Separating SSRI withdrawal symptoms


SSRI withdrawal symptoms are very complicated because they are primarily emotional in nature.  This makes diagnosing the difference between existing symptoms and those caused by SSRI withdrawal very difficult.  In withdrawal, it is the scale of emotions that define the problem.  Anxiety, depression, fear, even psychosis, are part of the normal human emotional spectrum.  In normal thought, all of these emotions come and go, but are regulated.  An irrational thought may float to the surface, but it is quickly dismissed as inappropriate.  During withdrawal, the normal regulation of thought is short circuited.  The control that we’re so used to exercising over our internal mental landscape disappears.  Rational and irrational thoughts hold the same weight in the conscious mind.  A healthy person who experiences an emotionally traumatic event still feels the full range of emotions, but is able to parse through them all and choose the appropriate response.  If he is cut off in traffic, all of the possible responses are available.  Ramming the car, cutting them off in return, speeding up, slowing down, tailgating, and ignoring the incident all surface in the mind of the driver.  Usually, a person will choose the most socially acceptable response.  It is the function of our higher brains to control our responses.  Withdrawal turns that process on its head.  Instead of evaluating the available responses and choosing the one that best fits into our internal social beliefs, the emotion with the most power overcomes the others.  A normally passive person may lash out in anger or fear during SSRI withdrawal.

One of the key tasks during SSRI withdrawal is to separate the emotions that are caused by withdrawal from those that rise normally.  Beyond the emotions themselves, it’s important to separate the scale of emotions as well.  Anxiety is a normal emotion, it is a programmed response to danger.  The difference during withdrawal is that the scale of anxiety is not regulated as it normally would be.  One of the complicating factors during withdrawal is that emotions have been suppressed during the period of SSRI use.  In a way, the drug takes over the emotional regulation task from the patient.  The patient is, in effect, relearning how to regulate emotions without the effect of the drug.  It’s almost as if the mind is cataloging what is required to regulate each emotion, one madness at a time.

There are several strategies that can be used to parse through the scale of emotions during withdrawal.  The least effective is to try to remember how you reacted to similar situations before starting the SSRI.  Memory is a tricky thing.  Trying to remember the scale of an emotion years later is even trickier.  Events and emotions tend to drift in our memories as we recall them.  Each time we recall an event, the memory is affected by our experiences.  We are essentially interpreting the memory based on what we’ve experienced since.  Memories are not stored in blocks like a computer hard drive.  Instead, different elements of the event are stored in different parts of our brains.  These separate elements are then gathered together to compile a composite memory of the event.  For example, the memory of a high school dance is separated into many different elements.  The smell of a corsage may be influenced by a trip to a garden that you took many years later.  When the memory of the smell is combined with the memory of the dance, you may unwittingly change the memory by combining elements of the garden into it.  Not specifics, your mind would immediately recognize garden elements intruding into the dance memory.  Instead, emotional elements of the garden trip may influence the way you recall the dance.  That is the pitfall in trying to remember your pre SSRI emotional responses.  Your memories may be influenced by experiences you have had since.  Also, since you were not specifically trying to capture your emotional responses at the time, they become more susceptible to memory drift.

Trying to gauge how other people respond to an emotional event is likewise very difficult.  Observing a person’s response does not give a good indication of their internal mental state.  It’s very hard to associate their external response to your internal state.  First, you are relying on your interpretation of their response.  Then, you have to compare how you feel to that interpretation.  Just like personal memories can be influenced, interpersonal emotional interpretations are susceptible to our own experiences.

The best method to parse out withdrawal symptoms from normal emotions is to practice mindfulness and self awareness.  Keeping a journal can help.  It’s really the ongoing experience of withdrawal that teaches the most about the differences.  Withdrawal symptoms come and go during the process.  As they wax and wane, your personal norm becomes more apparent.  Everyone has a different “normal”.  Pay attention to how you are feeling when your symptoms are slight, and apply that knowledge to the times when symptoms reassert themselves.  Most people who start taking an SSRI did so because of an existing condition, be it anxiety, depression, etc.  Separating that baseline from withdrawal is the goal of practicing mindfulness during withdrawal.  Pay attention to the rise and fall of emotions.  Don’t berate yourself if you overreact to a situation.  That’s very common in withdrawal.  Instead, use that experience to recognize what caused the overreaction.  That recognition and awareness will help you reassert the control that seems so fleeting during withdrawal.  As control returns, the worst symptoms of withdrawal should become more manageable.

