Waves and Windows in SSRI Withdrawal

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Tapering off of an SSRI can be very difficult.  It’s not like other ailments that have defined timelines and symptoms.  When a doctor treats a broken bone, there are long established milestones in recovery.  SSRI withdrawal is different.  Each case seems to be unique, with different length and severity of symptoms.  One of the frustrating parts of withdrawal is the way that symptoms fluctuate over time.  People call them waves and windows.  At first, withdrawal is unremitting.  There seems to be no respite from the symptoms.  After some time, which varies from person to person, symptoms begin to break up into cycles.  There are times when symptoms aren’t as bad, and other times when they are quite severe.  It’s not a universal pattern.  Some patients find that they have constant symptoms that slowly go away.  The wave/window pattern seems to be the majority, though.

Waves

Waves describe those times when symptoms are more severe.  Symptoms can be physical or emotional.  It feels like getting sick.  When you start to get a cold, you can feel little changes that presage the illness.  A sore throat or headache, then the full symptoms of the cold start in a day or two.  A wave has similar precursors.  Usually, physical symptoms are the first sign that a wave is coming.  A stiff neck, headaches, and dizziness are some of the symptoms.  A day or two later, the emotional symptoms become more pronounced.  These symptoms include obsessive or compulsive thoughts, depression, or anxiety.  It can be helpful to break waves up into different parts.  Knowing that each part of a wave is coming, and what to expect next, can make the whole process easier to handle.  The reason we’re so adept at knowing the cycle of a cold is that we’ve had them off and on all our lives.  we’re aware of the subtle changes in our bodies that tell us that we’re getting sick.  In the same way, it takes some experience before you can separate the parts of wave from each other.  It takes still more time to develop ways of dealing with each part of a wave.

Physical symptoms of a wave are hard to mitigate.  There isn’t much you can do about general joint pain, headaches, or dizziness.  You can try analgesics like aspirin or ibuprofen, but those aches are fairly resistant to those kinds of pain killers.  Dizziness is likewise difficult to deal with.  Withdrawal dizziness isn’t just something that happens when you stand up or spin around.  It’s hard to believe that you can feel dizzy when you lie down, but it happens in withdrawal.  Try to stay as still as possible until it gets better.  Try to use the physical symptoms as a sign that there are new symptoms coming that you need to deal with.

There isn’t really any way to avoid the emotional symptoms of a wave.  There is no way to “suck it up and get over it”.  Our minds create our reality in a fluid way.  The anxiety, depression, and obsessions of a wave are just as real as the screen in front of you.  The fact that our rational mind would recognize that it’s not real or overblown doesn’t mean much when you’re experiencing it.  That’s the essence of a wave.  It’s not rational or thoughtful.  Obsessive thoughts can be about almost anything from the benign to the surreal.  Self harm can suddenly seem like a rational idea.  In normal thought, the entire spectrum of emotions are right below the surface.  When you’re cut off in traffic, you have several choices.  You can ignore it, respond verbally or visually, speed up, slow down.  Even the psychotic is present in that moment.  We’ve become so accustomed to suppressing psychotic thoughts that we don’t even realize that the idea of ramming the other car didn’t rise up to our conscious minds.  In withdrawal, those thoughts that would normally be dismissed without a thought gain the same weight in our conscious minds as socially acceptable thoughts.  The only way to mitigate the emotional symptoms of a wave is to be mindful of the difference between normal thought and the unnatural power that irrational thought has in a wave.  It’s very hard to pick apart which thoughts are your normal responses and which ones are caused by the wave.  They mingle together in a chaotic way.  That’s what makes your reactions to a window just as important as your reactions to a wave.

