Diarrhea, insomnia, anorgasmia - they have got to be be kidding with this stuff. I now realize Listening to Prozac gave a very one-sided view of SSRIs. Very misleading to ignore the side effect issue. It was an interesting book from a theoretical point of view, but really painted an inaccurate picture of the cost of using these drugs. I can't express how disappointed I am. I feel like there is a gigantic experiment going on with the public as guinea pigs. I can't recall reading a single report here from anyone who was really cured long-term of social anxiety. It just seems like people hop from one drug to another and never really find satisfaction. I have already had enough of that process.
>
> I have a book on a cognitive approach to social anxiety and I guess I will read it and try to implement those techniques as a psychological approach. Maybe that will help.
>
> Thanks to everyone here for their insights and support. We are all fellow sufferers and I hope everyone finds something that works for them. I just don't trust the drug companies any more. I think their standards are too low.
Posted by Joe Schmoe on July 1, 2001, at 12:48:53
In reply to Re: Giving up » Joe Schmoe, posted by Rick on July 1, 2001, at 12:16:26
> Before settling on Xanax, did you try Klonopin/Rivitrol?
No. I don't take Xanax very often. I often go months without taking any, or only taking it once a month or so when things get bad. I am pretty functional in most situations, just not very happy. Klonopin sounded like more of a daily thing. I don't want to be tired or suffer cognitive impairment on a daily basis nor do I want to get addicted. Xanax seems better for crunch times like presentations and interviews. I would be tempted to try daily Klonopin if it weren't addictive, but I was addicted to Xanax once when I was first taking imipramine/Trofranil a decade ago, and detoxing from that was not fun.
> BTW, how long did you take Serzone, and how much did you take?
I slowly ramped up to 550 mg/day over the course of two months. All it did was make me a zombie and made my blood pressure so low I could hardly stay awake so I slowly ramped back down, so I was on it a total of three months at various dosages both coming and going. Extremely disappointing. It did not work at any dosage.
>it took a full twelve weeks before the Serzone started kicking in. With Serzone I think a lot of Social Phobics and their docs end up rejecting what could have been a big help just because they don't realize it can take quite awhile -- and a minimum 400 mg -- to kick in for this disorder.
You'll forgive me if I am skeptical about this. How on earth do you know what dosage to take if it takes that long for an effect to manifest itself? Trial and error with a three month gap between each change seems totally impractical. Doesn't this medication supposedly have a very narrow therapeutic window? How could you possibly find it if it takes that long? Anyway this drug made me very dopey and the dopiness did not wear off with time, nor did it help with the social anxiety at all. If anything it made it worse because people began to notice how dopey I was acting. My doctor was so startled by how low my blood pressure had become that she would not even tell me what it was for fear of scaring me.
> In the larger of the two open studies of nefazodone (Serzone) for social phobia, treatment benefit took by far its biggest leap between weeks 8 and 12!
I have read a number of Serzone studies but none of them were conducted over six weeks, at least none of the double blind ones. I am curious if you can give me a reference for this study. All the other drugs which work by serotonin reuptake effect and whatever that does to the brain seem to work in a couple of weeks. I don't understand why Serzone would take so much longer. Anyway I was on it for three months with no benefit.
> I know the meds merry-go-round can be damn discouraging, but don't give up!
Thanks, but I am pretty discouraged and don't feel like continuing to be a guinea pig for the pharmaceutical companies. Experimenting with drugs sounds like research, not treatment. My experiences so far have been so unpleasant that I have no motivation to continue with them.
Posted by SalArmy4me on July 1, 2001, at 14:10:55
In reply to Re: Giving up, posted by Joe Schmoe on July 1, 2001, at 12:48:53
I think you may want to take a look at venlafaxine because of this passage, which claims that a dual-action antidepressant works faster than a single-action AD like fluoxetine or nefazodone:
Nierenberg, Andrew A. M.D et al. Timing of Onset of AD Response With Fluoxetine Treatment. Amer J of Psychiatry. 157(9):1423-1428, September 2000:
"...The timing of onset of clinical improvement with the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, paroxetine, and citalopram, as well as with bupropion, trazodone, nefazodone, and mirtazapine, has been studied less extensively than the timing of improvement with the older generation of tricyclic antidepressants and monoamine oxidase inhibitors. Head-to-head studies of SSRIs and tricyclic antidepressants have indicated parallel improvements when measured by standard depression scales (8-11). In addition, on the basis of the hypothesis that combined norepinephrine and serotonin uptake inhibition causes a more rapid down-regulation of beta adrenergic receptors than with norepinephrine alone (12), Nelson and colleagues (13) found that combining fluoxetine and desipramine resulted in faster antidepressant effects than with desipramine alone. With a similar line of reasoning, that dual action speeds up response, a faster onset of action has been reported for venlafaxine than for SSRIs..."
Posted by Rick on July 1, 2001, at 17:41:28
In reply to Re: Giving up, posted by Joe Schmoe on July 1, 2001, at 12:48:53
Yeah, I can definitely see why you'd want to stay away from a daily benzo at this point. With its longer half-life Klonopin is less prone to causing addiction than Xanax, but there's still potential that the same thing will happen to you.
But Klonopin can definitely be taken on an as-needed basis as well. It may not be as good as Xanax where you need super-fast spur-of-the-moment help, but if you take it WITHOUT food 45 minutes to an hour before a challenging event like a presentation, it can be extremely effective. In my case as-needed Xanax made me somewhat more able to cope simply because it numbed me, made me feel kinda drunk...doped up and slow. I didn't like that.
The first Klonopin I took, on the other hand felt so much smoother. It made me a tad "mellow" rather than hitting me over the head with a hammer. To me, Xanax feels like great sleeping pill, not an optimal tool for fighting social anxiety. As always, dosage and timing is important for either one, whether as-needed or taken regularly.
BTW, regarding my own Klonopin experience: The first year I took it I got a promotion, won several awards for creative work, and suddenly started getting calls from clients who wanted me to participate in higher-level meetings. Not to mention injecting good ideas into meetings instead of sitting there with a pounding heart, afraid to speak.
If THAT's sleepiness and cognitive impairment (!), then hit me with a hammer and call me dumbstruck! Of course, YMMV, YMMV, YMMV! Klonopin didn't *directly* enhance my cognitive function of course. It just peeled away the social phobia that had my innate ability and desire to think, act, and participate restrained in a unyielding headlock (pun intended). I might add (OK, I WILL add) that there have actually been a few studies on rodents showing certain kinds of *cognitive improvement* from Klonopin.
Benzos aside, I agree that Effexor might be worth a try.
As for the Serzone skepticism, I had the luxury of (A) having a med that was already helping my SP alot and (B) concurrently taking a med that staved off any sedation (low-dose Provigil). So I just slowly ramped up to to a range that proved to be very typical in the main study for Serzone in SP. A month ago I wanted to see if Serzone was really adding anything to the treatment, so I ramped down pretty quickly -- all the way to zero at one point. I was still doing well, but definitely saw some nervousness creeping back in, even at 300. It's quite possible that Serzone helps me more by prolonging and smoothing out the biovailability and elimination of the other meds.
I, too, find it unusual that the hypotensive effects of Serzone are understated in the medical literature. It defintely lowers my BP, and I have a friend taking it who sees the same effect. (Works very well for her GAD, by the way, and it has never mades her sleepy at 400 mg, believe it or not. Her doc started her on 100mg week one, then 200mg wk 2 and then 400 mg wk 3-4. She saw no benefit at 100, mild at 200 and great benefit at 400).
You should be happy you have good BP. That's great for your health. If you want to see a med with REALLY strong hypotensive effects, its Nardil. I was hypertensive when I started Nardil, but within weeks I had sustained hypotension! Through weight loss and anxiety reduction, my BP had become low normal even before I started Serzone. Klonopin lowers my BP a bit, too.
> > Before settling on Xanax, did you try Klonopin/Rivitrol?
