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Dr. Bob is Robert Hsiung, MD,
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Posted by MuseMemento on August 30, 2015, at 17:04:05
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 29, 2015, at 21:17:22
I'm open to ERP and have tried a couple of exercises but the OCD and depression aren't well managed enough right now. I have fears and fixations around brain damage occurring as a result of contact with electricity and synthetic chemicals of all sorts (paint, cleaning agents, petroleum fluids). The fears are so strong that it's difficult for me to determine whether or not I'm psychotic but 20 mg of abilify for four weeks has done little to alleviate them. Thanks.
Posted by phidippus on August 30, 2015, at 19:12:42
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 30, 2015, at 16:48:38
Sertraline and Fluvoxamine have one thing in common: they both agonize sigma-1 receptors. So, if you respond to Zoloft, you may respond to Luvox. I was deep in intrusive suicidal ideations when I started taking Luvox and they just stopped. I'm surprised you haven't tried Luvox, yet you've taken lithium and nortriptyline, both of which have been shown in studies to be useless in treating OCD.
The first line of treatment of OCD is therapy. If you aren't involved in and practicing good therapeutic techniques, an antidepressant isn't going to be as effective.
OCD is a serotogenic disorder, with some involvement of dopamine and glutamate disfunction. Second line treatment of OCD is a serotogenic agent-you've been through many, but you still have to try Luvox, Viibryd, Brintellix, Trazandone, Cymbalta, Fetzima, Savella.
The key is to achieve a modicum of response from the anidepressant and then add an atypical antipsychotic if you still have intrusive and recurrent thoughts-an atypical antipsychotic will antagonize dopamine receptors (it is hypothesized that dopamine levels are attenuated in the nucleus accumbens in OCD) and antagonize 5ht2a and 5ht2c receptors which are implicated in the genesis of anxiety.
It is further hypothesized that glutamate plays a role in OCD. Several different studies have indeed indicated that those with OCD have higher levels of glutamate in their brains than those without the disorder. While this doesnt necessarily mean that high levels of glutamate cause OCD, studies continue to show there is some type of connection between OCD and glutamate. What does this mean? Studies have shown that adding a glutamate inhibitor to an antidepressant is effective in the treatment of OCD. Other studies have shown that adding a glutamate inhibitor to a atypical antipsychotic and an antidepressant is even more effective. There are several glutamate inhibitors you can add: Keppra, Zonegran, Riluzole, Lyrica, Gabapentin, Lamictal and NAC.
There are other agents that have shown efficacy in treating OCD: Tramadol, Dextroamphetamine, Caffeine, Ondensetron, Pindolol, but all when added to an antidepressant.
Why couldn't you take the sertraline?
Eric
Posted by MuseMemento on August 30, 2015, at 19:37:25
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 30, 2015, at 19:12:42
The sertraline helped with depression when I took it two years ago but when I tried it this time, I felt an immediate increase in anxiety and ocd, and only recognized then that I never responded to it for ocd symptoms. I forgot to mention that I have also tried brintellix at a dose of 20 mg but showed no response. Viibryd isn't available in Canada, so I'll have to try either luvox or something I've tried before but at a higher dose. Unless my pdoc is comfortable with either cymbalta or savella for me. The focus of my treatment has always been depression because I rarely talked about my OCD difficulties as they were so severe that I thought I'd never experience any alleviation and didn't even realize I had it. I thought I was mildly psychotic for years and didn't think it was even treatable. We'll see what the pdoc thinks tomorrow.
Posted by phidippus on August 31, 2015, at 14:48:06
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 30, 2015, at 19:37:25
I, too, thought I was psychotic when I first started having OCD symptoms. Then I came to embrace my psychotic nature and enjoy it (an ERP technique)-I came to understand I was not psychotic, but just having intrusive and recurrent thoughts. You need to train yourself not to be afraid of the thoughts.
Do you have compulsions?
I wouldn't be surprised if your depression is caused by your OCD.
Brintellix at 40 mg would have been sufficient for OCD. Remember, treatment with an antidepressant for OCD usually requires a dose twice that for depression.
What's an example of an OCD thought you have?
Eric
Posted by MuseMemento on August 31, 2015, at 15:06:29
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 14:48:06
I'm compulsively avoidant. I stay away from any synthetic chemicals and dry my hands twice after washing them before touching anything electrical or I have a panic attack. For example, I unplugged my radio the other night and kept thinking that I'd been shocked and damaged my brain. The worst part is that I have seemingly inexplicable psychosomatic symptoms from the fear. It actually feels to me like I've had a minor electrical shock, on par with static electricity, when I unplug or use electrical items.