Windows

Windows are periods of time when symptoms are not as pronounced as they were before.  At first, it feels like it’s over… you beat withdrawal, you’re free.  That’s the cruel joke of SSRI withdrawal.  Windows and waves are intertwined together.  The way withdrawal works for most people is that the windows slowly, ever so slowly, get longer, and the waves get shorter.  A window is more than a vacation from symptoms, though.  It is a huge relief to have some time off from feeling miserable.  Savor the good times in withdrawal, because that is what you have to look forward to in recovery.  More than relief, though, windows are an opportunity to prepare yourself to deal with waves in a better way.  Try to pay attention to how you feel.  Examine the way you think, the way you respond to things.  Try to recognize the way that you automatically choose responses and thoughts.  Emotionally, a window is a return to the normal way of parsing thoughts.  Instead of allowing all thoughts to rise to consciousness, you mind is automatically tuning out undesirable thoughts based on your personality.  Paying attention to the process during a window makes it easier to impose that same kind of structure during the next wave.  It’s that mindfulness that you’ll need during the next wave.  After a while, you can tell when a thought is out of character, and consciously dismiss it.

Withdrawal is a process of alternating good times and bad.  The more you’re able to mitigate the bad with mindfulness, the shorter the waves become.  Our minds often work in feedback loops.  One thought leads to another through association, creating the pattern of our minds.  Mindfulness allows us to shape the pattern to a certain extent.  The more you can recognize that a harmful thought is just part of a wave, and not a normal part of your normal mind, the faster you’ll get to the next window.  Eventually, that last window becomes reality, and the next wave never comes.  The mindfulness you’ve developed getting there will remain, though.

 

Meta symptoms of SSRI withdrawal

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SSRI withdrawal causes many symptoms, both physical and emotional.  In some cases, the emotional symptoms can combine to create larger symptoms, meta symptoms.   Renewed or new depression is one of the most common symptoms of withdrawal.  Depression is an inward emotion.  It forces the patient to examine themselves in an overly critical manner.  In that compulsive self examination, other symptoms can emerge.  It’s not the healthy self examination of mindfulness or self awareness, it is an uncontrollable focus on the negative.  The patient doesn’t see themselves in a mindful light, but through the dark lens imposed by the depression.  Even joyful memories are seen in that distorted way.

Regret and Guilt

The depression of withdrawal forces the mind to pick negative aspects out of any event and focus itself on that exclusively.  That single minded focus creates regret in the patient.  Many times, it is out of proportion to the event itself.  Regret and guilt are very similar to each other.  They feed on each other.  Withdrawal pushes the mind to see guilt in places that the patient normally wouldn’t.  Withdrawal depression narrows the focus of the mind to see only the negative in an event.

I only remember a few things from my 10th birthday.  My parents had organized a party for me and invited several friends to come over.  I had wanted toe clips for my bicycle for a long time, and was very happy that I got them for my birthday.  Being 10, I wanted to install them on my bike right away.  During withdrawal, the nature of that memory changed.  Instead of remembering the happiness of the event, I focused on the fact that my parents scolded me for installing toe clips instead of playing with my friends.

Compulsive memories

One of the symptoms of SSRI withdrawal is renewed memories.  While taking the drug, memories are largely suppressed.  Many patients report that they do not have a good sense of what happened to them while they were on the drug.  They know the larger arc of events, but many of the details are missing.  The emotional nature of memories is likewise suppressed.  During withdrawal, the emotional tie to memories is reawakened.  It doesn’t happen in a linear way, though.  Instead of recalling memories in an associative way, where one memory reminds you of another, memories flood into the conscious mind without context.  It can be profound or trivial, the only commonality is that the memory is not recalled, it is imposed on the mind.  It is a sign that the mind is reordering itself, cataloging memories and emotions into a new order.

For more than a month I couldn’t get the image of a fast food restaurant out of my mind.  I ate lunch there 2-3 times a week for a year, 4 years ago.  The restaurant didn’t have any particularly strong memories associated with it for me.  Every time I tried to go to sleep, though, the image of that Wendy’s just wouldn’t leave my mind.  There was no guilt or other emotion associated with the image, I just couldn’t see anything else when I closed my eyes.