>
> No. I don't take Xanax very often. I often go months without taking any, or only taking it once a month or so when things get bad. I am pretty functional in most situations, just not very happy. Klonopin sounded like more of a daily thing. I don't want to be tired or suffer cognitive impairment on a daily basis nor do I want to get addicted. Xanax seems better for crunch times like presentations and interviews. I would be tempted to try daily Klonopin if it weren't addictive, but I was addicted to Xanax once when I was first taking imipramine/Trofranil a decade ago, and detoxing from that was not fun.
>
> > BTW, how long did you take Serzone, and how much did you take?
>
> I slowly ramped up to 550 mg/day over the course of two months. All it did was make me a zombie and made my blood pressure so low I could hardly stay awake so I slowly ramped back down, so I was on it a total of three months at various dosages both coming and going. Extremely disappointing. It did not work at any dosage.
>
> >it took a full twelve weeks before the Serzone started kicking in. With Serzone I think a lot of Social Phobics and their docs end up rejecting what could have been a big help just because they don't realize it can take quite awhile -- and a minimum 400 mg -- to kick in for this disorder.
>
> You'll forgive me if I am skeptical about this. How on earth do you know what dosage to take if it takes that long for an effect to manifest itself? Trial and error with a three month gap between each change seems totally impractical. Doesn't this medication supposedly have a very narrow therapeutic window? How could you possibly find it if it takes that long? Anyway this drug made me very dopey and the dopiness did not wear off with time, nor did it help with the social anxiety at all. If anything it made it worse because people began to notice how dopey I was acting. My doctor was so startled by how low my blood pressure had become that she would not even tell me what it was for fear of scaring me.
>
> > In the larger of the two open studies of nefazodone (Serzone) for social phobia, treatment benefit took by far its biggest leap between weeks 8 and 12!
>
> I have read a number of Serzone studies but none of them were conducted over six weeks, at least none of the double blind ones. I am curious if you can give me a reference for this study. All the other drugs which work by serotonin reuptake effect and whatever that does to the brain seem to work in a couple of weeks. I don't understand why Serzone would take so much longer. Anyway I was on it for three months with no benefit.
>
> > I know the meds merry-go-round can be damn discouraging, but don't give up!
>
> Thanks, but I am pretty discouraged and don't feel like continuing to be a guinea pig for the pharmaceutical companies. Experimenting with drugs sounds like research, not treatment. My experiences so far have been so unpleasant that I have no motivation to continue with them.
Posted by Joe Schmoe on July 1, 2001, at 19:40:22
In reply to Re: Giving up/Klonopin ENHANCED Cognitive Function » Joe Schmoe, posted by Rick on July 1, 2001, at 17:41:28
Okay, you have me intrigued. I don't think my internist is big on benzos but I will try to talk her into giving me some Klonopin to try. On .5 mg of Xanax I feel like I could give a stand-up comedy routine in front of Congress so I know benzos at least are effective. I think I am through playing with serotonin chemistry though - I found imipramine more sexually tolerable than Paxil so I don't think the drug companies have been honest about their progress in this field, the new drugs aren't any better than the old as far as I am concerned, in fact they are worse. Thanks for your input, maybe Klonopin will be the answer for me.
Posted by Janelle on July 1, 2001, at 20:19:30
In reply to Giving up, posted by Joe Schmoe on July 1, 2001, at 10:12:15
I understand how you feel. All I can add is that when the SSRI's (Prozac, Paxil and friends) came out, the trade-off was that they decrease sexual function (which I imagine is worse for a male) but supposedly do not have the side effects of dry mouth, constipation, tardive-dyskinesia, as much drowsiness, etc. as their predecessors, the trycyclics (Imipramine, Nortriptline, Amytriptiline and friends). But the SSRI's are FAR from "perfect" or problem free (there is no such thing as a problem free med, is there?!). Paxil worked fine for me and I put up with the decreased sexual effects, and they did GO AWAY! Amazing. But it lost its efficacy when things in my life started causing me other problems.
Hang in there, and hope you find what you're looking for.
Posted by dana on July 1, 2001, at 22:44:22
In reply to Re: Giving up » Joe Schmoe, posted by Emmah on July 1, 2001, at 11:56:28
Please don't say you are 'giving up'.....you are in fact.......'moving forward'......
Posted by gilbert on July 2, 2001, at 0:44:49
In reply to Re: Giving up, posted by dana on July 1, 2001, at 22:44:22
Hey Joe,
Makes me think of Hendrix.......I have tried all the ssris and all the nsris and all the tetracylcis and some tricyclics all too avoid what works ....benzos. If your internest won't prescribe klonopin for you tell her to give her old man paxil for a couple of weeks and I gaurantee she will begin to understand what you mean. These docs kill me...I finally said hey doc if you think this drug is so damned safe and so damed good you try it for a couple of weeks and we'll talk. I gaurantee he wouldn't tolerate the side effects.....
Gil
Posted by Neal on July 2, 2001, at 12:47:23
In reply to Re: Giving up, posted by gilbert on July 2, 2001, at 0:44:49
Hey Rick,
Are you the "Social Phobia Wow!" Rick? ie, your post from last June? Care to share your cocktail for SP? How much Klonopin to you take? Thanks --Neal
Posted by Rick on July 2, 2001, at 21:24:55
In reply to Re: Social Phobia Cocktail -Wow! -Rick, posted by Neal on July 2, 2001, at 12:47:23
> Hey Rick,
> Are you the "Social Phobia Wow!" Rick? ie, your post from last June? Care to share your cocktail for SP? How much Klonopin to you take? Thanks --NeaYeah, that would be me! The cocktail still has the same three meds as before: KLONOPIN (still at 1.25 mg), SERZONE (been at 450 mg since late lat year), and PROVIGIL (now usually 100 mg instead of 200, although I occasionally spike it for a day or two at a time).
A few notes:
-- This is just a guess, but if I started all the meds at once, instead of having already been on Klonopin quite awhile, the combo may have taken
some getting-used to. I think starting the benzo first, and then adding an AD, is the opposite of the way it usually works. Obviously for someone with concomitant depression, they should be on an AD from the start. But for me this approach worked out great. Also, I was able to wait for Serzone's s-l-o-o-o-w kick-in for SP because Klonopin was already helping so much. (This is not imply that Serzone's kick-in -- when it works -- will necessarily be slow with other disorders, too. In fact, for GAD just the opposite seems to be true.)
-- The Serzone/Klonopin combination may have been pretty sedating without the Provigil. I think ramping up quickly to 200 mg Provigil, and later cutting back to 100 as my body adjusted more to Serzone+Klonopin sedation, was a good approach.
-- A number of people on this board dislike Provigil. Of course, they were taking it with different meds than I, and most had other disorders in addition to SP. This is just a guess, but I think some of them may have felt the initial mild euphoria side effect that Provigil can have, and mistakenly concluded "poop-out" after that quickly subsided (BTW, I have definite OC tendencies, and I don't think the combo does much for that.)
-- I take all of the Provigil and most of the Klonopin and Serzone first thing in the morning. I usually don't take anything after mid-afternoon.
-- If I could only take one of the three meds, I'd definitely choose Klonopin.
Sorry if my "few" notes were more detail than you wanted!
Rick
Posted by Joe Schmoe on July 3, 2001, at 10:43:11
In reply to Re: Social Phobia Cocktail -Wow! -Rick ª Neal, posted by Rick on July 2, 2001, at 21:24:55
Okay, talked to my doctor and she has given me Klonopin to try for my social anxiety and Wellbutrin SR to try for my depression. Wish me luck. I don't know if this would be better than Paxil+Wellbutrin but I tend to trust the benzos more since I know Xanax works, and I know Paxil neutered me (quickly too - like a freight train hitting me below the belt within days of starting the stuff).
Anything I should know about Wellbutrin? I figure Klonopin is like a long-acting Xanax. My Klonopin dosage will be .5 mg per pill - that sounds large compared to the .25 mg Xanax pills I take now on occasion but I will try it. Wellbutrin dosage will be 150 mg, twice a day for 300 mg total. Trying not to get hit by the horses as I climb back on the merry go round....