Posted by phidippus on August 31, 2015, at 16:06:58
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 31, 2015, at 15:06:29
I work with a therapist to help administer ERP to patients-I'm sort of a PA. I've worked with a lot of patients and I can tell you right now, ERP is going to be far more valuable in treating your symptoms than medication, though the right medication should reduce your anxiety some.
>I unplugged my radio the other night and kept thinking that I'd been shocked and damaged my brain.
A strategy for dealing with this kind of thought is to agree with it and tell yourself you have damaged your brain, then start acting like your brain is damaged. Stumble around, slur your words, etc. (have fun with it). The point is to agree with the thought, rather than argue with it and then neutralize it with humor.
I once had a thought someone poisoned the water in my CPAP. To deal with it, I went along with the thought and put on my CPAP and pretended that I was dying from poisoning. I flailed my arms around and screamed 'Rosebud'...
If you go to www.psychologytoday.com and click on the 'find a therapist' tab, you can look up a therapist who specializes in ERP and anxiety disorders in Canada.
What kinds of reactions did you have to the various SSRIs?
Eric
Posted by MuseMemento on August 31, 2015, at 16:30:03
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 16:06:58
I've never really responded to any SSRIs, save for sertraline worsening my OCD. Then again, only clomipramine, venlafaxine, sertraline and citalopram were administered at a recommended dose for OCD, 250, 350, 200 and 60 mg, respectively. We'll see how I respond to fluoxetine at 80 mg or fluvoxamine at up to 450 when I switch in a couple of weeks.
Posted by phidippus on August 31, 2015, at 17:28:10
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 31, 2015, at 16:30:03
Is there any one antidepressant you've had some sort of response to? Perhaps a reduction in panic symptoms? A reduction of global anxiety? The point of antidepressant therapy in OCD is a reduction of anxiety-so you can have the anxiety producing thoughts without anxiety.
I wouldn't do more than 300 mg with the Fluvoxamine-studies show it isn't much more effective at doses above 300 mg, plus you start to get a lot of sedation.
Eric
Posted by MuseMemento on August 31, 2015, at 17:30:30
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 17:28:10
The only medications I seem to have responded to are vyvanse, wellbutrin and lamictal. Still looking for something serotonergic that supports my recovery.
Posted by phidippus on August 31, 2015, at 17:46:43
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 31, 2015, at 17:30:30
>vyvanse, wellbutrin and lamictal.
Did you take these as an adjunct to an antidepressant?
I'm surprised Wellbutrin worked for you. Most studies show it exacerbates OCD symptoms. I wonder if it helped by treating the depressive component of your illness.
Eric
Posted by MuseMemento on August 31, 2015, at 17:49:10
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 17:46:43
Abilify's helping somewhat, too. Yes, they were all taken as adjunctive medications but I only ever noticed any relief from depression and in turn OCD when I was taking them. I think I may try fluoxetine first because I smoke and I know that reduces plasma levels of fluvoxamine just as it does clomipramine.
Posted by phidippus on August 31, 2015, at 18:10:12
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 31, 2015, at 17:49:10
I'm glad you found some tools that have helped with the OCD. The fact you have used them adjunctively to an antidepressant tells me the AD is working in some capacity. An atypical antipsyhotic won't work, if not make things worse, if used on its own. Lamictal does little on its own as well-it too needs to be taken with an antidepressant.
I know why the Wellbutrin worked-its an nACHr agonist, which like nicotine has been shown to be useful in the treatment of OCD.
SO, you need to settle on a antidepressant that works some, then add an atypical antipsychotic you know works, then add a glutumate antagonist. Keppra is rather powerful.
Eric
Posted by musememento on August 31, 2015, at 18:19:02
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 18:10:12
What sort of dosing would I be looking at for Keppra? Do you still think it's time to discard the clomipramine at ten weeks in with negligible positives and sedation that can't be countered by 70 mg vyvanse AND 6 large mugs of coffee daily?
Posted by phidippus on August 31, 2015, at 18:51:59
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by musememento on August 31, 2015, at 18:19:02
I found 3000 mg of Keppra was a real sweet spot. It had the effect of reducing anxiety about the thoughts-I imagine for you it might reduce anxiety about thoughts like your brain is damaged from electrical appliances.
I don't think you're getting much benefit from the clomipramine and its causing barely tolerable side effects. I would switch over to Luvox and see how you do on it. And honestly, I would stay on the Luvox (if you tolerate it) and add an antipsychotic and a glutamate inhibitor.
What's the status of ERP and therapy?
