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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by Prefect on January 12, 2013, at 10:02:20
If an SSRI seems to have lost its effectiveness on anxiety and panic, would it not logically mean your brain has outsmarted it and reuptake inhibition or receptor downregulation is no longer taking place?
And so does this not mean a really conservative taper process is no longer required, since your brain will not be affected by the reduction in drug levels? And you shouldn't expect a discontinuation syndrome if you don't take 6 months to taper it?
Posted by Phillipa on January 12, 2013, at 12:05:10
In reply to Pooped out SSRI - No discontinuation problems?, posted by Prefect on January 12, 2013, at 10:02:20
That sounds logical but don't know if true? Which SSRI. For me some are worse. Luvox has a hold on me but lexapro I can stop? Go Figure. Phillipa
Posted by poser938 on January 12, 2013, at 13:00:46
In reply to Re: Pooped out SSRI - No discontinuation problems? » Prefect, posted by Phillipa on January 12, 2013, at 12:05:10
I think that I correct. Reuptake inhibition is no longer taking place. Do you know if your mood is any worse than before even starting the SSRI?
Posted by poser938 on January 12, 2013, at 13:14:45
In reply to Re: Pooped out SSRI - No discontinuation problems?, posted by poser938 on January 12, 2013, at 13:00:46
I think it could be because there is less serotonin available.
Posted by poser938 on January 12, 2013, at 13:27:08
In reply to Re: Pooped out SSRI - No discontinuation problems?, posted by poser938 on January 12, 2013, at 13:14:45
> I think it could be because there is less serotonin available.
Over time certain people that are sensitive to this effect, SSRI's and other reuptake inhibitors, direct agonists and I believe MAOI's as well stimulate the presynaptic receptors (which act somewhat like a thermostat for neuron synthesis) but as the ssri increases the stimulation, serotonin synthesis and release will decrease. Making less serotonin available for the reuptake.
Posted by europerep on January 12, 2013, at 13:43:36
In reply to Pooped out SSRI - No discontinuation problems?, posted by Prefect on January 12, 2013, at 10:02:20
I don't think it works like that. And I haven't ever heard that an SSRI "pooping out" is actually due to it having lost its pharmacological properties. I would assume that discontinuation syndrome is identical, regardless of whether or not an SSRI is or was effective for you.
Posted by poser938 on January 12, 2013, at 13:58:23
In reply to Re: Pooped out SSRI - No discontinuation problems? » Prefect, posted by europerep on January 12, 2013, at 13:43:36
> I don't think it works like that. And I haven't ever heard that an SSRI "pooping out" is actually due to it having lost its pharmacological properties. I would assume that discontinuation syndrome is identical, regardless of whether or not an SSRI is or was effective for you.
I wanted to copy and paste the text from this article but it wouldn't let me.
http://www.sciencedirect.com/science/article/pii/S0006295201007985
Posted by linkadge on January 12, 2013, at 17:17:44
In reply to Re: Pooped out SSRI - No discontinuation problems?, posted by poser938 on January 12, 2013, at 13:58:23
Poop out is not understood simply because nobody really knows how the drugs work in the first place.
Serotonin is only one of dozens of key mood regulating chemicals. Some researchers have found evidence that the dirtier drugs (ie TCAs) actually poop out less. Targeting one brain chemical may alter the levels of other important neurotransmitters.
Dosage increase or reduction and or augmentation with another agent may help you get better.
May I ask what drug(s) you are taking, at what doses and what is your problem (i.e. sadness, apathy, anxiety etc.)
Posted by jono_in_adelaide on January 12, 2013, at 17:42:27
In reply to Pooped out SSRI - No discontinuation problems?, posted by Prefect on January 12, 2013, at 10:02:20
I think I'd still do a taper, even if it was a relatively fast one - withdraw over 2 weeks say, unless there is some urgent reason to get off of the drug now.
