The subtle effects of an SSRI

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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

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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

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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

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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

Derail

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.

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.

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.

Paxil Withdrawal Symptoms

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Paxil affects the brain and body in profound ways.  Before I tried to wean myself off of Paxil, I had worked for 20 years in a technical field and become fairly successful.  I did not have serious mental issues.  I was originally prescribed Paxil to treat mild situational anxiety.  I am shy in social and work settings.  I did not realize the ways that Paxil changed my behavior and personality until I tried to stop taking it.  At that point, I began experiencing nearly all of the withdrawal effects that Glaxo Smith Kline’s literature claims only affect a small minority of users.  In company sponsored studies, less than 10% of users experience serious side effects from what they call “Discontinuation Syndrome”.  The effects are only supposed to be “mild and last from 1 to 3 weeks”.  I have been trying to wean myself off of Paxil for 7 months.  I am better able to manage the symptoms at this point, but am unable to stop taking the drug.  The worst symptoms occurred for me in the initial stages of weaning.  As I lowered my dosage from 40mg/day to 10mg/day over the course of 4 months, the withdrawal symptoms became unbearable.  I was confined to my living room for most of that time.  Once I finally finished weaning, I entered a two month window of clarity.  My friends remarked at the profound difference they saw in me.  I felt clear minded and confident in a way that I hadn’t experienced in years.  Unfortunately, I crashed about two months after stopping Paxil entirely.  I was again confined to my living room floor, feeling desperate and suicidal.  I was forced to start taking Paxil again because I felt that my life was in danger.  I have been able to get back to 10mg/day, but my quality of life has diminished again to bare existence.  This is a list of the withdrawal symptoms I have experienced from my attempt to stop taking Paxil.  I didn’t experience any of these symptoms before I started taking Paxil.  These are not reemergence of existing problems, but directly related to my attempt to stop taking Paxil.

Head zaps: the feeling of electric shocks in the brain

Headaches

Head pressure

Aching joints and muscles

Dizziness, both when standing up and sitting

Severe Anxiety

Depression

Irrational anger

Suicidal thoughts

Intrusive and obsessive thoughts

Vivid and frightening nightmares

Insomnia

Numbness in my hands (pinky and ring fingers)

Shaking in my hands

Pounding and irregular heartbeat

Loss of appetite, inability to eat, rapid weight loss

Nausea

Gastrointestinal distress

Memory loss

Trouble concentrating

Ringing in the ears

Clenching jaw, teeth grinding

Paxil affects the way that the brain works, and directly affects the mind.  By blocking neural receptors that reabsorb Serotonin, the brain becomes dependent on the drug to regulate Serotonin levels.  Once the drug diminishes or is removed, the brain can no longer self regulate.  As a result, the mind is thrown into chaos.  It will be months before my brain is once again able to regulate Serotonin levels to an acceptable degree.  I started taking Paxil for a mild problem, but have found that the solution I was presented was much worse than the problem.  I don’t feel that taking a larger dose of Paxil is the solution, either, though.  I can compare the way I was on the drug with my drug free self, now.  I was unresponsive and insular while taking Paxil.  I gained a lot of weight and was unable to control other problems like smoking or soda drinking.  Most importantly of all, Paxil didn’t treat the problem that I originally started taking it for.  I still suffered social anxiety and depression at the same levels I did before I started taking the drug.  In fact, I was more prone to outbursts and unexplainable behavior than before.  Paxil has not been a therapeutic drug for me.  To the contrary, it has been a very negative experience.  Perhaps there are patients with severe problems who benefit from these treatments.  The companies market the drugs for mild problems that would be better treated by other means, though.