Adventures with Benzodiazepines and SSRIs

[AmZ]

Thanks Daniel.

Well, I have to say that my stomach issues have followed the same pattern for 4 weeks now. Even though on one hand, I can say that I can not control the same daily routine of waking up at 5-6am without fail and at least in my stomach feeling bad (either resulting in bowel movement or not), of course, on the other hand, it follows such a pattern that I have somehow ingrained this in my mind of expecting it to happen every day, and therefore, it keeps happening! It's so horrible and something that I don't want of course, but I haven't succeeded in stopping it happening.

All I can hope is that with the mix of short term medication and the sessions with the psychologist, that this is not going to go on for much longer.

When this all started, I decided that no way I want to take medication and that it's all power of the mind and that I can control it myself along with going to therapy. But things got bad real quickly and now, I've come to the point of not being able to control much and relying on medication for now to stop the physical things. Now I say it, it makes me cringe that I need to do this and it's scary to think that somehow, I need to be able to (first of all, get the right medication and) come off of the medication sometime and be able to control all of this by myself.

To be honest, I can't even talk about it now. I'm feeling real messed up and concerned for not just the present, but for my future. I'm anxious about feeling anxious, about feeling anxious.

---------- Post added July 6th, 2010 at 12:31 AM ---------- Previous post was July 5th, 2010 at 11:49 PM ----------

New world record for me. Within an hour, I have managed to go from thinking positively and feeling OK, to the total opposite and now feeling anxious as hell AND in having my first nighttime anxiety AND whilst being on the medication which I took 2 hours ago. Yey, and it's 12.40am now and I am meant to go back to work tomorrow after a few days off.

Success!

Now what?

Two options... well, one really. Lay down, close my eyes and take in a deep breath, hold it for a second and let go. Keep doing that and get in control of your mind. 30 minutes later, that didn't work.
Second option. Asides from the extra 0.25mg I have taken this evening that I wasn't meant to... Maybe more medication will work!? But can't do that, as I've been bad enough in taking what I wasn't meant to tonight and yesterday also.

So....?

 

[Daniel E.]

Taking a warm bath/shower and then walking into a cool room is one way to reduce nighttime anxiety/insomnia.

Other tips:

http://forum.psychlinks.ca/anxiety-and-stress/615-tips-for-night-time-anxiety.html

http://forum.psychlinks.ca/sleep-dreams-insomnia/13508-fall-asleep-with-no-medications.html (a bedtime snack always helps me )

• Get out of bed when you're not sleeping. Sleep as much as needed to feel rested, and then get out of bed. If you can't sleep, get out of bed after 15 minutes and do something relaxing, such as reading.
• Avoid trying to sleep. The harder you try, the more awake you'll become. Read or watch television until you become very drowsy, then go to bed to sleep.

Insomnia: Lifestyle and home remedies - MayoClinic.com

For the future:

The key is not to wait until bed time to start winding down. If you keep you mind up and alert all evening, and then try to shut it off at 11 pm, you're going to have difficulty. You need to start slowing down both your body and your brain a good 2-3 hours before you want to be sleeping.

http://forum.psychlinks.ca/sleep-dreams-insomnia/18826-how-to-sleep-when-not-tired.html

 

[AmZ]

TY for the links. I am reading them now.

Just had a warm shower and cooled off after, but hasn't helped much.

Funny how my stomach has started to feel bad. And you know what that means? When this happens in the morning, once I have bowel movement, I feel better after. (Well, asides from having no appetite and still not sleeping good). (but still...) this is why it's become such a self-fulfilling prophecy. Seems like such a great plan now to go ahead with seeing that it's 1am and I will first of all wake up at 5am, so that's probably 2-3 hours sleep (if I ever manage to fall asleep now), then maybe stay awake or go back to sleep for 2 hours on and off and get up for work.

Sucks!!!!!!!!!!!!!!!!!!!!!

And the worst part of it all, is that I can so see how medication can be addictive. All I want to do now is take more so that it will make me calmer and drowsy/sleepy so that I can just sleep. That's all I want to do. 0.25mg does hardly anything or me.

---------- Post added at 02:29 AM ---------- Previous post was at 12:53 AM ----------

O well.

Ended up taking a full tablet this evening (0.25mg 2 hours ago and 0.25mg 30 minutes ago) and it's done absolutely nothing anyway, so my plan hasn't worked. 2.30am and still wide awake. Don't think I could get addicted to this if I tried lol... Well, unless if I'd take one more now, but don't worry, I won't. I've been bad enough in taking 1 1/2 tablets today, when it was only meant to be a half this morning and that's it.