Posted by Prefect on January 12, 2013, at 19:28:00
In reply to Re: Pooped out SSRI - No discontinuation problems?, posted by linkadge on January 12, 2013, at 17:17:44
I was in a 7 year remission from agoraphobia on 50 mg Luvox/day (no benzos, nothing else). I began to doubt the Luvox could possibly be the reason for such a long remission at such a subtheraputic dose.
I took 6 months to taper down to 37.5 mg/day and to my shock ended up having a relapse! The relapse has lasted for 6 months, during which I've slowly dosed back up. Every higher dose works for a couple of days and then I get even more anxious than before. Currently on 100 mg/day (for 4 weeks) and it had some theraputic effect for a week or two, but again, currently too anxious to consider the drug as "working".
Poop out? Not sure. This whole thing has baffled me to no end. My anxiety is much worse during this relapse than the original onset 8 years ago.
I've given some hard thought to going off meds. I've been reading research indicating SSRIs delay fear extinction during exposure by downregulating cortisol. Cortisol release is an important part of the stress response that results in eventual desensitization. In other words, ironically I'm not getting scared enough during exposure to get desensitized enough to cure my agoraphobia! I should mention my incidents of avoidance during this 6 months relapse has been nil! I even drove 10 hours away for the holidays. But i'm still anxious going out. My agoraphobia is resistant to exposure?!! I don't understand. The medication must be interfering with the theraputic effects of exposure...Other than that I'm out of ideas!
So I'm begining to be faced with the choice of sticking it out on this dosage or tapering down to medication free expose and see what happens.
Unless someone else has any ideas? Quite a humdinger.
Posted by Phillipa on January 12, 2013, at 20:56:06
In reply to Re: Pooped out SSRI - No discontinuation problems? » linkadge, posted by Prefect on January 12, 2013, at 19:28:00
Exposure theraphy doesn't work for me either I just block out any sensations phillipa
Posted by linkadge on January 13, 2013, at 13:40:24
In reply to Re: Pooped out SSRI - No discontinuation problems? » linkadge, posted by Prefect on January 12, 2013, at 19:28:00
As far as efficacy. SSRIs are powerful medications (at least in terms of altering brain chemisty - for good or bad).
Reducing the dose could upset brain chemistry and increasing it might not immediately restore that ballance. You can try the 50mg of luvox again for a longer period of time.
As far as fear extinction you are right. The medications can possibly block the aquizition of new fear (by blunting stress hormones). But, they interupt emotional processing (REM supression). Basically the placticity of the amygdala is impaired.
Exposure therapy for very specific phobias can be effective. Social phobia is complex however. Improvement requires not just the blunting of reaction to social situations, but improving skills that make you feel in control socially.
I would personally go back to 50 mg of luvox. Can you add a benzodiazapine?
Posted by SLS on January 13, 2013, at 15:20:06
In reply to Re: Pooped out SSRI - No discontinuation problems? » linkadge, posted by Prefect on January 12, 2013, at 19:28:00
Linkadge is always a source of accurate information. I like his ideas regarding non-pharmacological strategies for addressing your condition(s).
Before SSRIs became available, imipramine, a tricyclic antidepressant (TCA), was the drug most commonly used for treating agoraphobia. You can just add it to the Luvox to see if it will be of any benefit to you.
If you get desperate enough, you could look at Paxil. Paxil is most powerful of the SSRIs, and often works for anxiety disorders when other SSRIs do not.
If you do decide to go with imipramine, be prepared to experience a few annoying anticholinergic physical side effects like dry mouth. I find that these side effects abate with time, but may not totally disappear. Imipramine does not usually produce the emotional blunting and apathy that SSRIs can. In addition, I think poop-out is less probable with the TCAs.
- Scott
Posted by jono_in_adelaide on January 13, 2013, at 17:07:48
In reply to Re: Pooped out SSRI - No discontinuation problems? » Prefect, posted by SLS on January 13, 2013, at 15:20:06
Agree with SLS - there is plenty one can do if an SSRI doesnt work, imipramine or clomipramine can be very helpful in the appropriate dose, as can adding a low dose atypical to your SSRI.