Posted by Else on July 3, 2001, at 17:55:07
In reply to One more try - Klonopin and Wellbutrin, posted by Joe Schmoe on July 3, 2001, at 10:43:11
> Okay, talked to my doctor and she has given me Klonopin to try for my social anxiety and Wellbutrin SR to try for my depression. Wish me luck. I don't know if this would be better than Paxil+Wellbutrin but I tend to trust the benzos more since I know Xanax works, and I know Paxil neutered me (quickly too - like a freight train hitting me below the belt within days of starting the stuff).
> Anything I should know about Wellbutrin? I figure Klonopin is like a long-acting Xanax. My Klonopin dosage will be .5 mg per pill - that sounds large compared to the .25 mg Xanax pills I take now on occasion but I will try it. Wellbutrin dosage will be 150 mg, twice a day for 300 mg total. Trying not to get hit by the horses as I climb back on the merry go round....> Good thing your doctor gave you Klonopin along with the Wellbutrin. On Wellbutrin alone, especially at the beginning of the treatment, I had the most annoying tremors and couldn't sleep for three days straight. The second time I tried it (Wellbutrin) I was on Klonopin and none of these problems occured (presumably because of the anti-spasmodic and/or anticonvulsant and sedative properties of benzos, needless to say, but I said it anyway).
Posted by Rick on July 4, 2001, at 4:40:29
In reply to One more try - Klonopin and Wellbutrin, posted by Joe Schmoe on July 3, 2001, at 10:43:11
Believe me, Wellbutrin won't neuter you! It almost never causes sexual dysfuntion. In fact, sometimes it actually enhances sexual function.
But as Else suggested, it definitely has the potential to make you feel wired, especially until you get used to it. I trust your doc is going s-l-o-w working you up to the 300. If you have the opportunity to first try the Klonopin solo for awhile, that would be a good because within a week or less you should have a sense of whether it's working out for your SP (which I fully expect). Of course if you experience pretty severe depression, it may be best to start ramping up on the AD right away.
I actually tried Wellbutrin (100 mg.) with Klonopin and Celexa, before I hit on the cocktail I've used for a year now. The Wellbutrin was added to offset lethargy and apathy brought on by the Celexa. It did indeed help on that count, but it also reversed some of the SP benefit of the Klonopin by making me kind of jittery. That said, if I had ramped up on it real slow, it might not have had the adverse effect. (My pdoc actually suggested starting at 25 mg and moving up slowly...I should have followed his advice. I felt no adverse effect at 50mg, so I made the mistake of jumping up to 100 mg too quick.) And there are definitely anxious people who do well with it once they get used to it, although there should usually be something of a more calming nature in the mix -- in your case, Klonopin. Wellbutrin can cause insomnia in a lot of folks, especially early on, but Klonopin should do a lot to help prevent that -- even if taken during the morning or afternoon.
BTW, you mentioned the size of your Klonopin pills, but not the daily dosage. Does this mean you're taking it as-needed? If so, you *might* find you need it pretty regularly as you adjust to likely activation effects from the Wellbutrin.
Good luck to you. I think you've got a real good chance of doing well with this combo for both your depression and your SP, especially if you start-low-go-slow with the Wellbutrin.
Rick
Posted by Joe Schmoe on July 4, 2001, at 19:44:16
In reply to Re: One more try - Klonopin and Wellbutrin » Joe Schmoe, posted by Rick on July 4, 2001, at 4:40:29
> I trust your doc is going s-l-o-w working you up to the 300.
My schedule is a 150 SR tablet once a day for three days, then two 150 SR tablets per day after that. I took my first one about 7 hours ago, so far I feel a little euphoric but with some tightness in my chest. I used it as motivation to go exercise.
>If you have the opportunity to first try the Klonopin solo for awhile, that would be a good because within a week or less you should have a sense of whether it's working out for your SP (which I fully expect).
Well I have taken a few days off work so I decided to get the Wellbutrin going so I can get the worst parts of it out of the way. No way to test the Klonopin at home for SP....although I may end up taking it anyway just to test drive it and help with any Wellbutrin jitters.
>Of course if you experience pretty severe depression, it may be best to start ramping up on the AD right away.
I would say I am more dysthymic. It comes and goes. I have never spent days in bed or anything like that, but I have a pretty negative outlook on life most of the time along with hopelessness at times.
>(My pdoc actually suggested starting at 25 mg and moving up slowly...I should have followed his advice. I felt no adverse effect at 50mg, so I made the mistake of jumping up to 100 mg too quick.)You must have been taking the non-SR version then? The smallest SR pill is a 100 mg I believe. And you are not supposed to divide it or it will ruin the SR properties. There is nothing I can do with these 150 mg pills except take them whole. My doc was out of samples, I wonder if the sample pacs have smaller doses for SR?
>And there are definitely anxious people who do well with it once they get used to it, although there should usually be something of a more calming nature in the mix -- in your case, Klonopin.
I usually don't suffer from free floating anxiety. I am not sure if I am considered an "anxious person" or not, since my anxiety is almost always caused by some obvious external factor, i.e. social scrutiny, worrying about some upcoming confrontation or performance, etc. If there is nothing wrong in my life, I feel fine and can go months without Xanax. That is why I think of myself more as "sensitive" and prone to catastrophic overreaction to problems, rather than anxious. Probably why I was always given Xanax instead of Klonopin. Of course Xanax is only useful if you get advanced warning...."These people just showed up, can you give them a little presentation about our organization?" "Sure....*gulp*"
> BTW, you mentioned the size of your Klonopin pills, but not the daily dosage. Does this mean you're taking it as-needed?
Yes, she wants me to figure out what I will need. Due to my past experience with xanax I am still reluctant to take a benzo round the clock for fear of developing tolerance. I will try to get away with taking it on weekday mornings and see if that works. I am afraid even that will cause a tolerance/dependance to develop but at this point who cares, I want a better life.
I guess my fear is building a tolerance, having to up the dose, repeat, etc. till I am at the maximum dose and what do you do then when you develop a tolerance? I wish I knew how often I could take it and still avoid a tolerance.
> Good luck to you. I think you've got a real good chance of doing well with this combo for both your depression and your SP, especially if you start-low-go-slow with the Wellbutrin.
Thanks. Wellbutrin seems to have a lot of positive commentary compared to the other ADs. I was scared away from it by the seizures thing, but on closer examination, it seems to have the same seizure rate as Paxil and Zoloft. I don't understand what is going on. I will start a new thread on this.
Posted by Rick on July 5, 2001, at 1:54:47
In reply to Re: One more try - Klonopin and Wellbutrin » Rick, posted by Joe Schmoe on July 4, 2001, at 19:44:16
> > I trust your doc is going s-l-o-w working you up to the 300.
>
> My schedule is a 150 SR tablet once a day for three days, then two 150 SR tablets per day after that. I took my first one about 7 hours ago, so far I feel a little euphoric but with some tightness in my chest. I used it as motivation to go exercise.“Exercise”...The more I hear that word, the better. Maybe I’ll finally get off my butt and get serious about doing it.
> >If you have the opportunity to first try the Klonopin solo for awhile, that would be a good because within a week or less you should have a sense of whether it's working out for your SP (which I fully expect).
>
> Well I have taken a few days off work so I decided to get the Wellbutrin going so I can get the worst parts of it out of the way. No way to test the Klonopin at home for SP....although I may end up taking it anyway just to test drive it and help with any Wellbutrin jitters.The jitteriness I experienced with Wellbutrin was pretty much low-level and inconsequential when I was by myself or with someone I’m close to. But it was magnified in situations that triggered social phobic reactions. During those times, the benefits of the Klonopin would be reduced, e.g., I’d tense up some, speak less, and sound kind of nervous and shaky when I did get myself to speak up. Note that I’m talking in relative terms here...even with some renewed social anxiety, I was still a lot better off than pre-Klonopin.
I think your idea of using the time off to get accustomed to the Wellbutrin is a good one, especially if you do want to follow “doctor’s orders” on the quick ramp-up. There’s a good chance that this will work out well for you. But that’s still a pretty fast ramp-up of an activating AD for someone with social phobia, so don’t be caught off guard if you find yourself more anxious than you expected during your first “SP-challenge” situations, even with Klonopin. Things could go just great; or they could start out iffy but improve as you adjust; or you could end up needed to re-assess (e.g., try backing down on the Wellbutrin for awhile or, if that doesn’t help, add more Klonopin to offset the Wellbutrin activation). Again, I’m not saying to *expect* any problem, but just be prepared to realize that some kind of further adjustment could very well be necessary with this kind of combo in SP.
