The subtle effects of an SSRI

2007-08-18_152

One of the things that has puzzled me as my dose of Paxil has gotten lower is the way that old friends marvel at all the changes they see in me.  Even causal, but long time, acquaintances say that I seem like a completely different person.  They’re even people who I haven’t told about my Paxil tapering.  Somehow, I’ve transformed in front of their eyes over the past year.  I haven’t questioned them too closely about how I’ve changed, even though I’m very curious.  To me, I seem exactly the same.  I’ve always been “me”, haven’t I? I keep looking for specific things that I do differently, but they seem like little things.  I don’t interrupt other people’s conversations to say something that just popped into my head anymore.  I think that’s different.  Still, that seems like a small personality change, not something that people would notice immediately.

That changed a bit yesterday.  I had a difficult day at work.  I was configuring two routers in our network to talk to each other for a customer.  The interfaces weren’t built, the NNI was designed on the wrong router, I had to redistribute MPLS routes across two different sections of our edge network.  Suffice to say, it got complicated.  And, it lasted for 14 hours.  By the time I got home, I had only eaten a few candy bars in the previous 36 hours and I was dead tired.  I stuffed a couple cheese sandwiches in my mouth and went to bed.  I had to be back at work 7 hours later.

This morning, I woke up tired and grumpy.  I had a bit of a persecution complex as I showered and watched the DVR from last night.  I shuffled into work and started getting ready for the day.  A friend of mine asked if I was going slomo today.  Everyone else noticed the difference, too.  “Are you ok?” “How late did you stay last night? I left at 10 and you were still here.”

I realized that I was feeling the same way I had felt every day while I was on 40mg/day of Paxil.  I never seemed to get enough sleep, and I was always irritated.  There were long stretches where I would sleep for 12-14 hours a night, and still wake up exhausted.  Every little thing annoyed me.  I didn’t contribute at work, I just went through the motions.  The difference today was that irritated feeling faded away like it would for a normal person.  By the end of the day, I was joking and helping my next door neighbor with a config.  In my Paxil days it would have lingered all day, and I would have gone home much as I had left it, irritated and tired.

I didn’t think yesterday was a good day.  Looking back, it was pretty good.  I got the customer working eventually, and I learned something about the ways that I’ve changed since I started tapering off Paxil.  It turns out, Paxil made me feel like I was working on an intractable problem for 16 hours a day, every day.

Repetitive Thoughts in SSRI Withdrawal

It spins me round

SSRI withdrawal symptoms can range quite a bit.  There are physical symptoms, emotional symptoms, mood symptoms, and bizarre symptoms.  One of the more difficult symptoms to deal with are repetitive and recursive thoughts.  These are thoughts that keep repeating over and over again in the mind.  They can be about anything.  Sometimes, they feel like a dark mantra that won’t stop.

I talked to a person in withdrawal who repeated the same sentence for four hours.  “If only I could…”  It varied a little bit over time, but it didn’t really change for that whole conversation.  Repetitive thoughts grip your mind and won’t let go.  It’s very hard to break out of the mental cul de sac that they create.  Everything you try to replace it with inevitably leads back to the central thought.  Usually, the thought is a regret, or a memory.  It’s very common to critically review the past in withdrawal.  Somehow, the past becomes incredibly important and inescapable.  In our society, we grow up believing that the emotional and intellectual parts of the mind are separate.  “Mind over matter”, “Walk it off”, “Pick yourself up and go on”.  In reality, the intellectual and emotional parts of our minds are two sides of the same coin.  You can’t ignore one without damaging the other.

The first thing to do in combating a repetitive thought is to recognize it as one.  That seems like an obvious thing, but it’s not as clear in withdrawal.  Even irrational thoughts take on a certainty and weight that they wouldn’t normally have.  For a “normal” person, the memory of pulling a girl’s hair in kindergarten would be a passing regret.  In withdrawal, that regret becomes the centerpiece of an elaborate story about self inadequacy.  I was a terrible person for pulling her hair.  That has only grown as I have grown, and now I am the result of a lifetime’s worth of regret.  That’s the thought process in withdrawal.  It sounds remarkably like a diagnostic marker of depression, and it is.  That’s why withdrawal is often misdiagnosed as a new or existing condition.  The difference is that withdrawal is iatrogenic, caused by the drug, not a condition.

The thing that makes it hard to recognize a repetitive thought in withdrawal is that each step from the original thought feels natural.  The progression from the memory of pulling a kindergartener’s hair to a dark assessment of your adult life seems rational and correct.  We naturally filter out the more wild connections our minds are capable of making and don’t realize that something’s wrong when that check is missing.  In withdrawal, you need to make a conscious effort to moderate thought.  That’s not very easy when the thoughts are so persistent.