In the long term, the mindfulness required to track withdrawal symptoms becomes helpful because you will eventually have to address the original symptoms that first prompted you to start taking an SSRI.  Being aware of emotional triggers and your response to them will provide more emotional stability as time goes by.  Not only can emotional self awareness provide relief from withdrawal symptoms, but it may also provide a method for managing underlying anxiety problems.

26 Responses to “Separating SSRI withdrawal symptoms”

  1. Altostrata Says:

    With all due respect, npath, SSRI withdrawal symptoms are *not* primarily emotional in nature. Some people do mostly experience the emotional symptoms, but most also experience physical symptoms such as brain zaps, dizziness, a harsh sleeplessness, waves of disorientation, palpitations, leg jitters, etc.

    Often people will focus on the emotional symptoms, or others such as sexual dysfunction, and attribute the sleeplessness etc. to conditions rather than withdrawal. (They may start rounds of medical tests which usually reveal nothing.)

    However, as all withdrawal symptoms, including the emotional ones, which can be extraordinarily intense, are distressing, people need to stay as calm as possible to deal with them and allow neurological healing to take place. Your advice to separate self from symptoms with mindfulness and other techniques is right on.

    As you rightly point out, developing ways to manage symptoms will be valuable life skills long after withdrawal is over.

  2. npanth Says:

    I agree that withdrawal symptoms are not exclusively emotional. I do think that some physical symptoms like heart arrhythmia are physical manifestations of an internal emotional state. I wanted to focus on the emotional aspect of withdrawal in this post. I’m exploring the connections between emotions and physical symptoms. I think that first sentence was a bit off, I’ll be more careful when I’m editing in the future. Thanks.

    • Altostrata Says:

      I appreciate what you’re doing, npath. I feel I must add this for your consideration.

      From my knowledge and personal experience, withdrawal-related heart arrhythmias are not due to an emotional state. They are due to surges of cortisol and adrenaline from a dysregulated autonomic system.

      However, these distressing symptoms can be aggravated by the person becoming anxious or panicky. It’s very important to stay calm, become an observer of one’s symptoms, and focus on “this too shall pass.”

      • Gina Says:

        I completely agree with Altostrata. I did a foolish rapid taper off my Lexapro back in mid July. When I began to have heart palpitations and and an escalation in panic and anxiety, I tried to reinstate, but couldn’t handle the physical symptoms. This was only a few weeks later. I saw a psychiatrist who tried to help me reinstate at a lower does in mid August, and still I couldn’t manage the physical symptoms. The heart racing was the worst of it, but there was and still is the accompanying loss of appetite, fatigue, insomnia, bouts of diarrhea, agoraphobia, and loss of tolerance to heat and cold. I haven’t had a dose of anything since August 21st, and most of my symptoms have only slightly improved, but still I can’t sleep. I wake up every two hours out of very negative REM sleep with a racing heart and have to constantly reassure myself that I’m not going to die. For me, the physical symptoms have completely undone me. I’m exhausted, frustrated and still without a real solution. I’m hoping time is the answer, but I’m not an expert by any means.

      • npanth Says:

        The connection between heart arrhythmia and emotional states or physical symptoms is something I’ve been thinking about lately. I’ve noticed that some arrhythmia coincide with stress, while others seem to be unrelated. I think that both can be causes. SSRI cause circulatory problems, which can be exacerbated in withdrawal. I don’t want to dismiss emotional causes for problems, though. For a long time while I was taking Paxil, I didn’t really experience emotions, but I did have symptoms. Instead of feeling stress or anger, I would sweat or get heart arrhythmia. I thought I had some heart problem, but it went away when I got down to a low dose of Paxil, which strongly associates it with the drug in my mind.