BTW, with my own brand of SP, it would be easy to test things when I’m not at work. Things like ordering a pizza, talking to a postal clerk, or picking up a prescription could make my heart beat fast and my voice tremble. Never had any problem at grocery stores, though, which seems to be a common problem for a lot of socially anxious people. Go figure. (A prescription pick-up incident was especially bad on my second day of Celexa. In fact, the Celexa almost completely wiped out Klonopin’s benefits for me from days 2-6 after appearing to help on day 1. For a few days I was worried that the Klonopin had pooped out. But that worry didn’t last long.)
> >Of course if you experience pretty severe depression, it may be best to start ramping up on the AD right away.
>
> I would say I am more dysthymic. It comes and goes. I have never spent days in bed or anything like that, but I have a pretty negative outlook on life most of the time along with hopelessness at times.
>
> >(My pdoc actually suggested starting at 25 mg and moving up slowly...I should have followed his advice. I felt no adverse effect at 50mg, so I made the mistake of jumping up to 100 mg too quick.)
>
> You must have been taking the non-SR version then? The smallest SR pill is a 100 mg I believe. And you are not supposed to divide it or it will ruin the SR properties. There is nothing I can do with these 150 mg pills except take them whole. My doc was out of samples, I wonder if the sample pacs have smaller doses for SR?
>
Nope, it was SR. He suggested original Wellbutrin, but I asked for Wellbutrin SR. My pdoc wrote the prescription for 100 mg once a day, saying that a pharmicist would have a fit if handed a script for 25 mg./day Wellbutrin. Even though he’s a very non-conservative pdoc on many ways (e.g., major fan of MAOI’s and says the food restrictions are way overstated), he’s a big start-low-go-slow proponent, especially for anxiety. Plus, he had seen how low-dose dopamine-selective selegiline had made me nervous; was taking into account that this was being added to another AD (Celexa); and wanted to be cautious on the seizure front. (Not sure why on the latter. Maybe because of the mild in-bed body jerks I had with Nardil and the intense in-bed body jerks I had from 1 day of lithium augmentation of selegiline. I don’t understand much about extrapyri-whatever side effects.)I did in fact find it odd that he was suggesting splitting an S-R tablet, into quarters no less. But he insisted that this was OK to do. And I *have* seen others post that their docs said the same thing. (For the record, though, there are a number of areas where I don’t think he knows what he’s talking about. Even though he’s NOT benzophobic, he never even wanted me to try Klonopin, and I had to really had to do the full-court press to get him to prescribe then-unfamiliar Provigil instead of Ritalin. He later thanked me for turning him on to the anxiety-fighting properties of low-dose Provigil, which he’s now used successfully in some treatment-resistant cases of GAD and depression.)
> >And there are definitely anxious people who do well with it once they get used to it, although there should usually be something of a more calming nature in the mix -- in your case, Klonopin.
>
> I usually don't suffer from free floating anxiety. I am not sure if I am considered an "anxious person" or not, since my anxiety is almost always caused by some obvious external factor, i.e. social scrutiny, worrying about some upcoming confrontation or performance, etc. If there is nothing wrong in my life, I feel fine and can go months without Xanax. That is why I think of myself more as "sensitive" and prone to catastrophic overreaction to problems, rather than anxious. Probably why I was always given Xanax instead of Klonopin. Of course Xanax is only useful if you get advanced warning...."These people just showed up, can you give them a little presentation about our organization?" "Sure....*gulp*"That’s why I prefer daily Klonopin, so that it’s steady state. Not for general anxiety (although I’m sometimes a worrier, even with Klonopin), but so I don’t have to worry about come-as-they-may social situations. Sometimes, if a presentation, big meeting, or social event is coming up, I’ll rearrange my dosing schedule a bit (NEVER dosing less than four hours apart, though) and/or add .25 mg extra K, or .5 on rare occasions.
I frankly don’t think as-needed is optimal, but it should still be a big help. Besides, it sounds as if you plan to try out a daily .5 mg morning regimen, anyway. That sounds like a good compromise approach.
>
> > BTW, you mentioned the size of your Klonopin pills, but not the daily dosage. Does this mean you're taking it as-needed?
>
> Yes, she wants me to figure out what I will need. Due to my past experience with xanax I am still reluctant to take a benzo round the clock for fear of developing tolerance. I will try to get away with taking it on weekday mornings and see if that works. I am afraid even that will cause a tolerance/dependance to develop but at this point who cares, I want a better life.
>
> I guess my fear is building a tolerance, having to up the dose, repeat, etc. till I am at the maximum dose and what do you do then when you develop a tolerance? I wish I knew how often I could take it and still avoid a tolerance.Certainly some people can develop benzo tolerance, but that seems to be the exception to the rule when the benzos are used responsibly. (E.g., see attached study abstract for Klonopin in panic disorder). I’ve slowly been reducing the amount of Klonopin I take all along, with no intention whatsover of tapering off of it completely at this point. I started at 3 mg/day which helped a good deal, but quickly found that 1.5-2.0 helped a lot more while almost completely eliminating any sedation. I’ve been at 1.25 mg. for many months, and last week went to 1.0 (and then from 450 to 300 on the Serzone). After an iffy start, it seems to be working out OK, but I can’t say for sure yet. On Psycho-Babble I see a lot fewer complaints about poop-out in posts on benzos than I do in posts about ADs or other psychotropics.
>
> > Good luck to you. I think you've got a real good chance of doing well with this combo for both your depression and your SP, especially if you start-low-go-slow with the Wellbutrin.
>
> Thanks. Wellbutrin seems to have a lot of positive commentary compared to the other ADs. I was scared away from it by the seizures thing, but on closer examination, it seems to have the same seizure rate as Paxil and Zoloft. I don't understand what is going on. I will start a new thread on this.Yes, again that’s one area where I think my pdoc’s knowledge was behind the times. From everything I’ve read, with SR the seizure rate is about the same as with other AD’s. I’ve also heard lots of great things about Wellbutrin for depression, and specifically for dysthmia, too. My friend’s sister started it about two months ago (her first prescription psychotropic ever), and she’s thrilled with how much better she feels, apparently without side effects. BTW, her GP was going to give her Serzone – and this is a woman who has had three accidents in the last year from falling asleep at the wheel! If anyone needed an activating AD rather than a sedating one, she was it. (Although I suppose one could argue that nighttime-only dosing with Serzone could help her sleep through the all-night barking of the dogs she breeds.) So I had my friend arm her with some literature on Wellbutrin, and her GP prescribed that instead.
1: Psychopharmacol Bull 1998;34(2):199-205 Books
Long-term experience with clonazepam in patients with a primary diagnosis of panic disorder.Worthington JJ 3rd, Pollack MH, Otto MW, McLean RY, Moroz G, Rosenbaum JF.
Department of Psychiatry, Massachusetts General Hospital, Boston 02114-3117, USA.
This study examined the use patterns and efficacy of the high potency benzodiazepine (HPB) clonazepam in panic patients who were treated and followed naturalistically in the Massachusetts General Hospital Longitudinal Study of Panic Disorder. Of 204 patients followed over a 2-year period, 46 percent were receiving clonazepam alone or in combination with an antidepressant. Treatment was not controlled at initial evaluation or during the followup period. The main variables assessed in this analysis included global severity of the panic disorder and stability of clonazepam dose. All treatment groups tended to improve over time without significant differences in outcome between groups. Clonazepam doses remained stable over time. Results of this study suggest that treatment of panic disorder with the HPB clonazepam achieved and maintained a therapeutic benefit similar to that obtained with alternative pharmacologic treatments, without the development of tolerance as manifested by dose escalation or worsening of clinical status.