Breaking the cycle of repetitive thoughts is something that takes practice.  Being mindful of your thoughts is a frustrating thing at first.  It can feel like you’re just watching as things fall apart in front of you.  It’s important to keep trying to control those thoughts, though.  It starts with recognizing that a particular chain of thoughts is originating from withdrawal.  If you notice that the whole chain of thoughts keeps referring back to a single event to propel it, that is most likely withdrawal related.  It’s almost impossible to “discard” a whole chain of thought, but recognizing it can help in dealing with it.  Try to focus on something else, something with its own chain, like a story or a game.  It may not be in keeping with the societal norm of heroically overcoming a struggle to reach the happy ending, but the goal is to overcome, not to be a hero.

Inside the SSRI bunker

2007-03-03_016

SSRI withdrawal is a notoriously variable thing. For most people, the symptoms vary from day to day, even hour to hour. This variability makes planning a day in withdrawal very difficult and leads to a general fear of the future and an inability to plan ahead because of anxiety about which “me” will show up tomorrow. Withdrawal also breeds a profound desire to withdraw from life and other people. It’s sometimes hard to deal with your own internal state, let alone social interactions.

It’s still important to try to push the boundaries of personal comfort during withdrawal. One of the strange aspects of withdrawal is that it’s very hard to tell when symptoms are improving. Often, the best way to gauge progress is during a social interaction. You may notice that today’s trip to the market didn’t produce as much stress as last week. Even though your internal state may feel the same, having a successful trip outside can show you subtle signs of progress. Getting out can also be a way to “make” progress happen. Powering through an encounter can provide confidence going forward.

Withdrawal is not just an emotional or intellectual problem, though. It’s also an imbalance of neurotransmitters. After having Serotonin levels managed artificially by the SSRI, it takes a while for the brain to find a new balance. serotonin is intimately involved in our emotional state. As much as we would like to believe that we can control our emotional state, our minds are much more complex than that. The mind has intellectual and instinctual elements. It’s important to heal both aspects during withdrawal. Just as you wouldn’t “walk off” a broken leg, you can’t push through some of the symptoms of withdrawal. The broken bone analogy is apt when discussing withdrawal. When recovering from a broken bone, it’s important to exercise to speed healing, but over doing it can actually set back recovery. The same applies to SSRI withdrawal. Pushing the emotional boundaries of withdrawal can speed healing and make for a stronger internal mental state. Likewise, pushing through social interactions that produce a lot of fear or stress can set back recovery.

It’s important to manage stress during withdrawal. It’s hard to apply general principles to it because each person’s tolerance to stress is different. An individual’s stress tolerance can change over time, too. Since withdrawal follows a chaotic pattern, it’s hard to manage. The only way to manage stress is to take it day by day, even interaction by interaction. You may reach your stress limit after one trip to the market. Tomorrow, though, you may be able to go to a movie theatre. Try to be flexible and only retreat when you feel you need to. Don’t hesitate to retreat a bit if you become overwhelmed, but also don’t hesitate to jump out there again.

Emotional Biases in SSRI Withdrawal

2006-08-12_009

If you flip a coin 4 times, and the first three come up heads, there is a built in human bias to assume that the next flip will be tails. Even though the coin has no memory of previous throws, the human mind still assigns a bias to the series as a whole. Similarly, withdrawal symptoms create their own momentum. The timeline of withdrawal is much longer than a short series of coin flips, but the principle can still apply.

For many people, withdrawal occurs in windows and waves. It oscillates between times when symptoms are lighter and times when they are more severe. Since the mind always seeks to find or create patterns in what it experiences, it’s natural to try to anticipate the next cycle, and predict what it will be like. This can be good and bad. In the middle of a wave, it gives the mind something to look forward to. Instead of being mired in a wave, the mind can anticipate the symptoms improving. Likewise, a window can be seen as an opportunity to consolidate gains and take stock of overall progress towards recovery.

The relief that you get from lighter symptoms can be squandered by anticipating the next wave, though. In many ways, it’s a one sided bias. There is fear of slipping into a wave during windows, but no anticipation of a new window during a wave. There is an emotional weight associated with each stage.  It’s like our perception of a coin flip instead of the actual binary nature of the flip. While you’re in a wave, that negative feeling gains a sense of permanence that it shouldn’t. Even though waves inevitably give way to windows, except in the case of a chronic conditions (withdrawal is usually episodic, not chronic), there’s no anticipation, just suffering in the moment. That fear persists into the next window, coloring our interpretation of the window. Instead of recognizing it as an improvement, it’s seen as a brief respite or interlude before the next wave.