Eric
Posted by MuseMemento on August 31, 2015, at 19:06:03
In reply to Re: Asenapine (Saphris) for OCD » musememento, posted by phidippus on August 31, 2015, at 18:51:59
Psychiatrist is committed to ERP already. If my overall anxiety can be alleviated some, I'm game to try it but it doesn't seem feasible until I find something to alleviate the anxiety. Thank you for all your input.
Posted by phidippus on August 31, 2015, at 19:21:23
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 31, 2015, at 19:06:03
Right now, the thoughts are feeding your anxiety and to deal with that you have to take the power out of those thoughts. ERP will help take the power out of the thoughts that are wreaking so much havoc in your brain.
From a medication standpoint, antidepressants will help a great deal with the overall anxiety you feel and antipsychotics may reduce some of the intrusive thoughts while a glutamate inhibitor will further reduce anxiety. The thing is none of these drugs will train your brain not to be afraid of the specific thoughts you are having.
Have you used any benzos to reduce your anxiety?
Eric
Posted by MuseMemento on August 31, 2015, at 19:25:58
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 19:21:23
Yup. I'm also taking 2 mg lorazepam daily. My total cocktail is 325 mg clomipramine (because I smoke), 20 mg abilify, 2mg lorazepam, 70 mg vyvanse and a pot and a half of coffee.
Posted by phidippus on August 31, 2015, at 19:40:11
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 31, 2015, at 19:25:58
There was a study that showed caffeine treated OCD symptoms. Its a glycine agonist and glycine agonist have been shown to be helpful in OCD spectrum disorders.
I just read a study comparing clomipramine with Luvox and they found both comparable, but Luvox was more tolerable.
How has the Abilify helped?
Eric
Posted by MuseMemento on August 31, 2015, at 19:55:39
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 19:40:11
Interesting. I'm sure that my intake is considered excessive even for that purpose, though. The abilify, in my personal opinion, helps me feel less out of control generally. I don't have the same sense that I'm losing my mind in the midst of the symptoms. Does luvox have a general tendency to be sedating at doses I would need for OCD alleviation?
Thanks so much.
Posted by phidippus on August 31, 2015, at 21:11:35
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by MuseMemento on August 31, 2015, at 19:55:39
You're never losing your mind and I know it feels that way, but the thoughts you are having are no psychosis but just OCD trying to scare you.
I'm glad to hear the Abilify has had some impact, giving you a feeling of control over some of your symptoms. I take 30 mg of Abilify and Brintellix 40 mg to control my OCD. I also take 70 mg of Vyvanse for my ADHD which also helps with the OCD. If I have breakthrough OCD symptoms, I add Keppra or Riluzole.
Luvox tends to be sedating at low doses, but far more stimulating at higher doses.
Eric
ps. You should sit on the floor, in a circle of electric appliances and dare to touch them, one by one.
Posted by musememento on August 31, 2015, at 21:27:32
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 31, 2015, at 21:11:35
Thank you so much for all your help!
Posted by phidippus on September 1, 2015, at 0:15:23
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by musememento on August 31, 2015, at 21:27:32
You're very welcome. Feel free to Babblemail me anytime.
Eric
Posted by MuseMemento on September 1, 2015, at 16:23:28
In reply to Re: Asenapine (Saphris) for OCD » musememento, posted by phidippus on September 1, 2015, at 0:15:23
Thank you. I will.
Posted by SLS on September 10, 2015, at 7:47:33
In reply to Re: Asenapine (Saphris) for OCD » MuseMemento, posted by phidippus on August 30, 2015, at 19:12:42
> Sertraline and Fluvoxamine have one thing in common: they both agonize sigma-1 receptors. So, if you respond to Zoloft, you may respond to Luvox.
Don't these two drugs act in an opposite manner with respect to sigma-1 receptors? I believe sertraline is an antagonist.
I found this article interesting regarding psychotic depression:
http://www.ncbi.nlm.nih.gov/pubmed/20492642
There is also some evidence that fluvoxamine (Luvox) can actually reduce the severity of akathisia produced by aripiprazole (Abilify).
- Scott
Posted by phidippus on September 15, 2015, at 20:58:58
In reply to Re: Asenapine (Saphris) for OCD » phidippus, posted by SLS on September 10, 2015, at 7:47:33
>Don't these two drugs act in an opposite manner with respect to sigma-1 receptors? I believe sertraline is an antagonis
Yup, you're right. Sertraline is a sigma 1 antagonist.
Sertraline vs. Fluvoxomine in the treatment of psychotic depression:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881105/
Eric
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