50mg of Luvox is quite a low dose, you also have plenty of wriggle room there if you want to increase it and try and get some of the old magic back.
Posted by Prefect on January 13, 2013, at 19:48:37
In reply to Re: Pooped out SSRI - No discontinuation problems?, posted by linkadge on January 13, 2013, at 13:40:24
I have no social anxiety. As a matter of fact, outside my agoraphobia I'm as cool as a cucumber when it comes to tangible life issues and I can even do public speaking.
My anxieties strictly revolve around the absurd concept of my distance from home. So when I leave home, the farther I am, the more anxious I get. This culminates periodically to panic, where I have a crazy adrenaline rush, after which I feel very calm. I may periodically feel aftershocks afterwards with lesser intensity. This is how I recovered the last time. I went out and panicked till I didn't. Reponse fatigue.
This time around, this thing has come back with a few new karate moves and much higher panic intensity, which makes me believe your point about chemical imbalance when dropping an SSRI.
I'm a little reluctant to drop back down to 50 mg, because I think this relapse has already been made complicated by constant dose changes. If the long haul on 100 mg /day doesn't help I have half a mind to quit drugs all together and tough it out with pure unadultrated exposure, maybe hire a CBT specialist too, though I'm not sure what they could teach me with my experience and previous recovery with this disease.
My GP wants me to switch to Pristiq, but I don't undertand how a norepineperine reuptake inhibitor's supposed to calm me down. The only reason I keep taking the Luvox is I'm wondering if I'm a lifer anyway (agoraphobia doesn't happen to normal people) and probably should be medicated, have downregulated receptors and possibly benefit from all the other implied long term SSRI theraputic effects such as neurogenesis, neuroprotection, anti-inflamatory, CCK antagonist properties all of which are most likely baloney anyhow.
Posted by poser938 on January 13, 2013, at 21:31:09
In reply to Re: Pooped out SSRI - No discontinuation problems?, posted by poser938 on January 12, 2013, at 13:27:08
> > I think it could be because there is less serotonin available.
>
> Over time certain people that are sensitive to this effect, SSRI's and other reuptake inhibitors, direct agonists and I believe MAOI's as well stimulate the presynaptic receptors (which act somewhat like a thermostat for neuron synthesis) but as the ssri increases the stimulation, serotonin synthesis and release will decrease. Making less serotonin available for the reuptake.
>Well I messed up on that last step. But this is what they do when inhibiting synthesis. You had a pretty good idea about it in your first post on this.
I have much the same problem as you. And after trying various meds over the years to try fixing my problem, I have gotten a pretty good idea on what's going on up there.
Posted by jono_in_adelaide on January 13, 2013, at 22:17:02
In reply to Re: Pooped out SSRI - No discontinuation problems? » linkadge, posted by Prefect on January 13, 2013, at 19:48:37
Some of the NARI's have a reasonably firm record in agrophobia/panic - imipramine, reboxetine and others, so pristiq would be well worth a try.
Posted by Prefect on January 14, 2013, at 18:13:33
In reply to Re: Pooped out SSRI - No discontinuation problems?, posted by linkadge on January 13, 2013, at 13:40:24
This does confuse me though. If SSRIs impair the plasticity of the amygdala, how is it all the availabe research seems to indicate the use of SSRIs and TCAs as the most successful tool in treating agoraphobia?
Posted by jono_in_adelaide on January 15, 2013, at 17:10:19
In reply to Re: Pooped out SSRI - No discontinuation problems? » linkadge, posted by Prefect on January 14, 2013, at 18:13:33
I guess it just goes to show that there is still a hell of a lot that we dont understand... we know certain drugs work for certain conditions, but as to why thats often still a bit of an each way guess
> This does confuse me though. If SSRIs impair the plasticity of the amygdala, how is it all the availabe research seems to indicate the use of SSRIs and TCAs as the most successful tool in treating agoraphobia?
This is the end of the thread.
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