Dealing with anger during SSRI withdrawal

Anger is a normal human emotion.  It’s a force of change for most people.  We see something we don’t like in the world around us and feel compelled to change or avoid it. In our nuanced minds, we’ve developed sophisticated ways of expressing and dealing with anger.  We use discussion and logic to make anger serve us in productive ways.  SSRI withdrawal turns this normal process on its head. In withdrawal, anger forms independently in the mind.  Instead of rising in response to an external event, withdrawal causes anger without context.  You’re just angry.  There’s no event or emotion preceding it, it just pops into your head.

Normally, there is a range of emotion to anger.  We’ve separated physical and intellectual anger, and each has a range of responses. We moderate ourselves to match the event.  Instead of fighting an insulting person, we debate or avoid them.  Extreme responses are withheld until there is a threat of physical harm.  Withdrawal blurs the line between intellectual and physical anger and eliminates the scale that we usually apply to situations to gauge our responses.  Since withdrawal anger rises independently, there is no external scale to give us queues to measure our response.  The mind is filled with anger that we then try to apply to the situation.  That’s the key difference between normal anger and the rage that accompanies SSRI withdrawal.  Instead of reacting to an external event, we’re applying an internal state to the external world.

Because the internal mental state doesn’t match the external anger queue, people in withdrawal can often dramatically over react to small annoyances.  The anger that the patient is experiencing is at the upper scale of the emotion.  It’s happening without an external event to trigger it, so the mind searches for the cause of the anger, and attaches it to anything it sees in the outside world.  The patient may feel enough anger to start a physical altercation, and apply that rage to a trivial interaction.  Road rage is one of the most common responses to withdrawal anger.  Combining rage with the anonymity of the road removes the last few barriers in the mind between anger and action.

Anger is one of the most difficult emotions to deal with in SSRI withdrawal.  It’s the one emotion that the patient is most likely to translate into action against friends or strangers.  Anxiety, depression and fear are also amplified in withdrawal, but those emotions tend to draw the patient into themselves.  Anger is more likely to be expressed outwards towards other people.  For patients, it’s important to be mindful of the difference between normal anger and that caused by withdrawal.  If you’re angry and can’t see what triggered it, it’s most likely caused by withdrawal.  It’s a delicate point in withdrawal.  Be very careful not to do or say something that you will regret later.  This stage of withdrawal causes more broken friendships and burned bridges than any other.  It’s very hard to control anger in withdrawal, though.  Don’t berate yourself too much if you do something out of character, a lot of people experience the exact same thing.

For friends and loved ones, it’s important to suspend reactions to a person experiencing anger in SSRI withdrawal.  No matter how hurtful or mean they seem, the emotion is not normal anger.  It’s an out of control emotion that they are expressing incoherently.  They can still use their imagination and intellect to lash out, but the basis for the anger is beyond their control.  Attacks can seem very personal and elaborate.  They may bring up very old problems that seemed resolved long ago.  They’re not really trying to relive those old arguments, they are just clinging to anything that can explain the sudden and overwhelming anger they feel.  We’re not used to experiencing anger without context, so someone in withdrawal will grab onto anything to explain it.  As much as you can, be relentlessly positive.  S/he needs your support to get through this crisis.  Responding with anger will escalate the situation.  The patient has no real upper limit on their anger, but you do.  Try to moderate yourself and control your emotions.  It’s very hard to deal with a person suffering from withdrawal rage, but escalating the situation will not serve either of you in the long run.

The anger phase of withdrawal does pass.  The goal for the patient and those around him/her is to recognize that it wasn’t a normal part of their personality.  As strange as it seems, withdrawal can temporarily change your personality and make you do things that you would normally never do.  It’s not an emotional state that you’re likely to return to, either.  Once you pass through anger, there are other phases of withdrawal to deal with, but anger should slowly become more manageable as time goes by.  You may find that you are better equipped to deal with normal anger now that you’ve experienced irrational anger.  Instead of fearing that you may relapse into anger in the future, take heart that you have passed through the most difficult part of SSRI withdrawal.