Nice try.

I think I'm going to just have to turn up to the psychiatrist in the morning and hope that I'll be able to see him, because I am meant to be going on Wednesday with my Dad (he lives abroad but is visiting now, and now he knows about what is happening, he said he wants to come with me to ensure I get all the answers I need), but no way am I going to sit there and admit that I've actually already tried a higher dose without the Dr's agreement (and that it didn't work anyway - If I don't admit this when I go with my Dad on Wednesday because I don't want him to know and the psychiatrist suggests this dose, I know it doesn't do a thing anyway!).

 

[Retired]

To address the original question in this discussion:

How much truth is there in Benzodiazepine Withdrawal?

Withdrawal from benzodiazepine therapy is a complex issue determined by the particular compound being used, the dose and the duration of therapy.

Every benzodiazepine has its own pharmacokinetic profile, meaning every compound is absorbed, distributed and eliminated from the body differently. Some are short acting, (alprazolam, lorazepam) meaning they possess a short metabolic half life, while others are long acting (diazepam, clonazepam) where they remain in the body longer. Furthermore, some compounds have active metabolites that add to the effect of the parent compound thereby complicating the effect, while others have no active metabolites. Some require a complicated metabolic process in the liver, potentially interacting with other medications, while others are clean metabolizers and have no interaction potential.

Some benzodiazepines reach a steady state in the bloodstream quickly as in the case of lorazepam which takes about three days where the amount being administered equals the amount being eliminated, while others take a week or two before steady state is reached.

A rapid steady state is beneficial when initiating therapy, but can lead to a sudden drop in blood levels when the medication is withdrawn suddenly and rapidly, resulting in what is described as withdrawal symptoms such as agitation, flu like symptoms and increased anxiety.

So getting back to your question about alprazolam, which is a fast acting short half life medication with no active metabolites, if one has been treated with this compound for several weeks/months, then the doctor would most likely recommend tapering off the dose when discontinuation is required to avoid withdrawal symptoms.

Other strategies might also be employed which might include using a different benzodiazepine compound with a different pharmacokinetic profile as a bridge to help curtail withdrawal symptoms.

So if discontinuation is contemplated, it should be done under a doctor's supervision, and the instructions for how to proceed need to be carefully followed to avoid unexpected adverse experiences.

 

[AmZ]

Thanks Steve.

Unfortunately, this morning was by far the worst I've had since this started.

I had 4 hours sleep and woke up at 6.45am feeling like I have a hangover or something weird... REALLY nauseous, bad stomach and shaky weak feeling.

First passed stool and still felt awful then ended up for 20 minutes dry heaving painfully and nothing coming up because there is literally nothing in my stomach. After 20 minutes of that, now the feeling of nauseous has gone, but I am left with my body feeling terrible and a headache.

Not sure whether to go to my family doctor in an emergency this morning or to the psychiatrist. Neither can do can really anything to help me right now, anything is going to take time to get to a solution, so I'm feeling a bit helpless here. I'd say that I will just normally get on with my day, but it's getting increasingly difficult to do this, especially with the not eating and sleeping. I need to travel 2 hours to work, stay there for 8 hours and travel back 2 hours, that's 12 hours I need to be up and about for, and I don't think I physically can.

 

[Daniel E.]

I need to travel 2 hours to work, stay there for 8 hours and travel back 2 hours, that's 12 hours I need to be up and about for, and I don't think I physically can

Certainly, driving while tired can be as bad as driving while intoxicated with alcohol, not to mention driving with a low blood sugar.

A classic example is a nurse that ran over someone after working a long shift.

But, of course, people can often drive just going mostly on adrenaline, etc, though it's not pleasant.

 

[AmZ]

I go to work on the bus. But nevertheless, I've just gotten to the point of not sleeping and eating enough in the last 4 days or so, that I am nearly finished here... Feel too bad.

 

[David Baxter PhD]

You might be well advised to take a day off work to get into to see one of them (doctor or psychiatrist) tomorrow. Things don't seem to be improving in a hurry.

 

[AmZ]

The not being active and sitting at home makes things worse for me, but I know that I need to stop telling myself that and just do it, because I can't go in this state.

It's just all bad timing as my family has been here and I've taken time off of work also, but not much I can do about that.