One of the big mental tasks in making progress during withdrawal is to separate waves and windows. Instead of viewing them as two sides of the same coin, inevitable partners, they should be viewed in the larger context of recovery. The window/wave pattern is a sign that the brain is recovering. Once the symptoms begin to break up, the waves should get shorter/milder and the windows should get longer/better. Waves and windows should also be viewed in isolation from each other, like a coin flip. Feeling better is not the cause of the next wave, just as feeling bad is not the cause of the next window. Those cycles are signs of deeper restructuring taking place in the brain. There are things that you can do to mitigate waves and extend windows. Mindfulness can help.  Being aware of the cycle between waves and windows can mitigate the bad, and extend the good.  It’s important not to obsess about your emotional state, but be cognizant of the ebb and flow of emotions.  At the same time, waves and windows need to be dealt with individually.  You can’t always be looking forward to the next change. At first glance, a window seems like an easy thing to deal with.  You’re feeling better! Normal!  What’s to do?  Actually, windows are opportunities to take stock.

Windows

Windows represent your progress towards normalcy during withdrawal.  It’s very hard to compare your mid window state with “normal”, though.  We all live in a relative mental state.  It’s very hard to step outside yourself and compare the way you are now with the way you’ll be after recovery.  It is possible to perceive changes from one window to another, though.  Keeping a journal can help quantify your well being during a window.  It’s human nature to avoid dwelling on negative emotions when we’re feeling good, so it takes a bit of discipline to go back to your journal during a window.  Many people post on withdrawal sites until they start to feel better, then only come back when they experience a wave.  Just like a course of antibiotics, it’s important to keep the mindfulness momentum going during a window, even if you feel better.

Waves

Dealing with waves is a defensive thing.  Being mindful that the symptoms of a wave are not a normal part of your mental makeup is a good strategy.  In normal thought, we only consciously perceive a small portion of what happens in the depths of our minds.  Our cultural and mental makeup parses most thoughts, and they don’t become conscious thoughts.  Anger, fear, anxiety, even psychosis, are all parts of everyday thought.  We only see the small part that our conscious mind actively thinks about, though.  Psychotic, angry, and fearful thoughts are normally not part of our daily interactions, so we don’t give them much “processor time” in our active minds.  We present the side of our minds that we want to the outside world.  In a wave, the normal checks and balances are suppressed.  Instead of automatically suppressing thoughts we don’t want, the mind presents everything all at once.  It’s important to actively take over the parsing role until that automatic system has a chance to re establish itself.

So, in a strange way, waves and windows should be seen in the larger context of overall recovery and also viewed as binary things (heads or tails).  It’s not easy to take the long view of withdrawal while still dealing with each individually.  One of the symptoms of withdrawal that makes it particularly hard is the suppression of cognition.  We simply don’t think as quickly or deeply as we normally would.  It creates a vulnerability to the symptoms that makes the waves more powerful and the windows less satisfying.  Even if you fail to have much of an effect on the cycles in the beginning, that effort will pay dividends over time.  It’s hard to keep trying through multiple “failures”, but you’re building a mental reserve that will eventually have an effect on the whole process of recovery.

Waves and Windows in SSRI Withdrawal

GFS-Fri02-2

 

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.

 

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.

Paxil Withdrawal

2006-08-05_038

I wrote all my passwords on an envelope next to my computer. I wasn’t sure I would survive, and I wanted my brother to be able to log into my computer and websites. Suicide had never been an issue for me. My particular depression never included thoughts like that. It was a complete shock when they intruded on my thoughts and started to sound plausible. Intellectually, I recognized that it might be caused by lowering my daily dose of Paxil, but I couldn’t separate my thoughts enough to see where they were coming from. Self annihilation clung to memories and old guilts so that they entered my conscious mind together. I had to sit and examine each feeling until I could pin down what was real and what was an imbalance. I knew my Serotonin levels were fluctuating and that would have significant impacts on my mood, but that knowledge was a bare comfort when I sat at my desk crying.

It’s hard to describe how powerful the effect is without experiencing it. I started losing a lot of weight, but the fact that my pants were falling off didn’t make me happy, it made me frustrated and mad. A rational person won’t understand the frustration I felt whenever I had to pull up my pants… I don’t understand it, now that I’m looking back at it. That was the most important thing to me for about two weeks. Each time I walked out of my pants, I’d yell at the walls, stomp around the room, I even yelled at the dog once. I put a big dent in my living room wall because I kicked it three or four times before I could cling to a doorframe and regain control. I’m a peaceful person, I’ve been in two fights in my life, 4th grade and 8th grade. I couldn’t stop kicking that wall for a second, though.