        • Gina Says:

          For me. it seems that when my physical symptoms taper, my emotional state relaxes considerably. But I know not everyone is the same, and our experiences vary based upon our physcal conditions, how long we have been on (or off) our medications, and just our autonomic nervous systems in general. The pendulum swings in every direction. I have been through withdrawal before, 7years ago after a run in with Klonopin. The Lexapro was my doctor’s solution after a protracted withdrawal effort. What I wouldn’t give for an undo button.

      • Viki Says:

        Smart thikning – a clever way of looking at it.

  3. Don Says:

    I was on Cymbalta for 7 years for genaralized anxiety. I tried a 6 week taper and failed. Severe anxiety was the primary withdrawal symptom. Re-introduced Cymbalta. The anxiety remained for a year and finally went away. I then did a 5 month taper and took my last 2 mg dose 10 days ago. Had bad physical w/d symptoms for a week and now just feel really depressed. Sex drive has not returned to normal Does anyone know anything about PSSD? I am very worried.

    • npanth Says:

      Sexual dysfunction and decreased libido are very common while taking and discontinuing SSRI/SNRI. It varies from person to person. Some people get over it quickly when they taper off the drug, others don’t experience it until they start tapering. It usually works itself out in time. It’s hard to say exactly how long it will take to get over it, just that most people do recover. What I did was concentrate on the other symptoms and try my best to ignore that one. My libido and function has fluctuated over time, but it’s getting better. It doesn’t seem like it will improve until you start to see progress. That’s what it felt like to me. Once it started getting better, it was easier to see that it will eventually get back to normal.

  4. Dee Block Says:

    Thank you for sharing your thoughts and experiences. This is one of the most thoughtful articles I have read about SSRI Discontinuation Syndrome. Particularly interesting for me are your strategies for dealing with separating withdrawl emotions from ordinary feelings and depression. It’s so hard to pick this apart and I think your analysis of the role of memory is spot on.
    I have been taking Fluoxetine 20 – 40 mg for 51/2 years, initially to cope with the decline and death of my partner, although I have a history of depression. I tried to stop taking the medication 2 years ago by tapering slowly, but after about 2 months I just crashed. My doctor felt that this was a recurrence of the depression, which I had doubts about. After a course of CBT earlier this year I felt strong enough to try again. Your suggestion to keep a journal is one of the most important components of the therapy and is enormously useful. I have been completely free of Fluoxetine for a month now and I am starting to feel like I am getting my mind and body back from a medically induced coma. I know it’s early days, but I feel much more positive that freedom is achievable. Many thanks, Dee.

    • npanth Says:

      Thank you. I’ve read about cognitive therapy and mindfulness. It seems like the best method to use to get control of emotions during withdrawal. I tried some supplements, but they didn’t seem to help my withdrawal symptoms. I know many people find that they help, I think it just wasn’t right for me.
      My doctor also diagnosed my withdrawal symptoms as a re emerging problem. That didn’t seem right to me at all, though. I started taking Paxil for mild social anxiety, yet he was trying to convince me that I had an underlying psychosis. I’ve met a few people diagnosed with psychosis, and I have never exhibited any of those symptoms… Not until I tried to stop taking Paxil, that is. Thankfully, his diagnosis was wrong, and those symptoms dissipated quickly. I’m just glad I didn’t start the handful of drugs he gave me. Who knows where I’d be if I’d started 2-3 new drugs.
      Isn’t it amazing how it feels to “wake up” from an SSRI? I had no idea that my mind was so suppressed until my taper had progressed to the point that the real me started to emerge again. Now that I look back, I recognize what was happening to me. At the time, though, I couldn’t see it. I think that’s one of the ways that a journal helps. It’s very hard to remember being at different stages of withdrawal, very hard to recognize progress for what it is. Writing it down seems to help. I hope you continue to get better. Don’t feel bad if some of your symptoms re emerge. Withdrawal can be a long process, with some ups and downs, but it’s definitely doable. 🙂

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  6. LilianG Says:

    Hi. 6 weeks ago I took my last dose of Citalopram. I had a two week taper from 30mg. 1 wk @ 20mg, 1 wk @ 10mg . I was then due to have a washout week before starting Sertraline. However, as I felt more ‘alive’ than I had done for years, I decided to stay off medication.
    I had also done some research on supplements eg omega3, vitamin D, and excercise etc.
    The first 2-3 says were fine.
    The next 10 days were horrendous….night sweats, insomnia, nausea, loose bowels, crying etc
    Then up to 5 weeks I felt really good.
    The last week or so,I feel the withdrawal symptoms are returning…night sweats, nausea, crying.
    But…..are these withdrawal effects or are my anxiety/depression returning.