Fear of relapse

At first, withdrawal is unrelenting and overwhelming.  The symptoms occur continuously.  As time goes by, symptoms begin to break up.  Withdrawal becomes a cyclical thing.  There are times when symptoms are severe, and times when they are light.  People call them Windows and Waves.  A window is a period where symptoms are lighter, waves are times when symptoms are more pronounced.  There is an inevitable fear that arises from feeling better.  It’s not intuitive to an outside observer, but it is a real phenomenon for the person going through it.  Withdrawal creates a mental relativism where the way you feel at the moment feels like a permanent state.  Combined with uncontrollable negative self examination, waves begin to feel “realer” than windows.  That breeds a distrust of windows.  There is always the fear that a window is just a prelude to another wave.  Windows and Waves are closely connected, they are part of the cycle of recovery in SSRI withdrawal.  There is some validity to that fear of relapse in the beginning.  Windows will revert to waves, just as waves will break up into new windows.  As time goes by, the windows become longer and the waves become shorter.  There is no point in time that the patient can point to when the severity of waves falls below the level of awareness.  It’s one of the subtleties of withdrawal that progress can only be measured once it has occurred.  You just realize one day that you haven’t experienced a wave in a long time.  The last window has just extended longer than the others, with no wave afterwards.  The fear of relapsing into a wave lingers, though.  It becomes one of the central thoughts during recovery.  Slipping into a wave feels like getting sick, just mental instead of physical.  It begins with a subtle feeling of instability.  It then progresses into more profound feelings of despair.  Waves are very difficult to deal with.  The entire context of the mind has been altered.  There is little memory of feeling better, just the emotions associated with the wave.  So, when the wave breaks up into a window, there is a legitimate fear of the next, seemingly inevitable, wave.  The inevitable thing about withdrawal is that recovery will happen, though.  Many people have experienced prolonged feelings of despair, even suicidal ideation, and recovered themselves in the end.

The best way to deal with the window/wave cycle is to recognize that it is occurring.  It’s difficult to think of waves as temporary phases in recovery.  Somehow, it’s easier to believe that the windows are the temporary phases.  Being mindful of the cycle between windows and waves helps.  Just as windows are temporary in the beginning of withdrawal, waves likewise become temporary as recovery progresses.  Think of the last time you started a new job.  At first, all the new information felt overwhelming.  It’s easy to think that you will never absorb it all.  You quickly become accustomed to the new routine, though.  Eventually, the daily tasks lose their overwhelming quality and become easier to accomplish.  Withdrawal is similar in some ways.  At first, it’s very hard to believe that it will ever end.  Eventually, you begin to reclaim yourself, and it gets easier the longer you do it.

How long do SSRI withdrawal symptoms last?

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This is one of the most common, and hardest to answer, questions about SSRI withdrawal.  Withdrawal from psychiatric medications is still officially a mystery.  According to the manufacturers, SSRI do not cause severe withdrawal.  Instead, symptoms from “discontinuation syndrome” are mild to moderate and last one to three weeks.  This is in direct contrast to some patients that experience prolonged, severe, symptoms.  The disparity between experience and official information causes a lot of confusion for patients.  When we break a bone or pull a muscle, there are long established timelines for recovery.  Individual recoveries can vary in time and intensity.  Overall, most patients follow the timeline and recover close to the time expected.

The lack of information about SSRI may be part of the reason why it is so hard to predict how long withdrawal symptoms will last.  Most studies of SSRI are limited to 8-12 weeks and do not address cessation of the drug.  Manufacturers study their drugs in this manner to gain regulatory approval for sale, not so much to study the effects of the drugs.  Studies of the effects and withdrawal would be more of an academic pursuit and wouldn’t contribute to the commercial application of the medications.  Fewer people would begin prescriptions for SSRI if they knew that there was a chance that they would become dependent on the drug and have to go through an extended withdrawal period when they decide to stop taking it.