Posted by Rick on July 5, 2001, at 3:09:44
In reply to Re: One more try - Klonopin and Wellbutrin » Rick, posted by Joe Schmoe on July 4, 2001, at 19:44:16
A few afterthoughts (as if I haven't already blabbed enough...):
I was re-reading your last post and realize that in a few cases my replies weren't directly responsive to what you had to say. But even if they had been, I believe I would have ended up voicing pretty much the same opinions (e.g., that daily Klonopin dosing is optimal)...although I might have taken a different route getting there or expressed it a little differently.
I am a little curious, though, about the relationship -- if any -- between your earlier addiction to Xanax and your concern over *tolerance* potential with Klonopin. Regardless, as you no doubt know, Klonopin has less addiction potential than Xanax. Withdrawal symptoms (due to dependence) are certainly possible, although even that represents a minority situation, especially where the dose is under 3.0 mg. and a slow taper is used.
Posted by Joe Schmoe on July 5, 2001, at 14:25:40
In reply to Re: One more try - Klonopin and Wellbutrin » Joe Schmoe, posted by Rick on July 5, 2001, at 3:09:44
> I am a little curious, though, about the relationship -- if any -- between your earlier addiction to Xanax and your concern over *tolerance* potential with Klonopin.Sure there is a relationship. I was told the reason that xanax was a temporary measure until the imipramine kicked in was because in the long run xanax was not practical due to the way tolerance developed; you upped and upped the dose till you hit the ceiling, and then what? When you are coming off a dose of xanax and hitting that rebound anxiety, you reach for the next dose and nothing is more scary than the idea that it might not be enough. It brings to mind images of heroin addiction.
>Regardless, as you no doubt know, Klonopin has less addiction potential than Xanax. Withdrawal symptoms (due to dependence) are certainly possible, although even that represents a minority situation, especially where the dose is under 3.0 mg. and a slow taper is used.
What about when you are between doses? If you are out on the town or something and your last dose wears off, do you start getting the shakes? That was the problem with xanax. I have never had that problem since because I don't allow myself to take xanax very often. Handled it on an as-needed basis for over ten years now with no problem, although honestly there are many times I would have been more relaxed if I had been using it. I guess I have become somewhat puritanical about using it in order to avoid dependence. I probably suffer more than I should. I am wondering if Klonopin will allow me to feel okay all the time, or if I will have to use it sparingly to avoid dependence - and if so, how sparingly.
The problem with as-needed regimens is that they make it impossible to have a job where you have to manage people and/or have confrontations or other unpleasant situations frequently and without warning. This is impeding my career. I need 9-to-5 protection and I am afraid to try to use xanax to get it. Thus my willingness to try Klonopin.
Posted by Rick on July 6, 2001, at 1:15:21
In reply to Re: One more try - Klonopin and Wellbutrin » Rick, posted by Joe Schmoe on July 5, 2001, at 14:25:40
>
> > I am a little curious, though, about the relationship -- if any -- between your earlier addiction to Xanax and your concern over *tolerance* potential with Klonopin.
>
> Sure there is a relationship. I was told the reason that xanax was a temporary measure until the imipramine kicked in was because in the long run xanax was not practical due to the way tolerance developed; you upped and upped the dose till you hit the ceiling, and then what? When you are coming off a dose of xanax and hitting that rebound anxiety, you reach for the next dose and nothing is more scary than the idea that it might not be enough. It brings to mind images of heroin addiction.What kind of doctor told you that? Don't answer, I know -- a benzophobic one. If they told you that tolerance is a *possibility* for some people, that's fine. But suggesting it's the typical course of events is irresponsible, and just plain wrong in cases where the drug is being used responsibly by someone who is experiencing theraputic benefit for a chronic anxiety disorder. Conversely, dependence (real or perceived need to continue the drug to avoid distress, NOT the addictive desire to take more and more) is a much more common possibility. But potential dependence is certainly no reason to avoid the med that helps most. Just ask any insulin-dependent diabetic. If the med is subsequently discontinued, there could quite possibly be withdrawal distress -- the same kind lots of folks experience when trying to get off of Paxil or Effexor. But a gradual taper usually minimizes the severity of that distress.
There are certainly a minority of people who fall outside the typical pattern. It's generally been felt -- even by non-benzophobic docs -- that benzos should be "used cautiously if at all" for individuals with a history of substance abuse or addiction. But some very recent studies are demonstrating that even this caution has been overstated in many cases.
> What about when you are between doses? If you are out on the town or something and your last dose wears off, do you start getting the shakes? That was the problem with xanax. I have never had that problem since because I don't allow myself to take xanax very often. Handled it on an as-needed basis for over ten years now with no problem, although honestly there are many times I would have been more relaxed if I had been using it. I guess I have become somewhat puritanical about using it in order to avoid dependence. I probably suffer more than I should. I am wondering if Klonopin will allow me to feel okay all the time, or if I will have to use it sparingly to avoid dependence - and if so, how sparingly.Can't you make sure you have at least a little Klonopin on you at all times, say in a little pillbox? (CVS has a great unobtrusive little round one. I taped some cotton to the bottom of the lid to keep the pills from rattling around as I walk.) Even if you took Klonopin regularly, missing a day probably wouldn't be too awful because of the long half-life. If you had problems because you had no access to Klonopin, they'd probably creep up fairly slowly. I don't know where you travel, but in towns of any significant size, you should normally be able to get an emergency supply before all the med in your system wears out. You know -- call doctor (their emergency # if nec) and have a prescription faxed to a local drugstore, etc. If it does start wearing off before you can get some, go to the emergency room. They certainly know that problems can occur if a patient goes cold turkey on a benzo. But the need for these kinds of measures should occur very rarely, if at all. Hey, there's always a possibility that I'll get hit and killed by a drunken driver when I'm on the road (a lot worse than even horrible withdrawal symptoms, no?), but I won't give up the benefits of driving because of it. Did you run out of Xanax a lot? How distressful were the shakes? How much were you using at the time, and on what schedule?
>
> The problem with as-needed regimens is that they make it impossible to have a job where you have to manage people and/or have confrontations or other unpleasant situations frequently and without warning. This is impeding my career. I need 9-to-5 protection and I am afraid to try to use xanax to get it. Thus my willingness to try Klonopin.Perhaps it's because I'm already in a long-lasting, strong relationship, but my biggest ongoing benefit from Klonopin has been been for my career. It's made a world of difference. I still don't like getting a sudden performance request thrown my way (and not just for reasons related to anxiety), but it's so refreshing not to suddenly panic. (On the other hand, I sometimes perversely enjoy watching myself calmly but firmly speak my mind during the confrontations that would freak me out in the past. Certainly not all at work!) It would seem that popping even a fast-acting pill after a swirl of anticipatory anxiety begins would be less beneficial than passively holding that anxiety at bay from the start.
BTW, how are things going so far with the new meds? I know it may be a little early to talk about theraputic benefits, but is everything going OK side-effect-wise?
Since I referred to "studies" several times,I feel compelled to include one small study abstract. This relates to both the mental and physical (withdrawal) effects of Klonopin discontinuation after 6-11 months of regular use.
YMMV, YMMV, YMMV!Rick
====
J Clin Psychopharmacol 1998 Oct;18(5):373-8 Related Articles, Books, LinkOut
Discontinuation of clonazepam in the treatment of social phobia.Connor KM, Davidson JR, Potts NL, Tupler LA, Miner CM, Malik ML, Book SW, Colket JT, Ferrell F.
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27710, USA.
Patients with social phobia who responded well to 6 months of open-label treatment with clonazepam were assigned to receive either continuation treatment (CT) with clonazepam for another 5 months, or to undergo discontinuation treatment (DT) using a clonazepam taper at the rate of 0.25 mg every 2 weeks, with double-blind placebo substitution. Clinical efficacy was compared between the CT and DT groups using three different social phobia scales. Benzodiazepine withdrawal symptoms were also measured. Relapse rates were 0 and 21.1% in the CT and DT groups, respectively. Subjects in the CT group generally showed a more favorable clinical response at midpoint and/or endpoint, although even in the DT group clinical response remained good. With respect to withdrawal symptoms, the rates were low in both groups (12.5% for CT and 27.7% for DT) with no real evidence suggesting significant withdrawal difficulties. At the end of 11 months of treatment with clonazepam, however, a more rapid withdrawal rate was associated with greater distress. This study offers preliminary evidence to suggest that continuation therapy with clonazepam in the treatment of social phobia is safe and effective, producing a somewhat greater clinical benefit than a slow-taper discontinuation regime. However, even in the DT group, withdrawal symptoms were not found to be a major problem. The study can be taken as supportive of benefit for longterm clonazepam treatment in social phobia, as well as being compatible with a reasonably good outcome after short-term treatment and slow taper.