I wasn’t trying to wean myself off of Paroxetine in a vacuum. I saw my doctor regularly, I was in contact with my family, I had support from friends on the Internet. I read about possible withdrawal symptoms before I attempted to lower my dosage. None of that helped me endure the process. At first, I tried to take my daily dose with intervening days. I wanted to establish an every-other-day routine because I knew that I would be cutting my 40mg pills into smaller and smaller segments by the end. I didn’t think I could scrape 2.5mg off that big pill every day. I talked to my doctor several times about prescribing smaller pills. Those conversations never went past the initial request, though. Instead, he tried to convince me to continue my regular daily dosage. He offered to supplement my prescription with samples and low cost pharmacy alternatives. Eventually, he prescribed new pills that he intended me to take while I was weaning myself off of Paroxetine. After researching the new prescription, I found that it’s contraindicated with some Serotonin Reuptake Inhibitors and has a new set of side effects, including withdrawal symptoms. I don’t think that my doctor was trying to cause an adverse reaction or that he was necessarily incompetent. I was presenting him with symptoms and problems that he wasn’t trained to deal with. Most of the doctors I’ve seen have been trained to see chemical and surgical intervention as the two pillars of modern medicine. He seemed genuinely taken aback when I first told him that I was going to stop taking Paxil. From a patient’s perspective, doctors’ offices are filled with Pharmacon advertising. I sign in with a pen advertising bladder pills, I sign out with a pen advertising liver pills, and the back office is filled with brochures and sample packs. I don’t think it’s unusual that the first solution a doctor thinks of is one of those pen pills.

There’s also the issue of corporate reporting and training. Glaxo Smith Kline was recently forced to admit that Paxil can cause suicidal ideation in teens. I think the issue extends far beyond that small group of patients, but I only have anecdotal conversations with other patients to support the idea. Each patient I’ve talked to who is stopping Paroxetine treatment has experienced some form of renewed depression not associated with their previous diagnosis. That’s the most difficult thing about judging the adverse effects of an antidepressant. It’s very hard to separate the original symptoms from the ones caused by the drug. The company literature goes to great lengths to minimize those side effects, which complicates the issue. Each side effect is couched in retractions and stipulations until a rational reader would assume that they only affect a tiny minority of users. This gave me a false sense of confidence when I started my withdrawal process. I believed that it would be a relatively simple process, with just a few short term side effects that I could easily manage. Instead, I’ve been dealing with these symptoms for six months. It’s only now, at 2.5mg/day, that I can see the end of it.

The line of least resistance would have been to start taking my normal dosage again. There was something deep inside me that kept me on track to wean myself off Paxil, something that I can’t completely describe. It was a sense that my life had been put on hold for 10 years. Paxil suppresses a lot of mental activity, both constructive and destructive. Paxil was suppressing more than just my particular symptoms of depression, it was also suppressing the mechanisms that would allow me to progress towards resolving those issues. I tried Directed Talk Therapy, social workers, Cognitive Behavioral Therapy, I even sat with a Jungian type psychiatrist for a while. I didn’t have a visceral sense of the issues that I was trying to deal with, though. I felt disconnected from my emotions in a way that disrupted the therapy process. It wasn’t until I was forced to examine those hurtful memories that I realized where they originate from, and what role Paxil had played in suppressing them. I couldn’t really deal with those issues until the level of Paxil in my bloodstream started to diminish. At that point, I had to deal with my existing problems, as well as fluctuating Serotonin levels. That complication changed the nature of my recovery. Instead of dealing with a lifetime of issues over the course of several years, they flooded down on me in the space of six months.

Emotional suppression may be at the core of the Paxil withdrawal problem. In our society we belittle mental issues, treating them as weaknesses or character flaws. That’s not the nature of mental illness, though. It’s a real medical issue, just like a torn muscle or a concussion. I spent a year working in a place where I was responsible for a system, but had no authority over that system. At the end of that year, I had an uncontrollable tremor in my right arm, and a breakdown of sorts in the Human Resources office. I was put on medical leave for six weeks. I kept the shades drawn and the lights out for the first two weeks. I really felt that I had broken something in my mind and it hurt just as bad as a broken leg. Our minds create our reality in a fluid and transient way so we can’t see when something is wrong because that becomes our new reality. Paxil enhances that sense of mental relativism. A temporary depression, whether it’s caused by a neurotransmitter imbalance or an existing issue, is perceived as a long term or permanent problem. Imagine someone thinking about their life, and realizing that the way they feel today will be the way they’ll feel forever. It’s not necessarily true, but it Feels like it’s true. Without a healthy context to compare those emotions to, they take on a permanence that they shouldn’t in our minds. The compounding effect of Paxil, and its suppression of a broad range of mental processes, makes that kind of introspection much more difficult.