Phases of SSRI Withdrawal

Not all people experience withdrawal symptoms when trying to stop taking a Selective Serotonin Reuptake Inhibitor. In clinical trials, the percentage is placed between 2 and 10 percent of patients. These studies are sponsored by pharmaceutical companies. In independent research that looked at several different company studies, the percentage of patients who experienced withdrawal symptoms from SSRI was placed between 40 and 60 percent. It’s difficult to ascertain which number is right, most studies are held privately by the drug manufacturers and not available for public scrutiny. The term used by the pharmaceutical companies for withdrawal is “Discontinuation Syndrome”. SSRI work by blocking receptors that absorb Serotonin between neurons, thereby increasing the available Serotonin in the brain. The theory is that depression, obsessive behavior, anxiety, and psychotic behavior are caused by a lack of sufficient Serotonin in the brain. This theory was first developed in the 1950′s when it was noticed that patients’ mood improved when their levels of Serotonin was increased. It is currently impossible to measure the levels of Serotonin in a living brain. 90% of the body’s Serotonin exists in the gut, so researchers measure that amount, and extrapolate a concurrent increase in levels in the brain. Ironically, studies have also proven that reducing Serotonin in the brain can lead to improved mood. These results have brought the chemical imbalance theory under question in recent years. It is beginning to appear that artificially adjusting Serotonin levels in the brain does not have the intended effect, and may be the cause of some of the symptoms that SSRI were originally developed to treat.

The method that SSRI use to increase Serotonin levels in the brain is at the heart of the withdrawal problem. By blocking Serotonin receptors on neurons, the brain becomes dependent on the drug to maintain consistent levels of Serotonin. As the brain becomes accustomed to the drug, it no longer has to produce or regulate Serotonin as it did before. When the drug is removed, the receptors that stimulate Serotonin production are still blocked, and levels of this neurotransmitter begin to fluctuate. Since Serotonin is closely involved in mood and the ability to cope with emotions, this fluctuation causes wide mood swings and uncontrollable emotions. It seems that the level of Serotonin in the brain is not as important as consistent levels. As the brain adjusts to the need to self regulate levels of Serotonin, many patients experience a cascade of extreme emotional and physical symptoms. Analogous to the stages of grief or joy, these symptoms don’t always come all at once. In most cases, withdrawal symptoms come and go as the user lowers their dose of the drug. Some common emotion symptoms include depression, anxiety, anger, confusion, insomnia, and memory loss. For most people, these are symptoms that they experience in every day life. Usually, they are manageable and temporary. The difference for the withdrawal sufferer is that these emotions become unmanageable and intense. The regular mechanism that we use to control our emotions no longer works during withdrawal. It’s hard to imagine the loss of control that accompanies withdrawal symptoms. When a normal person succumbs to anger, it is still a conscious decision. In withdrawal, there is no spiral that precipitates the uncontrollable rage, it springs fully formed in the mind and propels itself without any input from the person experiencing it. The other emotional symptoms of withdrawal act in a similar way. Even when the patient exercises mindfulness and self awareness, anxiety, depression, and the other symptoms come on with little warning. They have a realness and power that most people are not used to. Since the brain’s balance has been disrupted, reality itself has been changed for the patient. Instead of an emotional wave that must be conquered or endured, these emotions become reality, with no alternative.

As time goes by, the patient will eventually be able to self regulate each emotion at a level similar to before they began taking an SSRI. One of the frustrating things about weaning off an SSRI is that the patient is only aware of progress after a phase has passed. They may feel extreme anxiety, but realize that the rage they experienced a few months before no longer bothers them. While they are experiencing a phase, there is no context to compare their emotions to. Since the emotions are so powerful and uncontrollable, emotional self awareness is short circuited, leading to mental relativism. The patient doesn’t realize the whole range of emotions, just the small extreme range that they are experiencing at the moment. The alternative to blind rage isn’t calmness, as it would be in a normal person. Instead, irrational anger is the lower end of the emotional range.

During withdrawal, these realities change and evolve as some emotions become dominant. Patients may experience uncontrollable rage for a few weeks, then enter a stage where depression dominates. These emotional tides are outward signs of the brain readjusting to the need to self regulate neurotransmitter levels. It is almost as if the mind is going through the entire inventory of emotion trying to catalog what’s necessary to regulate each one. Some people will experience several uncontrollable emotions at the same time, but the uncontrollable aspect of them will fade away one at a time. The variety and severity of symptoms often lead doctors to prescribe other drugs to mitigate the effects. This strategy compounds the problems of withdrawal by adding a second effect to an existing condition. The patient now has to deal with withdrawal as well as the effects of a new drug and perhaps a new set of withdrawal symptoms. The best strategy for dealing with SSRI withdrawal symptoms is time and slow weaning. A prolonged weaning schedule will reduce the severity and number of withdrawal symptoms. The brain requires a certain amount of time to adjust back to a natural balance of neurotransmitters which can’t be rushed. By slowly weaning off an SSRI, the brain does not have to deal with a sudden change to Serotonin levels, and can adjust at a natural rate. It takes a great deal of time for receptors in the brain to regenerate. A schedule that reduces the drug by 10% each month is usually sufficient. Schedules can vary depending on the patient. Some will be able to reduce their dose more quickly, others may have to go more slowly.