Posted by Joe Schmoe on July 8, 2001, at 19:38:55
In reply to Re: One more try - Klonopin and Wellbutrin » Joe Schmoe, posted by Rick on July 6, 2001, at 1:15:21
> There are certainly a minority of people who fall outside the typical pattern. It's generally been felt -- even by non-benzophobic docs -- that benzos should be "used cautiously if at all" for individuals with a history of substance abuse or addiction. But some very recent studies are demonstrating that even this caution has been overstated in many cases.I wonder how "substance abuse" is defined. Are we talking people who smoked pot in college, or hardcore crack users trying to quit their habit?
What do these people do? Just take higher and higher doses of Klonopin to try to get high?
> Can't you make sure you have at least a little Klonopin on you at all times, say in a little pillbox? (CVS has a great unobtrusive little round one. I taped some cotton to the bottom of the lid to keep the pills from rattling around as I walk.)How similar our lives are. I have a little round gold pillbox that I pad with tissue paper so the pills don't rattle around, that I keep Xanax and Inderal in. I am always afraid of someone finding it - when sitting in deep chairs I find sometimes it slips out of my pocket (women have an advantage with purses!) and I have left it behind on chairs before. Of course when I realized it, there was a frantic search to go find it before someone else did. The big problem is not the convenience, it is trying to hide this stuff all the time. I usually keep it in my locked messy desk drawer at work now to avoid this problem. It also keeps my body heat from breaking down the medicine as it would if it was sitting in my pocket all the time. I am tempted to put it in some kind of prescription bottle, say a Claritin one or something, and just not make an effort to hide my taking it. I am tired of sneaking around. There must be a way for men without purses to work these things into their lives conveniently.
>Even if you took Klonopin regularly, missing a day probably wouldn't be too awful because of the long half-life.
I was more worried about missing a few hours than a day. If you are on an all-day assignment somewhere for example, it would be a catastrophe if your xanax ran out halfway through the day!
>Did you run out of Xanax a lot?
More of a case that I could really tell when a dose was wearing off. The anxiety would shoot upwards. Was it just my normal anxiety returning, or was it benzo-caused rebound anxiety? It is hard to tell, but it was a nasty effect, especially since it might take 30 or 45 minutes for the next dose to kick in. People would see you go from jumpy and nervous to dopey in the course of an hour. It must raise suspicions. And then you start taking the second dose earlier to avoid the anxious period between doses, and pretty soon you are taking more per day than you are supposed to because you don't wait the full time period between each dose...
> How distressful were the shakes? How much were you using at the time, and on what schedule?
I am an excellent responder to Xanax. My "mild relaxation" dose is .25 mg Xanax, and my "get ready to stand up and talk" dose is .5 mg. I have never taken more than that. .5 really knocks me out. If I take it around noon, it works for anxiety for maybe three hours, wears off, and then I start to get real tired, so by the time I get home I collapse on the couch and sleep for three hours in the evening. I am taking about occasional use mind you, not the "rebound" jumpiness that occurs with regular use. I have never taken xanax often enough to get a rebound reaction/shakes when a dose wore off, except that one month when I was tapering onto the imipramine long ago. I did not develop tolerance to Xanax in that time but I was addicted. When a dose started to wear off I was reaching for that bottle pretty quick, and when I came off it at the end of that month, for withdrawal I had overwhelming anxiety, muscle rigidity (neck would turn in little jerks, like a Parkinson's patient) and so on. That was over a decade ago and it was under bad circumstances (I had to do all this while working in a fairly stressful environment in a new job, and hide everything I was going through) so I have blotted much of this memory out. Suffice to say I have never been tempted to abuse xanax in the decade since, despite always having a bottle of it within reach. I get nervous if I take two or three Xanax doses in the same week, even though I know ratonally I would have to take it for weeks to get addicted.
> Perhaps it's because I'm already in a long-lasting, strong relationship,
I am too.
>but my biggest ongoing benefit from Klonopin has been been for my career. It's made a world of difference. I still don't like getting a sudden performance request thrown my way
who does?
>(and not just for reasons related to anxiety), but it's so refreshing not to suddenly panic. (On the other hand, I sometimes perversely enjoy watching myself calmly but firmly speak my mind during the confrontations that would freak me out in the past.
Man that is my dream scenario. Right now my throat tightens up and I get the feeling that I will lose muscular control of my neck (shivering and shaking) if I do not break eye contact.
> BTW, how are things going so far with the new meds? I know it may be a little early to talk about theraputic benefits, but is everything going OK side-effect-wise?
Very well. The first few days on the Wellbutrin I felt very upbeat (probably a little mania, I got this when starting Serzone as well) and high/euphoric (I assume this is the dopamine effects of Wellbutrin kicking in). I felt like I had taken a happiness pill. I mean it felt great. Since upping the dose to 300 mg I feel more normal. I went sparingly on the Klonopin at first but now I am taking it several times a day to get used to it. It is very subtle, doesn't make me continuously yawn like the xanax would.
The chemistry is complicated here. I am not sure if .5 mg per dose will be enough Klonopin; and if it isn't, I am not sure if that is because of the Wellbutrin; and if it is because of the Wellbutrin, I am not sure if that is because I have to get used to the Wellbutrin, or whether the Wellbutrin will always be activating and require more Klonopin even after the initial three weeks. In time I will get it sorted out. I suspect I may have to take more Klonopin for the first few weeks till the Wellbutrin settles down, and then cut back on the Klonopin. But that is assuming the Wellbutrin will settle down. It has not really made me anxious yet, except for occasional tightness in the chest which the Klonopin seems to relieve, but the effect of the Wellbutrin could well be simply negating some of the benefits of the Klonopin. I wonder if Wellbutrin becomes less activating after two or three weeks? I am definitely enjoying the reduced appetite (I am somewhat overweight) - wonder how long that will last!
> Since I referred to "studies" several times,I feel compelled to include one small study abstract.Thanks for all the information. The data on Konopin sounds very positive. My question is this: what is your dosing regimen? Do you take it three times a day? It sounds like that would be, say, 7 AM, 3 PM, 11 PM. But what is the point of taking a social anxiety drug at 11 PM at night? Is it to avoid a withdrawal reaction, or is there some therapeutic benefit to maintaining steady-state of this stuff?
Thanks again. So far I have been taking Klonopin once a day (first several days) and then twice a day (the last several days). Have not taken one late at night yet.
Posted by Rick on July 9, 2001, at 4:15:13
In reply to Re: One more try - Klonopin and Wellbutrin, posted by Joe Schmoe on July 8, 2001, at 19:38:55
>
> > There are certainly a minority of people who fall outside the typical pattern. It's generally been felt -- even by non-benzophobic docs -- that benzos should be "used cautiously if at all" for individuals with a history of substance abuse or addiction. But some very recent studies are demonstrating that even this caution has been overstated in many cases.
>
> I wonder how "substance abuse" is defined. Are we talking people who smoked pot in college, or hardcore crack users trying to quit their habit?I'm just paraphrasing what I've read, but I'm sure it's much more the latter.
> What do these people do? Just take higher and higher doses of Klonopin to try to get high?
Maybe. I know that some of my newsgroup searches on Klonopin have come up with posts in the recreational drug newsgroups. I think it's sold on the street for to be used in some kind of combo. I'm no expert here. Also, as I noted, recent studies are suggesting that past episodes of alcohol/drug addiction or heavy recreational drug use shouldn't necessarily raise a red flag for benzo-based treatments. That conclusion makes intuitive sense to me. Everyone's situation is different; these things aren't black and white.