From the symptom perspective, it’s very hard to say which patients will experience withdrawal.  Some patients do follow the accepted tapering schedule and are able to stop taking the medication with minimal symptoms, despite taking the drug for a long time.  Other patients experience extended symptoms after taking the drug for a short period.  The underlying predictors of which patients are sensitive to SSRI and which ones aren’t are not well understood.  Without enough knowledge to predict which patients will experience withdrawal, it is even harder to predict how long those symptoms will last.  It becomes a very personal, individual, struggle for each patient.  That being said, there are some ways to gauge progress and predict how long an individual will experience withdrawal.

When a patient first experiences withdrawal symptoms, they can be quite frightening.  Since the mind creates reality in real time, withdrawal can seem like it will become permanent and debilitating.  That is the reality that withdrawal creates, though, not reality as an impartial observer would see it.  We live in a relative state of mind, though, so that’s all we see.  If we could step back from withdrawal symptoms, we would realize that this is a temporary crisis and not a permanent state of mind.  Withdrawal forces the mind to act more on instinct than it normally would.  In normal thought, the intellect regulates instinctual responses, moderating them to match social situations and our own moral beliefs.  Withdrawal disconnects the intellect from its normal regulatory function.  Instead of moderating behavior, anger, fear, and anxiety are allowed to come to the conscious mind.  As an example, take a trip to a supermarket and pay attention to your reactions.  When another shopper blocks an aisle or cuts you off at an intersection, anger is a possible reaction.  Normally, that anger is easily suppressed and you let the incident go without any reaction.  Withdrawal removes that moderating behavior and allows anger to become the acceptable response.  For a person not experiencing withdrawal, it takes a great deal of introspection to even detect the anger that arises from the incident.  It’s almost automatic to suppress the anger because reacting to such a trivial interaction is socially inappropriate.

Reasserting the intellect during withdrawal is the best way to control symptoms and mitigate the power they have.  Being mindful of how you would normally react to a situation and forcing yourself to follow that course of action can help.  It’s easier said than done.  Because of the mental relativism that withdrawal causes, it can be very hard to separate yourself from the immediate symptoms you’re experiencing.  Mindfulness is the process of stepping back from a situation and evaluating the emotions that you are feeling, and then changing your behavior based on what you think rather than your immediate emotions.  Essentially, it’s replacing the automatic moderating behavior that’s suppressed in withdrawal with conscious effort.  It can slow down the flow a conversation quite a bit second guessing every thought, but it’s better than acting out in a way that you might regret later.  It’s not necessary to think your way through every interaction forever, just until the automatic moderating function reestablishes itself.

Taking a longer view of withdrawal can help as well.  It’s very hard to envision how you will feel in two months when you’re living with symptoms minute by minute.  SSRI withdrawal happens in waves and windows.  Those are the names that veterans give to the cycle of withdrawal symptoms.  Waves are periods of time when symptoms are more severe.  Windows are periods when symptoms are not as bad.  As withdrawal progresses, waves come and go.  In the long term, the waves become shorter and milder, while the windows become better and longer.  Eventually, you enter a “window” that doesn’t end.  Mindfulness allows you to see that waves are not permanent and not put too much hope in the permanency of windows.  It sounds fatalistic to acknowledge that windows do not represent a cure, but it’s more realistic.  It’s a delicate balance between hope and pragmatism.  Being aware of how you are feeling during a window is just as important as being aware of your feelings during a wave.  Just as you need to consciously moderate your feelings in a wave, you have to bank the good parts of a window to use when you enter the next wave.  It’s an intrinsic exercise that you can’t really start to practice until you have the experience of a couple cycles behind you.  In the beginning, it’s very hard to see the larger picture because all there is is the immediate symptoms.  Some faith that symptoms will get better is required.  Faith is one of the first things to be shaken in withdrawal.  Family and friends don’t understand, doctors don’t believe it’s withdrawal.  You can’t “suck it up”, either, it doesn’t work like that.  All that can shake anyone’s certainty.  The wave/window pattern is part of withdrawal, though.  Just as you will enter waves during withdrawal, they will also end at some point.