I can go to my family doctor right now, but not sure what's he's going to be able to do for me right now. The same with the psychiatrist. Unless there is some wonder drug he can give me that works straight away, I don't think that exists. I have the ones that I ca take also which will take possibly weeks to work, or a higher dosage of what I have now, which I can only guess has caused the nauseousness and everything this morning... Is that possible that in taking 0.75mg yesterday rather than 0.25mg, that the 0.5mg (0.25mg at 10pm and 0.25mg at 1am) could cause this physical sickness?

 

[David Baxter PhD]

Anything is possible, which is why you need to get some medical advice. Apart from anything else, you need to worry about dehydration and throwing your metabolites out of whack.

As for what they can do, as I've suggested previously, that can include

• changing the tranquilizer to another type for the short term
• starting you on an SSRI or SSRI/SNRI for the longer term
• perhaps adding in a sleeping medication for the short term
• giving you some medication for the gastric distress so you can start eating and drinking properly

But the longer you wait to get into see someone, the longer you're going to suffer. Personally, I hate pain. If I have it, I get my butt into a doctor to find out why.

 

[AmZ]

Thanks.

Well, the doctor will be my first port of call today then. He doesn't know about all that has gone on, just that my "virus" ended up to be anxiety and knows no other details like the symptoms or whatever is going on, so will see what he recommends.

Going to get moving on this now.

TY.

---------- Post added at 11:06 AM ---------- Previous post was at 08:31 AM ----------

Back from my family doctor. Waited 1 1/2 hours to see her and she just said to go to the psychiatrist. She gave me a letter of urgent referral and said to go straight away now. I luckily called the clinic with the psychiatrist and turns out, he's not there for another few hours, so I have to call back then. I'm meant to be going tomorrow to him, but I don't even feel like I can wait until then.

---------- Post added at 03:50 PM ---------- Previous post was at 11:06 AM ----------

Right. Another day, another Dollar.... (Well, didn't make it to work today, so I'm a few Dollars down, but OK!)

Family doctor said nothing she can do so as mentioned in the previous post, told me to go straight to the psychiatrist.

Managed to get to the psychiatrist a few hours later and the first thing he asked was if I'd been to my family doctor, so glad I had that covered. (I didn't mention straight away that I had gone in the morning to see her). So gave him the letter of urgent referral which she had given me.

We went over things again and he's said that I need to take more medication, the same, Alprazolam, and nothing new/extra. Asides from the lack of appetite (which is probably still due to a big majority of anxiety, but maybe slight depression, still to use the term mildly), the rest of the symptoms and problems I am having is due to anxiety (I can see that for sure). He said that because of this, I should stay on this at a higher dose and see how I am feeling by next Monday and speak with him then to see if it has solved the lack of eating, sleeping etc. If not, then I'll meet with him again and do something different maybe. He said that he hopes that in going to a psychologist also, some of these symptoms should die down also... I darn hope so, as I don't want to rely on medication for so long of course.

He's still a bit vague on how much I should take and when etc, but I do understand that on the other hand, he doesn't know how I am feeling so can't really tell me to take it then and that much. I don't like the idea so much of having free reign in this sense, but I'm just going to have to make sure to take as little as possible as I need and at good times of the day and really also, to test out a bit at the beginning when/how much to take to calm my body down when it needs to be.

He said that I can take 2-3 tablets a day when I feel like I need them... (again, a bit vague), but that would be a total of 1.5mg max a day according to that.

I'm sure that by now you get the gist of my symptoms and when I have them etc (like the 5-6am bad stomach 30 minute max stint, then no appetite until 1pm earliest, then by 5/6pm, feeling pretty OK - Unless like last night, I get a phone call about something that sets me off feeling anxious about something of course!).

What is the 'usual' dose for someone with this type of anxiety?

Dr Baxter, as you had mentioned before and as I had also thought myself, for sure, it sounds like a good idea to take just as I go to bed, to aid with the sleeping and relax me, even though, from what I hear, it works fast but then wears off fast so I hope that I can naturally get over the 5am wake ups (!), then maybe lunchtime the next day so that I can at least have it with food hopefully and that will be better also... So just trying to work out how much and when is a good idea. MMM.

Maybe just that for now, 0.5mg (1 tablet) right before bed (is it too much to take two?) and one more at lunchtime the next day, and see how I go with that. Of course, I don't want to be starting on 3 if I don't need it. I'm still freaked out about the whole addiction thing and to make sure that I don't start to go overboard taking them. Plus of course, the longer you take the medication and higher dose you have, that you need to taper off of it if you're on it for longer than a month or so.

I found a new psychologist also today who I am really hoping will be good for me. I am meeting with him Thursday morning. That gets exhausting by itself, to have to now go to a third one and start over, but I hope that he'll feel able to help me and that he will be able to help me!