>
> > Can't you make sure you have at least a little Klonopin on you at all times, say in a little pillbox? (CVS has a great unobtrusive little round one. I taped some cotton to the bottom of the lid to keep the pills from rattling around as I walk.)
>
> How similar our lives are. I have a little round gold pillbox that I pad with tissue paper so the pills don't rattle around, that I keep Xanax and Inderal in. I am always afraid of someone finding it - when sitting in deep chairs I find sometimes it slips out of my pocket (women have an advantage with purses!) and I have left it behind on chairs before. Of course when I realized it, there was a frantic search to go find it before someone else did. The big problem is not the convenience, it is trying to hide this stuff all the time. I usually keep it in my locked messy desk drawer at work now to avoid this problem. It also keeps my body heat from breaking down the medicine as it would if it was sitting in my pocket all the time. I am tempted to put it in some kind of prescription bottle, say a Claritin one or something, and just not make an effort to hide my taking it. I am tired of sneaking around. There must be a way for men without purses to work these things into their lives conveniently.Yes, this all sounds REAL familiar to me! Things constantly fall out of my pockets. But the pillbox has only fallen out a couple of times, and I've always been fortunate enough to notice it -- say when I open the car door and see it lying by the seat. I think somehow the fact that I keep it in the same pocket as my comb helps. Maybe the comb keeps it from falling out. I do know that I find myself reflexively pushing it deep into my pocket when I sit down or get up.
At least once or twice a month I forget to take the pillbox with me. That's created a little bit of worry and social anxiety on a few occasions (especially the first few times), but nothing too significant. My early-to-mid afternoon doses of Klonopin and Serzone are beneficial but seem a lot less essential than the larger doses I take first thing in the morning. In fact, I often forget to take the afternoon dose. Even with somewhat decreased benefit in a few cases, I'm stil SOOOO much better off than pre-Klonopin. Those really seem to provide the bulk of the "steady state feel".
I've sometimes dropped a pill on the floor in my office, hoping that no one walking by sees me scavenging around looking for it. While I'm still as discreet as possible (especially when I'm at the client's office, where I'll usually go into a bathroom stall to take a pill), I'm no longer as concerned about someone seeing me pop my afternoon regimen. I seem to be seeing more people, including my boss, openly downing pills from a pillbox. The Claritin bottle idea is a good one,.
I found your comment about degredation from heat interesting. I've never thought about it in terms of pocket heat, but I've had a lot of situations where I will, say, pick up a prescriotion at lunchtime and then have to decide whether I should leave it in the hot car for four hours (shaded whenever possible), or take it inside and try to keep it hidden away while also remembering to take it with me when I leave. I've done both. I've often wondered how much I should be concerned with the med breaking down in sit-in-the-car-in the hot sun situations.
> >Even if you took Klonopin regularly, missing a day probably wouldn't be too awful because of the long half-life.
>
> I was more worried about missing a few hours than a day. If you are on an all-day assignment somewhere for example, it would be a catastrophe if your xanax ran out halfway through the day!I highly doubt that will be as much of an issue with Klonopin, especially if you do take some every morning, as I believe you said you were doing or considering. I would think that ths would keep you well above "catastrophe" level at minumum -- especially if the Wellbutrin turns out to be helpful for your SP. BTW, I assume that you've checked out your caffeine sensitivity, if you're a coffee, tea or Coke drinker. I never would have believed that largely avoiding caffeine (during the week, anyway) would make a noticeable difference in social anxiety for me, but it really does. I think cutting back on caffeine is one reason I've been able to reduce the Klonopin dosage several times.
> >Did you run out of Xanax a lot?
>
> More of a case that I could really tell when a dose was wearing off. The anxiety would shoot upwards. Was it just my normal anxiety returning, or was it benzo-caused rebound anxiety? It is hard to tell, but it was a nasty effect, especially since it might take 30 or 45 minutes for the next dose to kick in. People would see you go from jumpy and nervous to dopey in the course of an hour. It must raise suspicions. And then you start taking the second dose earlier to avoid the anxious period between doses, and pretty soon you are taking more per day than you are supposed to because you don't wait the full time period between each dose...
Hope the Klonopin helps smooth that out. I bet it does.> > How distressful were the shakes? How much were you using at the time, and on what schedule?
>
> I am an excellent responder to Xanax. My "mild relaxation" dose is .25 mg Xanax, and my "get ready to stand up and talk" dose is .5 mg. I have never taken more than that. .5 really knocks me out. If I take it around noon, it works for anxiety for maybe three hours, wears off, and then I start to get real tired, so by the time I get home I collapse on the couch and sleep for three hours in the evening. I am taking about occasional use mind you, not the "rebound" jumpiness that occurs with regular use. I have never taken xanax often enough to get a rebound reaction/shakes when a dose wore off, except that one month when I was tapering onto the imipramine long ago. I did not develop tolerance to Xanax in that time but I was addicted. When a dose started to wear off I was reaching for that bottle pretty quick, and when I came off it at the end of that month, for withdrawal I had overwhelming anxiety, muscle rigidity (neck would turn in little jerks, like a Parkinson's patient) and so on. That was over a decade ago and it was under bad circumstances (I had to do all this while working in a fairly stressful environment in a new job, and hide everything I was going through) so I have blotted much of this memory out. Suffice to say I have never been tempted to abuse xanax in the decade since, despite always having a bottle of it within reach. I get nervous if I take two or three Xanax doses in the same week, even though I know ratonally I would have to take it for weeks to get addicted.I know Xanax has a shorther half life than Klonopin, but I'm surprised that the effects would wear out in three hours. Or now that I think back to my own experience with Xanax, maybe I’m not *too* surprised...I know when I took as-needed Xanax (my first-ever med for Social Phobia, in tandem with Nardil), it relaxed me to some degree by making me feel a little doped-up. I didn't really like the feeling, at least not in a work setting. It was as if I was drinking but without much cognitive degredation. (Is it the same for you by any chance?..or is the pre-crash impact strictly mental?...or would you describe your acute reaction in a completely different way?)
Xanax would make me feel exhausted hours later, usually as soon as I got home. I never had any craving for more except when I couldn't sleep. That was one hell of a sleeping pill for me when I was keyed up! Oddly, it quickly seemed to become less effective even for this. Whereas one .5 mg would zap me into dreamland for awhile, I got to the point where even 1.5 mg wouldn't do it if I was really keyed up. Since starting daily Klonopin, rarely taken after 4 p.m., I have trouble getting to sleep only about one night every month or two. And even then, I nod off in not much more than 30 minutes. I still have about fifteen Xanax's left from my original, 4/99 prescription of 90 .5 mg tabs (30 times three refills), since insomnia is no longer an issue.
One more thought...I wonder if your body metabolizes Xanax quickly. If so, the same might happen for Klonopin. But it should still exert an effect lasting at least twice as long as Xanax's, probably even longer.
> > BTW, how are things going so far with the new meds? I know it may be a little early to talk about theraputic benefits, but is everything going OK side-effect-wise?
>
> Very well. The first few days on the Wellbutrin I felt very upbeat (probably a little mania, I got this when starting Serzone as well) and high/euphoric (I assume this is the dopamine effects of Wellbutrin kicking in). I felt like I had taken a happiness pill. I mean it felt great. Since upping the dose to 300 mg I feel more normal. I went sparingly on the Klonopin at first but now I am taking it several times a day to get used to it. It is very subtle, doesn't make me continuously yawn like the xanax would.Sounds like an auspicious start.
I forgot about the yawning! I was afraid people would think they were boring me. Celexa also had that effect on me big-time, as did some of the other meds I tried, to a lesser degree. I still get into that mode about once every week or two.
> The chemistry is complicated here. I am not sure if .5 mg per dose will be enough Klonopin; and if it isn't, I am not sure if that is because of the Wellbutrin; and if it is because of the Wellbutrin, I am not sure if that is because I have to get used to the Wellbutrin, or whether the Wellbutrin will always be activating and require more Klonopin even after the initial three weeks. In time I will get it sorted out. I suspect I may have to take more Klonopin for the first few weeks till the Wellbutrin settles down, and then cut back on the Klonopin. But that is assuming the Wellbutrin will settle down. It has not really made me anxious yet, except for occasional tightness in the chest which the Klonopin seems to relieve, but the effect of the Wellbutrin could well be simply negating some of the benefits of the Klonopin. I wonder if Wellbutrin becomes less activating after two or three weeks? I am definitely enjoying the reduced appetite (I am somewhat overweight) - wonder how long that will last!