    Do the waves and windows go on for months??

    Any comments would be appreciated.

    • ginalogrande Says:

      IMHO, you tapered entirely too quickly. Like you, I did exactly the same thing. Gave myself about two weeks and went from 10mg Lexapro down to 0. When I had a resurgence of intense panic and anxiety a month later driving home from a lunch meeting, I knew something was wrong, so I made an attempt to reinstate the medication at the full dose. The first day I was fine – the next day, all hell broke loose. My heart was racing like a freight train, I completely lost my appetite, cried constantly, had nausea, diarrhea, chills, sweats and unrelenting insomnia. I couldn’t read, listen to music or watch television. I went in to see a psychiatrist who tried to reinstate me more slowly, but the same effect kept happening. We tried several different meds all with the same or worse effects. The last one, Remeron, appeared to be settling things down a bit, but two weeks into it I developed an all over body rash so I had to stop. From August of 2012 until March of 2013, I dropped 20% of my body weight, couldn’t sleep more than two hours at a time, had continuous nightmares, and still could barely eat. The anxiety was constant, my heart was racing non-stop and I was unable to leave the house for any length of time or drive more than a half mile away from home. Essentialy, my whole life was shut down by discontinuation syndrome. In May, I ended up in the emergency room because I had a cardiac episode after I was unable to stifle a panic attack. I was kept overnight where I wore a holter monitor and had an echocardiogram to see if there was any permanent damage. Fortunately for me, my heart was fine – it was just a situation of demand ischemia, which usually corrects itself once the heart rate comes down to normal for a couple of days. (Too fast, not enough oxygen)

      At that point, because I was most concerned about my heart, I decided to go on a very low dose beta blocker (25 mg Toprol XL). It helped tremendously with the constantly racing heart, and took away many of the physical symptoms of the anxiety, but brought along some other symptoms that I wasn’t crazy about. I get congested, have some ongoing stomach problems, feel occasionally fatigued and I have vivid nightmares, which are common on this med. However, even the nuisance symptoms are tolerable compared to the daily hell I was dealing with. It’s a small price to pay for moderate relief.

      What I explain to most people is that SSRIs are like a governor bolt on a vehicle that keeps it from speeding out of control, both physically and emotionally. When the bolt is removed, the car just keeps going faster and faster. here is no off switch. So when you have an emotion (any emotion), it’s like firing up the car – but instead of the car just idling, the emotion explodes and escalates. The same thing happens when you have any physical symptoms. Instead of dreams, you have nightmares. Instead of moderate excitement when you watch tv or a movie, your heart races out of control. Instead of singing along with the radio, the sounds either overhwhelms every sense you have and leaves you frantic, or makes you cry like a baby. I still have trouble with music today and it’s been almost a year and a half. Every situation, no matter how benign it seems, poses a threat. The grocery store, your kid’s basketball game, a quiet dinner with friends, just sitting in front of your computer taking your online class, or walking on your treadmill. Even driving to your therapists just 2 miles down the road has the potential to unravel and dismantle you emotionally and physically.

      So the short answer to your question is yes, the symptoms can go on for months. or even YEARS. The longer answer is that everyone is different. Each person brings a unique range of genetic and physiological components to the table when exposed to medications. I was very fortunate in that when I began taking the Lexapro – it worked BEAUTIFULLY. And it continued to do so for SEVEN years – so much so, that I thought I was cured. Which is why I thought I could stop taking it. Of all of the asinine things I have done in my life, I would have to say this one was by far the most stupid, and the decision I most regret. The drug did not rob me of my life, it empowered me to live it. Taking it away ruined me, and I’m stuck with whatever new normal this is now. It pisses me off daily and although the symptoms have calmed down – they are by no means gone. And yes, even now, if someone said I could safely get back on it and move ahead feeling like I did before – I would happily do it. You better believe it.