As time goes by and you become accustomed to the cycle of waves and windows, the question becomes less about how long will withdrawal last.  Mindfulness becomes a habit, something that is almost second nature.  It’s something that you can apply to your life after withdrawal.  Most people started taking an SSRI to treat an existing condition.  The decision to stop taking an SSRI usually comes after the drug has lost efficacy or the side effects outweigh the benefits.  That requires some way of dealing with the symptoms of the condition after withdrawal is over.  It’s hard to see the mindfulness that withdrawal forces on you as a benefit of that trauma, but it does give you a good way to handle an existing condition.  In the long term, the goal becomes less about getting off the drug as fast as possible, and more about getting off the drug with as much quality of life as possible.  In a way, a good way, the coping tools you develop during withdrawal will serve you for the rest of your life.  The adage that alcoholics use to describe recovery is apt for people suffering from SSRI withdrawal. “One day at a time” is the best way to approach recovery.

Memory and Cognition

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There are several theories about how we create memories and how we use those memories to interact with our worlds.  Take a restaurant as an example.  When you think of a restaurant, a fairly specific memory is used to represent restaurants in general.  Now think of a fast food restaurant.  The image changes.  One theory of cognition is that we create lists that represent different interactions.  For example, we have a script for restaurants so we know what to expect when we go to one.  We enter, wait to be seated, order, eat, pay, leave.  The script is modified to account for different types of restaurants.  in the fast food example, waiting to be seated won’t work.  So, we create a new list to account for it.  In that list, we enter, order, pay, eat, leave.  The other theory of cognition is that we store elements of previous encounters and use those to assemble an appropriate mental picture that we can apply to a specific situation.

The way we recall events and integrate them into our minds isn’t as simple as recording them.  The analogues to memory that we have created, hard drives, web sites, etc. record events in a linear way.  Human memory doesn’t record events in the same way.  Instead of remembering an event like a wedding one instant at a time, we record a representation of the event that we can later recall.  This method of remembering can alter the event in our minds in interesting ways.  Each element of an event is stored in different parts of the brain and then reassembled when we recall it.  Each time we remember a wedding, the mind assembles the different parts together to create a new representation of the event.  In essence, we’re recreating the event each time we remember it.

For the wedding example, the ceremony is broken into different elements.  The visuals sounds, smells, and tactile memories are compiled together from different areas of memory to create the memory that we then recall.  The way that the elements are stored allows the mind to free associate those parts with other memories that can then impact the recollection of the whole.  When you recall a wedding, the smell of the flowers can be influenced by other memories that include smells.  A trip to an arboretum can influence the wedding memory in subtle ways.  Discrete elements of the arboretum won’t intrude on the wedding memory, the mind would recognize those parts as being out of place in the wedding memory.  Instead, the sensations and smells of the arboretum can influence the recollection of the wedding.  When the mind assembles the wedding memory, it pulls the smells from the same area that stores the smell memories of the arboretum.  In doing so, the two memory fragments influence each other.  The memory of the arboretum would likewise be influenced by memory fragments from a wedding.

When the mind assembles a memory, it has to free associate within each part of the memory to assemble to whole.  Each sense, smell, touch, sight, sounds, and taste has its own area.  As the mind recalls each sense, other memory fragments can influence how we recall each element of the whole.  This is one of the reasons why eye witness testimony can be problematic.  When the witness tries to assemble the memory of an event, other experiences can influence how that memory is assembled.  Since the mind essentially creates the memory each time it is recalled, that recollection can drift over time.  As other experiences change the memory, a discrete memory can start to change the more we recall it.  That’s why police want to get eye witness testimony when it’s “fresh” and people say that the first impression is usually the right one.  It’s not necessarily true, but it does leave the memory less time to be affected by other experiences and memory fragments.