Yeah, it's hard sorting these things out when you have to start both meds at once (even though that's what most pdocs want you to do, since they typically view the benzo as a temporary augmentation or adjustment aid to the AD). All of the possible scenarios you presented are plausible, and it sounds like you’ve already got some good “contingencies” in mind. There are a lot of current and past Wellbutrin users on this board, likely including some with both Social Phobia and some shade of depression. Would be interesting to see what they have to say about adjustment to Wellbutrin activation.
> Thanks for all the information. The data on Konopin sounds very positive. My question is this: what is your dosing regimen? Do you take it three times a day? It sounds like that would be, say, 7 AM, 3 PM, 11 PM. But what is the point of taking a social anxiety drug at 11 PM at night? Is it to avoid a withdrawal reaction, or is there some therapeutic benefit to maintaining steady-state of this stuff?
Frankly I don't think there *is* much benefit to taking it at bedtime, and I don't. I initially avoided bedtime dosing because I had sleep apnea (since gone away since I shed quite a few pounds), which can be exacerbated by benzos. So I inadvertently learned that I didn’t need a bedtime dose. (The logic of an 11 p.m. dose seemed strange to me, too.) The aforementioned fact that Klonopin helps me sleep, even though I often take my final dose as early as 1 p.m., should be testament that -- at least for me -- 3-time dosing is unnecessary to maintain consistent benefit.
I find it *very* important to make the first dose the biggest one - 2/3 to 3/4 of the daily total. I usually take the rest of the daily amount 5-7 hours later. If there's a difficult challenge coming up (e.g. a big presentation) I might change the timing a little so that I get some an hour ahead of the event. Once in awhile I'll take an extra .25 (or even .5), especially if I'm facing a whole day of social. business-social and/or performance situations, say at an out-of-town convention. But I find the "extras" less and less necessary as time goes on. I do have two rules that I've learned I need to follow consistently: 1) Never take more than 1.0 mg at a time, and 2) Don’t take doses of any size less than 4, preferably 5, hours apart. If I violate either of these the result can be sedation/dopey feeling and some loss of effectiveness.
But, again, the worst that happens with some variation in the routine is a temporary, modest degradation in effectiveness, not an “Oh, shit, I’m f**d” situation. I obviously can’t guarantee the same will apply for you, but I’d be surprised if you don’t see significant movement in that direction vs. your experience with as-needed Xanax...especially after the gradual experimenation and fine-tuning.
>
> Thanks again. So far I have been taking Klonopin once a day (first several days) and then twice a day (the last several days). Have not taken one late at night yet.I'd suggest you don't. The few times I gave that a try, I just woke up groggy.
Posted by Pattisun on July 9, 2001, at 6:16:18
In reply to Re: One more try - Klonopin and Wellbutrin » Joe Schmoe, posted by Rick on July 9, 2001, at 4:15:13
The psychiatrist that the family practice doctor insisted I go to told me that Klonopin was NOT a drug that you can get a high from, so he was not concerned about me being on it. And, that Klonopin was not a drug his 'recreational drug user patients' tried to get.
He wrote a report back to my doctor that said my anxiety disorder was "moderately well controlled and my use of Klonopin should not be interrupted"
And, as far as Klonopin and recreational drug use--well, back in the 80s I used to get Klonopin from my girlfriend because they were the perfect soother after a bout of cocaine use. {{that's that period of life when I briefly lost all control of myself and used cocaine for a while}}--that's hard to admit to.
I leave Klonopin at work on a prescription bottle OR in a Motrin bottle, just in case ((I've rushed to work in the mornings, forgetting to bring it with me)) . And, I've never discussed Klonopin with anyone, just told them it's meds I have to take every day. Never take my Klonopin bottle with me (just because I always kept that one at home with the refill # so I can call the pharmacy). And, of course I do have a purse, but I also keep Klonopin in my fanny pack, or in my husband's fanny pack (if I am not carrying one). I've ridden big roller coasters and it's set off a panic attack, or I work out too hard.
I take my Klonopin at 11:00 and 2:00 (or close to it). And, on a really bad night or during a bad panic attack I'll take another one (.5 mg). They no longer make me sleepy at all--it's been six years for me. And, I have a pretty functional life THANKS to Klonopin (and cognitive therapy).
Good luck to both of you. Never met anyone else besides me that took it until I just found this board.
Posted by Mark H. on July 9, 2001, at 20:19:07
In reply to AD-provoked hypomania - is it diagnostic?, posted by Zo on July 9, 2001, at 14:39:44
> The literature seems about evenly divided.. ..
Hi Zo,
My reading suggests the literature is divided on(but leaning toward) the hypothesis that when STARTING an anti-depressant the occurrence of a hypomanic episode may indicate bipolar disorder, but I haven't seen any references that hypomanic activity as a rebound effect from STOPPING anti-depressants has diagnostic significance. However, other respondents to your post will be better informed than I am and may recall citations regarding withdrawal and diagnosis.
As a person with Bipolar II, I can tell you that when I quit taking Effexor the first time, all of my bodily, emotional and mental systems that had been suppressed by the medication rebounded wildly. I had to put out a memo to my colleagues asking them to cut me some slack while my systems regained some equilibrium. It was far more intense than any hypomania I had experienced.
If you're wondering whether you're Bipolar II, the main things to look at are the cyclicity of your depressive episodes (for instance, my two deep troughs usually come at roughly the same two times each year), the occurrence of one or more hypomanic episodes (that are NOT attributable to withdrawal or other external stimuli), and -- by the book -- the absence of psychotic mania or mixed states (highly agitated depression).
Absent those criteria, I would guess that a hypomanic-like state caused by abrupt withdrawal would not be diagnostic, but hopefully others will have more information.
Best wishes,
Mark H.
Posted by xraytech on July 9, 2001, at 20:21:04
In reply to regular Klonopin users, posted by Pattisun on July 9, 2001, at 6:16:18
i was on klonopin for nine years for headaches and anxiety. i became physically addicted to not only klonopin, but also oxycontin, and soma a muscle relaxer that is "non-addictive". let me tell you, after a 5 day detox, it took MONTHS to get that klonopin out of my system. it literally was in my bones. my doc said that it was in my fat and as i lost weight, it got released a little here and there. what a nightmare.
i never actually abused klonopin, well maybe once or twice, to fall asleep faster, i might have taken more than the usual does a coupla times.. but thats how youcan get into trouble.
be careful!
just letting you know what can happen sometimes, not what will happen, what can or might happen.
KNOWLEDGE IS POWER.good luck
robin:)
Posted by Rick on July 10, 2001, at 19:53:41
In reply to regular Klonopin users, posted by Pattisun on July 9, 2001, at 6:16:18
Thanks for sharing your own Klonopin "story" + "tips and tricks", Pattisun. It was great that your psych intervened to make sure you got the med that really helps keep panic at bay!
Now, stay off those rollercoasters!
Rick
Posted by Rick on July 10, 2001, at 20:09:00
In reply to Re: regular Klonopin users, posted by xraytech on July 9, 2001, at 20:21:04
Sounds like a pretty awful experience! You must have had some unbearable pain to need all three of those meds. How are you doing now? If you still need meds, what are you using?
I learned about Klonopin's pain-relieving properties inadvertently. When I began taking it for social anxiety I was surprised to find that my frequent jaw/facial pain (sometimes morphing into headaches) unexpectedly disappeared. I had just been getting ready to start checking into whether I had TMJ or some related syndrome. (My sister got it from nighttime bruxism, but has been doing well since she began wearing a splint at bedtime that prevents her from grinding her teeth.)
I'm not sure I'd want to take Klonopin soley for pain (never researched it), but that's a moot point for the forseeable future since I'm definitely sticking with it for the Social Phobia.
Rick
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