I’ve experienced nearly all of the withdrawal symptoms that company sponsored studies claim affect only a small minority of patients. The disparity between the claimed side effects and my personal experience leaves me with a profound distrust of Pharmaceutical companies. I don’t want to broadly characterize Pharmaceutical companies based on an anecdotal experience, but it’s hard to differentiate between my own internal feelings and justifiable anger. Just as mental relativism makes a small problem seem much larger, the disparity between the predicted effects and my own experience leaves me with an abiding sense that I’ve been lied to. I recognize that some of those feelings are strongly linked to an existing condition I have, but it’s more profound than that.

My sense of outrage hasn’t diminished over time, but it has changed. I don’t think that corporations are trying to make money off my depression, but I do think scientific studies that would illuminate these problems have been sidelined or minimized. The very nature of company sponsored studies make it impossible to be certain without inside information. Patients like myself are left with their own feelings and sense of mental stability. It’s the nature of the business that these drugs are used on patients that do not have a strong sense of self; it’s one of the symptoms that Serotonin Reuptake Inhibitors are designed to help. The irony is that the drugs themselves dissolve the boundaries between meta cognition (a person’s sense of their own thoughts) and random thought. I think that the development of Paxil stopped or slowed down once a formulation with any sort of efficacy was found. The fact that the effect is very broad was seen as an asset rather than a detriment. In the case of depression, that broad effect can be a very limiting factor, making treatment and resolution much more difficult for the patient. Pharmaceutical companies are trending towards broader applications of their drugs and less scrutiny from the government over the effects. Medical science has always been about developing techniques with finer applications and results from treatment. This new trend of marketing drugs to a wider audience doesn’t benefit the patient or their course of treatment. The company benefits financially, but that’s only half of their business. Mental illnesses are the most nuanced diseases that humans have thus far tried to treat. Using broad acting drugs on these very specific problems isn’t the best solution. Flooding the brain with “feel good” neurotransmitters masks symptoms rather than allowing the patient to safely address their specific illness.

One of the nuances of Paxil withdrawal is the way that changing the dosage affects the patient as much as the total dosage. In my case, even small changes in my daily dosage caused large mood swings. It didn’t seem to matter if I was going from 40mg/day to 30mg/day or 15mg/day to 10mg/day. For me, it was the change in dosage that initiated withdrawal symptoms, not the total dosage. Once I was stable at a new level, my symptoms diminished until I tried to lower my dosage again. There is a point where a large daily dosage of Paxil will overwhelm the brain’s Serotonin regulation mechanisms and cause its own problems. There are only anecdotal reports to support the idea that large amounts of Paxil cause mild overdose conditions, but the people I’ve discussed it with uniformly report the same effect. Artificially controlling Serotonin levels in the brain creates a dependance on the drug where the brain tries to regulate levels at the old level, but is confounded by the flood of neurotransmitters. As the drug builds up in the body, the brain no longer has to produce Serotonin at the previous levels. Once the patient tries to lower their dosage, the brain requires some time to ramp up neurotransmitter production again. This discrepancy leads to large fluctuations in the level of Serotonin, and withdrawal symptoms.

I started taking Paxil without knowing its effects or side effects. I described my symptoms to my doctor, he prescribed Paxil, and I started taking it. There was no discussion of the effects beyond “It will make you feel better”. Looking back, that reason was insufficient. Paxil has been a significant part of my life for a decade, influencing me in both positive and negative ways. I don’t regret starting the treatment, I didn’t understand the foundations of what I was feeling. I always thought that depression sprang from some unknowable source. Now I know that there are discrete sources for depression. Each time we experience something new we use previous memories to evaluate it. If a child grows up with criticism and no sense of self worth, they will apply those experiences to new encounters as an adult. Constructive advice becomes a personal attack. Without a concrete idea of the foundations of that misconception, there’s no basis for a person to separate the older memory from the new experience. Paxil is a valuable tool, but it seems incomplete and ill used by modern medicine. Instead of recognizing the limitations of the treatment, the emphasis is on expanding its use with little regard for the pitfalls.