      Give yourself some time, and if the symptoms continue unabated, speak with your doctor.

      • LilianG Says:

        Thank you so much for your insight. It helps so much to hear other experiences

      • MD Says:

        Gina, I realize this post is more than three years old, but, since my experience discontinuing SSRI is EXACTLY like yours, I have to ask: After three years, have you found relief from the longer-lasting symptoms?

  7. New Treatments For Depression » Blog Archive Antidepressant Withdrawal Symptoms Lexapro Says:

    […] Separating SSRI withdrawal symptoms | James Heaney – Aug 02, 2012 · SSRI withdrawal symptoms are very complicated because they are primarily emotional in nature. This makes diagnosing the difference between existing …… […]

  8. Steve S Says:

    Hi James,
    What a wonderful site, I keep reading your blogs over and over again for reasurrance. I went off of Effexor 150mg cold turkey for 10 weeks now. I suffered from depression and I fought through it. Now it appears I am struggling with fear and Anxiety. I really do believe this is another phase of the withdrawal process. I read your blogs to convience myself that this is not me, but the withdrawal. Thank you for sharing such great Material

  9. New Treatments For Depression » Blog Archive Antidepressant Discontinuation Syndrome Duration Says:

    […] Separating SSRI withdrawal symptoms | James Heaney – Aug 02, 2012 · SSRI withdrawal symptoms are very complicated because they are primarily emotional in nature. This makes diagnosing the difference between existing …… […]

  10. New Treatments For Depression » Blog Archive Antidepressant Discontinuation Syndrome Symptoms Says:

    […] Separating SSRI withdrawal symptoms | James Heaney – Aug 02, 2012 · SSRI withdrawal symptoms are very complicated because they are primarily emotional in nature. This makes diagnosing the difference between existing …… […]

  11. cherylwissler Says:

    Wonderful and comforting information….just want more. Knowledge is power and helps one relax.

  12. Davy Says:

    It’s extremely difficult to separate original anxiety symptoms from the side effects of the medications from the possible withdrawal symptoms from symptoms of a possible different non-associated condition. I’ve been on paroxetine for about 8 years, during which time my life was only worsening because of the Seroxat. Heart, liver, kidneys, eyes, weight gain, food allergies, depression (which I have never had before starting the SSRI’s), to name a few damages of this awful drug…
    Emotional issues I was always able to cope with and find a way to get out, but physical symptoms are a real satanic bitch from hell… half a dozen times I have tried to tapper them off, ending up in ER’s and not being able to get out from my house for months at a time. I don’t want to sound like I’m spamming or anything, but I thank Jim Harper for his The Road Back program, if it weren’t for those supplements, I can’t imagine how I would’ve survived… Withdrawal is the single most difficult thing I’ve ever had to go through, like a nightmare you can’t wake up from for months…

  13. Debra Bekker Says:

    I have just read all of your SSRI Withdrawal articles and I’m crying. All I’ve wanted is some way to explain to people what I’m experiencing in a way they can understand – inasmuch as this can be understood. I went cold turkey (circumstances, lack of knowledge) off Effexor 2 years ago. The physical symptoms were, as you can imagine, ridiculous, but the emotional symptoms are, it seems, worse. I experience the “Waves and Windows” as you describe, but the intensity of the emotions seems to be getting worse with time, not better. Perhaps I’m just depressed because it feels like I’ll never be normal again. Anyway, I just wanted to say thank you for your excellent articles.

  14. Jean Says:

    Most help articles on the web are inaccurate or inhrteoenc. Not this!

  15. Barbara Kerr Says:

    I am writing this as I battle yet another round of anxiety after tapering carefully from an SSRI. The waves as you call them are enormous and I’m meditating daily to be in the now. The physical symptoms as well are hell….ears ringing incessantly, nausea, dizziness and stomach issues. Your blog is inspiring to me and I too read it for encouragement to get through this. Thank you to all of you as it sucks to do this alone. At present we are on a vacation and I’m sitting in the dark with a churning tummy trying to get myself together to join my friends. I’ve had peeks at what life without this drug can be. I want that life.

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