The list and fragment theories of memory aren’t exclusive to each other.  We could use memory fragments to create the lists dynamically.  The list theory is tempting because that is the way it feels when we go to a place like a restaurant.  We create a script that we expect to follow throughout the whole episode.  How we create the list may be more interesting than the list itself.  In many ways, every memory is the culmination of all our experiences.

Psychology of Abilify Commercials

 

The psychology used to make Abilify commercials effective marketing tools is rather remarkable.  The goals for the advertisement are to generate a positive feeling towards the product in the consumer, minimize the effect of negative connotations, and ultimately sell the product.  In this series of commercials, Abilify is being marketed as an additional drug that existing users of antidepressants can take to enhance the effectiveness of the primary drug.  The process begins with the choice of an animated commercial with a very soft color palette.  The pastel colors used in the commercial serve to create a subtle undertone of calmness.  All of the colors are secondary colors rather than primary colors, which are meant to illicit both attention and emotion in the viewer.  The soft colors are in contrast to the primary colors used in most regular programming, which makes the commercial stand out in the broadcast.  In addition, secondary colors also create an emotional state in the viewer that makes the message of the commercial more effective.

The choice of a female narrator serves two purposes.  The majority of antidepressants are prescribed for female patients.  Some estimates claim that 1 in 5 women take an antidepressant.  In addition to marketing the product to the largest consumer base, a female narrator also touches on deep cultural biases concerning the role of women in society.  The traditional role of women in society is as protector and nurturer.  A female narrator touches on these biases to create a sense of safety in the viewer.  The intention is that this sense of safety will be transferred to the product in the mind of the viewer.

Anthropomorphizing depression serves several purposes in the commercials.  Creating a character for depression gives the viewer a way to focus their attention on depression, which is essentially a feeling that normally can’t be easily described.  It also removes depression from the main character, creating the idea that the protector/nurturer is being assailed by an external force.  Using depression as an external force, rather than an internal emotional state, gives the viewer a more concrete focus.  It also reinforces the struggle with depression visually as well as through dialog.  The narrator struggles with this external representation several times in the commercial.  After fighting the depression character, the narrator eventually succumbs, which sets the stage for the authority figure to enter the story.

As the narrator struggles to overcome her depression, a doctor comes and pulls her out of her pit.  Having the doctor save the patient serves to establish him/her as a protective figure and a source of relief for the problems that the narrator is having.  The doctor is also used to discuss the side effects of the drug.  When the doctor discusses side effects, s/he doesn’t do it personally.  Instead, the doctor uses a movie within the cartoon to list side effects.  This serves to remove the side effects from being a primary topic in the commercial.  All of the positive effects of the drug are delivered visually through the cartoon and through direct narration.  Side effects are delivered through a secondary image of the doctor which the doctor, narrator, and depression character watch.  This puts the positive and negative effects of the drug into different categories of awareness for the viewer.  The positive effects are made to be more prominent than the side effects, and minimizes the idea of side effects for the consumer.

This framework is used in several Abilify commercials.  The characters and dialog change, but the essential motif remains the same.  The same psychological methods are used.  It’s not manipulation, per see, but it is carefully designed to create emotion in the viewer rather than facilitate critical thinking.  That is the goal of all advertising, of course.  The difference in this case is that anti psychotics like Abilify were not intended to be used as mild boosters for other antidepressants.  Instead, they were intended to treat chronic and untreatable psychosis.  The way that the effects and side effects of these drugs are trivialized through these commercials is troubling to me.  Instead of prompting a serious discussion between patient and doctor over appropriate treatments, these commercials encourage patients to ask for a specific drug without really understanding the possible effects, positive or negative, of taking it.