 

[David Baxter PhD]

Maybe just that for now, 0.5mg (1 tablet) right before bed (is it too much to take two?) and one more at lunchtime the next day, and see how I go with that.

That sounds like a reasonable plan for me, at least until you get caught up on your sleep.

 

[AmZ]

Thx.

1 or 2 before I go to bed though?

 

[David Baxter PhD]

Try one. If that works, great. If not, you can try two but you might feel groggy in the morning. Your psychiatrist has given you scope to experiment a bit, as long as you don't exceed three in 24 hours.

 

[AmZ]

Agreed. He said 2 (ideally) to 3, and 3 max like you say, so will start with one before bed time and one at lunch time the next day and see how it goes.

I didn't take anything this morning as I wasn't sure if he was maybe going to switch me to something else or whatnot, so after I saw him, about 4pm my time here and got home, I took one pill. Then had the best 2 hours sleep of my life and feel great for it, so whether or not that was a coincidence and/or because I was exhausted anyway, it was good, so no complaining!

The dose before (that I've been taking for the last 7 days) was so small that it didn't do anything really (had anxiety only 2 hours after taking it for example one day) so I'm going to pretty much count from now me actually taking this medication. I am still aware of the max month recommended usage so everything will hopefully go in a good direction from now with the new psychologist also on Thursday and I can finally move forward with this and get myself better.

It's been all very up and down for the last 5 weeks and very difficult, but I hope that this time around, I have exactly what I need in order to only move forward from now on.

Your advice (Dr Baxter, Daniel and Steve etc) has been very much appreciated and I'm sure I'll be posting back before you know it haha.. I hope nothing too negative of course.

---------- Post added July 7th, 2010 at 10:25 AM ---------- Previous post was July 6th, 2010 at 07:07 PM ----------

Last night, I took one pill at 12.30am as I got in to bed, after 10 minutes I was asleep, still woke up at 5am and was awake for 5 minutes but went back to sleep and slept a great 9 hours total... Haven't done that in over 5 weeks now, and boy, did I need it. AND, no bad stomach this morning... First time in 5 weeks also!

Still aware that this may not happen every day and I still have things to work on etc, but it's a good start.

 

[David Baxter PhD]

Excellent.

 

[AmZ]

Thank you

I hope that progress will continue this way.

My appetite has been a bit better today also. Enough energy to go to the gym this evening which is great.

Meeting with the new psychologist tomorrow morning so hope that will go good also.

I decided today not to take a full pill at lunch time, in the fear that it will send me off to sleep whilst standing or something (!). So I took half a tablet instead then was planning on taking another half at 6pm or so, but haven't done so. For now, I'll stick to this and if I feel like I need the other half a pill early evening also then will take also, but for now, I'm good. So one at bed time and half at lunchtime.

---------- Post added July 8th, 2010 at 06:20 PM ---------- Previous post was July 7th, 2010 at 06:36 PM ----------

Hey.

So, the session with the psychologist went good this morning.

Lucky that I am at least at a stage where I know from my previous sessions with the psychologist that in the space of an hour, I can rather easily explain the sequence of what has brought me to where I am now and the main events that have affected me to cause this anxiety. Before, I wasn't so aware of how the things were affecting me of course.

First of all, I have a question about something if I may ask your professional opinion Dr Baxter. The psychologist today said that I have 'Separation Anxiety' (using the term in the form of diagnosis). Now, there have been 4 or 5 people of whom I have been very close with that I have 'lost' since the age of 15 or so (Mother [abandoned by her], Grandmother [passed away], my Father [to a certain degree] as I moved countries and my Sister [since she got married] but it's not like I have a fear now of the possibility of 'loosing' someone else. (I actually haven't got anyone else to lose, asides from myself!). Fine, I can say that I have ' Separation Anxiety' from the past, as in, the several separations/losses has caused this culmination of anxiety, but to my mind, it's not a 'disorder' or something is it? Just life circumstances that have happened to me?

Quite correctly, as Dr Baxter you had said, and that I was also thinking, is that it's not a good idea to just carry on with the Alprazolam that I am on now. The psychologist said that I need to add an SSRI also now, because I shouldn't take the Benzo for more than a few weeks, and alongside that, the things that I have to work on will not and can't be 'fixed' within a matter of 2/3 more weeks... It could take 2 month, 3, months maybe even 6 months. So he has recommended that I go back to the psychiatrist and discuss this with him and ask to be put on an SSRI already, so that it can 'kick-in' the next 2-3 weeks or whatever and that I can then stop with the Benzo.

