Dealing with anger during SSRI withdrawal

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

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

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

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

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

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

Reinstating SSRI use during withdrawal

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You decide that you want to wean off an SSRI. The reason can vary.  Perhaps you want to see what you’re like without the drug.  Perhaps you think you’ve outgrown whatever problem prompted you to take an SSRI in the first place.  Perhaps the drug no longer works like it did before.  At first, your doctor is taken aback and tries to convince you to continue taking the drug.  Eventually, he or she tells you that it’s relatively simple to get off an SSRI.  A doctor’s schedule usually includes skipping days and reducing the dosage by 25% every 10 days until you’re down to 0.  For many people, that schedule will work, but a significant percentage can’t tolerate a fast weaning schedule.  These people quickly start to feel withdrawal symptoms that can vary from mild to severe.  Persisting in a doctor’s weaning schedule can eventually turn mild symptoms into severe symptoms.  The brain reacts to lower dosages of SSRI at its own schedule, not ours.  There is a lag between a lowered dosage and the onset of symptoms that can catch up with you after several drops.  The result is that you feel the effects of several dosage drops all at once.  In worst cases, patients can experience rage, anxiety, fear, even psychotic symptoms.  The best way to wean off an SSRI is to do it very slowly.  Most people who taper off an SSRI do it very quickly at first.  It’s not until symptoms appear that they question the schedule.

Once withdrawal symptoms have appeared, the nature of SSRI use has changed.  There is a point where you put yourself on a track to wean off the drug and can’t really get back to the previous state of SSRI use.  You can take your original dose, but the effect will be different.  Instead of creating the mental environment that you experienced before, it’s now a mix of withdrawal and the SSRI numbness.  Once you’ve experienced a mental state without an SSRI, it’s very hard to go back.  Just as you’re very aware of the effects of withdrawal, restarting an SSRI makes you very aware of the effects of the drug.  Reinstating an SSRI is a mixed bag.  Deciding to start back on an SSRI should be done carefully.  Be prepared to experience some form of withdrawal symptoms as well as the general slowing of mental functions that accompanies SSRI use.  Reinstating should be done to prevent the worst withdrawal symptoms and provide some relief from symptoms that threaten your well being.  It is an opportunity to slowly wean off the drug after weaning too quickly on your first try.

Reinstating an SSRI should not be viewed as a permanent thing.  It’s another step in weaning off of the drug.  It’s very difficult to try taking another drug to treat withdrawal symptoms.  Often, you will get the start up effects of the new drug, as well as the withdrawal symptoms of the last drug.  It’s best to restart the same SSRI you were taking before.  As an example, say you were taking 40mg/day of Paxil for 5 years.  You begin tapering as recommended and reach 0mg/day after 2 months.  At about the 3 or 4 month point, you feel that your well being is in jeopardy.  Normally, the brain would adjust to reductions in Paxil at about 10% each 4-6 weeks.  After 4 months, your brain would be expecting about 20mg/day.  You can reinstate at 20 mg/day, which should mitigate the worst withdrawal symptoms.  After a month, the worst withdrawal symptoms should dissipate and you can continue weaning off the drug at a slower rate.  The next step should be about 18mg/day.  After another month to six weeks, you can move to 16.2mg/day.  Weaning 10% each month or so will eventually bring you down to 0mg/day with fewer withdrawal symptoms.  The slower schedule does not eliminate withdrawal, but it should allow you to live a mostly normal life while doing it.  It’s very difficult to measure pills to that precision, but small changes in dosage can have large effects on withdrawal symptoms.

In order to decide what dosage to reinstate at, take your previous maximum dosage and reduce that number by 10% for each month since you started weaning.  Since your goal is to wean off of an SSRI, you don’t want to start at too high a dose, but at the same time, you don’t want to start at too low a dose.  A low dose reinstatement will take longer to reach stability, which will extend the whole process of tapering.  It’s very tempting to restart at a low dose.  One of the common feelings for people who are weaning off an SSRI is that they just want to be done with it as quickly as possible.  It’s disconcerting to realize that you’ve been “hooked” on this drug for a long time when you thought it was just a therapeutic drug.  SSRI weaning is a long process, often feeling interminable.  It’s important to stick to a slow schedule, though.  Quality of life is more important than the larger goal of being SSRI free, which will happen eventually.

Phases of SSRI Withdrawal

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

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

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

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

Paxil Withdrawal

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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.