Separating SSRI withdrawal symptoms

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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.

Tapering off an SSRI

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Many people can wean off an SSRI very quickly.  Most doctor’s schedules last for a month or two and consist of skipping days and tapering by 20-25% every few days.  Some people cannot tolerate that fast schedule, though.  There is some speculation about the reasons why some people cannot tolerate a fast weaning schedule.  Without clinical studies of long term SSRI use and withdrawal, there is little official information about the proper method for sensitive patients to wean off the drug.  SSRI studies generally last 8-12 weeks and study the efficacy of SSRI versus placebo.  The goal of these studies is not to study the side effects of the drugs, but to gain FDA approval of the drug.  It’s ironic that these short term studies are then used to justify long term, even life long, prescriptions.  Since there is little information about the long term effects of SSRI on the brain, the reasons for some patients’ sensitivity to fast weaning is open to speculation.  Withdrawal is not a recognized problem with SSRI, though.  Most doctors will seek to diagnose a new or existing condition to explain the symptoms.  This is a delicate subject because there are cases where an existing condition will emerge as the drug is removed.  It can be very difficult to discern between existing symptoms and those caused by withdrawal.  Usually, if the symptoms can be closely tied to removal and reinstatement of the drug, that points strongly to a withdrawal problem.  The patient’s history can also be used to distinguish between withdrawal and existing illnesses.  A patient who does not have a history of psychosis or a severe anxiety disorder may exhibit symptoms of both during withdrawal.  Source.  The strongest link between cessation of an antidepressant and withdrawal are the initial symptoms.  Head zaps, dizziness, and electric sensations in the head are some of the first symptoms that most people experience if they are sensitive to fast weaning off an SSRI.  These initial physical symptoms are often followed by more severe symptoms that mimic other illnesses.  It is the similarity between withdrawal symptoms and other illnesses that cause the most confusion for doctors trying to diagnose the problems that their patients are exhibiting.  Since withdrawal is not an accepted part of the pharmacology of SSRI, doctors are left with few diagnostic tools to explain the symptoms that they see in their patients.  A doctor’s role in the prescribing of SSRI is not to break new ground in the diagnosing and treatment of withdrawal, but to use existing tools to describe and treat the symptoms that they see.  It’s incumbent on the patient to bring up the subject of withdrawal and work with their doctor to develop a weaning plan that serves both their needs.  A misdiagnosed case of withdrawal can lead to a spiral of new treatments which compound the problems for the patient.  Instead of treating the underlying withdrawal problem, the patient can be prescribed several drugs in succession to treat the symptoms caused by the previous drug/s.  As the cross prescriptions add up, it becomes more and more difficult to discern which drug is causing which symptoms.  Add in withdrawal from the original drug, and the diagnostic task quickly becomes overwhelming.

Once a patient recognizes that they are very sensitive to SSRI, the regular weaning schedule is not sufficient.  Weaning off an SSRI very quickly may seem like the best plan, like pulling a bandage off quickly to minimize the pain.  Withdrawal doesn’t work like that, though.  The brain combines mental and physical processes in a way that a sudden shock to the Serotonergic system can actually prolong symptoms rather than minimize them.  Once the patient realizes that they are dependent on the drug, it can be very tempting to get the drug out of their system as quickly as possible.  This feeling is compounded as the long term issues with SSRI use become more apparent in withdrawal.  The patient becomes more aware of the cognitive and emotional numbness that SSRI can cause.  The suppression of self awareness and inhibitions becomes more apparent as the SSRI dose goes down, too.  Things that seemed quite normal at the time become more inexplicable as self awareness returns.  Even though the emotional imperative is to wean off the drug very quickly, sensitive patients need to exercise patience.  The goal for a sensitive patient is to wean slowly rather than quickly.  Weaning at a very measured pace minimizes symptoms and actually shortens the overall length of withdrawal.  The goal of slow weaning isn’t just to stop taking the drug, but to maintain as much quality of life as possible while doing it.  It’s important to express that desire to wean slowly to your doctor.  S/he may maintain that a fast schedule is best, but you need to balance their diagnostic imperative with your own sense of well being.  Once you have divided symptoms into existing problems and withdrawal, you want to minimize the withdrawal issues as much as possible.