 

[David Baxter PhD]

Separation Anxiety Disorder is a real DSM-IV-TR disorder, although it's one more commonly given to children or young adolescents.

BehaveNet? Clinical Capsule™: Separation Anxiety Disorder

Diagnostic criteria for 309.21 Separation Anxiety Disorder

A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

(1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
(2) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
(3) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
(4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation
(5) persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
(6) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
(7) repeated nightmares involving the theme of separation
(8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
​

B. The duration of the disturbance is at least 4 weeks.

C. The onset is before age 18 years.

D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder With Agoraphobia.

Specify if:
Early Onset: if onset occurs before age 6 years

 

[AmZ]

Thanks for the info Dr Baxter.

Well, can't say that I fit in to any of those categories, so not going to look in to that 'diagnosis' of sorts - We'll just call it 'anxiety' which was caused by several things including the loss of the close people in my life.

I have issues that are not good and also have negative connotations that go against what I am being told that will be good for me to do/change in my life - Asides from a few things I would like to make closure on in my life or come to understand more, the main thing everyone is ranting on about is that I need friends and more people in my life etc... Truth is, I am so used to not having a social group of friends, I don't know if it would even make me happy and stop all of this anxiety and way I am feeling. The last time I had proper close friends was when I was in my late teens, so a good 5 years ago now - Since then I am just used to (now) my own company (and since recently, my Sisters company of course) and I can't say that looking back at when I had friends, it's something that I particularly desire so much really now.

There has to be more than what I even understand about myself here, maybe I am totally wrong, I don't know... I can't say that the anxiety has been caused by a lack of friends, but just from 'loosing' or becoming a lot less closer with the 4 family members since the age of 16 and now it culminating in having nobody there family-wise much. Just by making some friends over the next few months is going to make me that much happier?

Somewhere deep down, I just feel like, eww, it's horrible to say it, but that I have everything missing... Very negative I know, but I will use the horrible word that teenagers use 'whatever' - I just really feel 'whatever' about everything. Maybe this is where some twisted deep depression is inside of me. And that's where I just wonder if all of this psychologist and family support in saying "yes, join that club" "go and do that and meet friends" etc will EVER work for me. No aspects of life excite me and I can't say I have a desire for anything really.. Like a career, etc. Just so that I can work a 9-5 job, do the same old monotonous mundane things every day for the rest of my life. My list could go on.

Lucky it's about medication time for me now... I feel that lovely pulsing sensation in my left temple - I can diagnose myself as to what that is from.

---------- Post added at 12:29 AM ---------- Previous post was at 12:07 AM ----------

Whilst I am on a roll... I will add, from my deepest thoughts this evening, that as messed up as it sounds, I'd rather just medicate myself up and feel numb, rather than deal with all of this life rubbish! Even if I could say that I WILL make some good changes in the next few months, I'd still rather just for my mind to be somewhere else in another place. Anywhere but here.

Escapism sounds good.

Over and out.

 

[Daniel E.]

Maybe this is where some twisted deep depression is inside of me. And that's where I just wonder if all of this psychologist and family support in saying "yes, join that club" "go and do that and meet friends" etc will EVER work for me. No aspects of life excite me and I can't say I have a desire for anything really.. Like a career, etc. Just so that I can work a 9-5 job, do the same old monotonous mundane things every day for the rest of my life. My list could go on.

Even when I was 25 or so like you are now, I was told I could still have "adjustment issues" regarding the transition to adulthood. The late teens and the 20s can be the most stressful time in adulthood.

In any case, one way out of a worry trap ("what if" thinking) is the "one day at a time" or "fake it till you make it" approach or, more technically, using mindfulness techniques, opposite action, cognitive restructuring, developing an internal locus of control, etc.

For example:

What is phishing and how do you use it in your workbook?
Phishing is a term we use to describe the trickier activities of the reactive mind. Like phishing scams on the internet, mental phishing involves being tricked into attaching to highly provocative mental content (like the thought, “I will never be happy in life”) and treating it as real. When a person is phished, they act on the basis of this imaginary reality, even though the actual event that happened is that the person had a thought called, “I will never be happy in life.” Seen as a thought, and just a thought, there is no trick played. Part of learning to be mindful and to detach from mental processes is the ability to recognize negative content that is likely to be form of phishing from the reactive mind, the world's most accomplished phisher!

http://forum.psychlinks.ca/depression/20499-mindfulness-and-acceptance-for-depression.html