In sensitive patients, the weaning schedule can extend out to many months.  Instead of weaning off the drug in a month or two, it may take a year or more to fully stop taking the drug.  The best method to lower SSRI dosage is to do so at 4-6 week intervals.  This lets the brain adjust to the lowered dose in a measured way and minimizes the shock that the patient experiences.  Many symptoms of a lower dose are delayed by a few days or even weeks.  The brain has taken a great deal of time to adjust to the drugs presence, so it follows that it will take some time for it to readjust to a lowered dose of the drug.  A longer schedule also minimizes the build up of symptoms that can happen in fast schedules.  Since some symptoms are delayed during the weaning process, the patient can sometimes feel the effect of several dosage drops at once.  The longer schedule separates the onset of symptoms and allows the patient to consolidate each dosage drop before attempting another one.  It’s important to not attempt another dosage drop before you feel that you have stabilized at the new dose.  Instead of relying on a strict calendar schedule, base your decision to drop your dosage on how you feel.  There is no reward for dropping too quickly.  Again, the goal of a prolonged weaning schedule is to minimize withdrawal symptoms.

It is very important to take the drug each day.  Skipping days leads to off and on withdrawal symptoms, which can complicate the weaning process.  As an example, Paxil is metabolized by the body in about 22 hours.  Skipping a day leaves the body with no drug about half the time.  Consistency is the best way to minimize withdrawal symptoms.

The amount of each drop varies by individual.  Each person reacts to dosage drops differently.  Most people who are sensitive to SSRI can drop by 10% each time.  For example, a patient taking 40mg/day can initially drop to 36mg/day.  After an adjustment period, they can then drop to 32.4mg/day.  Each time you taper your dose, it’s important to drop it by 10% of your previous dose.  In the 40mg/day example, don’t drop by 4mg/day each time.  It’s a diminishing schedule that will slow down the dosage changes as weaning progresses.  It may seem like a schedule that will never end, but it is the best way to keep withdrawal symptoms manageable.  Here is an example of a weaning schedule from 20mg/day

20.0, 18.0, 16.2, 14.6, 13.1, 11.8, 10.6, 9.6, 8.6, 7.7, 7.0, 6.3, 5.6, 5.1, 4.6, 4.1, 3.7, 3.3, 3.0, 2.7, 2.4, 2.2, 2.0, 1.8, 1.6, 1.4, 1.3, 1.2, 1.0, 0.9, 0.8, 0.8, 0.7, 0.6

It can be very hard to measure dosages to the granularity that the 10% reduction schedule requires.  Small dosage drops like those described here are hard to accomplish with a pill splitter.  Again, it depends on the level of sensitivity that the patient has to dosage drops.  Some people will be able to estimate the drops, and the important concept is to wean more slowly.  Other people will be more sensitive to dosage drops.  Those people should ask their doctor about changing their SSRI prescription to the liquid form, which is easier to measure at precise dosages.  They can also purchase a jeweler’s scale which can measure pill fragments into very precise dosages.  Source.

The most important thing about developing an SSRI weaning schedule is to personalize it to your own needs.  It takes some time to do the introspection required to place yourself within the spectrum of sensitivity.  It also takes some time and experience to recognize which symptoms are caused by withdrawal, existing conditions, and normal day to day events.  Most people begin the weaning process on their doctor’s schedule and don’t realize that they are sensitive to dosage drops until the symptoms drive them to seek out more information.  In those cases, stay at the last dosage that you felt stable at, and continue from there using the 10% reduction method.  For more information about restarting an SSRI after weaning too quickly, see this post.