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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by jujube on January 6, 2005, at 14:32:23
Ok, I am, no doubt, beginning to seem like a pain in the butt with my indecision and insecurities about my meds, but I am in need of some advice and guidance again. I'll try to keep this brief.
Since last Friday, I have not been able to take anything. This is really because of how my body reacts to aneastetic (had unplanned surgery on Friday) which results in, among other things, my already low blood pressure really dropping, my temperature remaining low, my skin feeling like a block of ice, and it taking days and days for things to get back to normal. Then there is the effect that pain killers, which I had to take, have on me after a few days of use.
Anyways, I had been taking Anafranil for the past 7 weeks, and had managed to go up to 75 mg for a few days before my accident by taking salt tablets to increase my blood pressure so that I could tolerate the higher dose. However, after 7 weeks (mostly at 50 mg), there has only been a modest improvement in mood, general and social anxiety relief and motivation. I was to have continued taking Celexa with the Anafranil, but kept forgetting to take it. I was happy to have experienced some increased energy and motivation and what I thought (hoped) was the beginnings of a return to my old self prior to Christmas after adding some natural supplements (Vitex, NADH and DMAE), but, since the surgery, those are not helping as much and I am feeling empty, scared and anxious. I feel like such a hopeless loser, and have been on the verge of tears all day.
Anyways, it has become increasingly obvious to me that I will not be able to tolerate a high dose of Anafranil. So, I was hoping to get some suggestions on what to try next. I could restart the Celexa at a low dose (for anxiety relief) and ask my pdoc for Provigil if that sounds like it may be effective. Or perhaps I could see if the pdoc is willing to prescribe Nortriptyline to combine with the Celexa. Or . . . I just don't know anymore.
I also have a prescription for Xanax, which I use as needed. I am wondering if Klonopin might be better for social and anticipatory anxiety.
Well thanks all for reading and sorry for the long-winded message. Any advice would be greatly appreciated.
Tamara
Posted by sabre on January 6, 2005, at 15:38:53
In reply to Some advice needed (hopefully last time), posted by jujube on January 6, 2005, at 14:32:23
Hello Tamara
I hope the surgery went well and that you are recovering. I think surgery and just being in hospital can be traumatic especially if you suffer from social anxiety. All that questioning, constant interaction, sounds, smells etc not to mention the physical stresses of the surgery are stressful and anxiety provoking.I can't offer any medication solutions for SA. I was reading a study yesterday that said the strongest evidence for treatment of SA was with SSRIs http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495010
I don't see a lot of support for their effectiveness in Babble posts. Maybe all the success stories don't need to post?I hope it goes well for you. If I find the SA answer the first thing I'll do is post it here!
Best wishes
sabre
Posted by zeugma on January 6, 2005, at 19:51:53
In reply to Some advice needed (hopefully last time), posted by jujube on January 6, 2005, at 14:32:23
Hi Tamara. I'm sorry about your medical difficulties. Psych meds complicate things enormously, especially the TCA's.
Nortriptyline was a painfully slow titration process for me, because of the hypotension- I was pouring salt on everything and eating soups, pickles, etc., to get my blood pressure up. So nortriptyline is not free of hypotensive properties, either. the difference is that dosages of nortript are lower, so 50 mg would be a plausible therapeutic dose. You'd still need those salt tablets though!
provigil is unlikely to cause hypotension. I think it also has antidepressant/anxiolytic effects.
-z
Posted by jujube on January 7, 2005, at 0:02:03
In reply to Re: Some advice needed (hopefully last time), posted by sabre on January 6, 2005, at 15:38:53
Thanks Sabre. I know what you mean about the hospital experience - not pleasant or easy even for those who don't have anxiety. At least this time I didn't have a flare up of my night terrors in the days following the surgery.
Thanks for the link. I will have a look at it. I actually was under the impression that SSRIs were somewhat effective for general anxiety, but that meds that worked on norepinephrine were better for social anxiety. That is why I had hoped to be able to tolerate a higher dose of Anafranil. It is supposed to work on both serotonin and norepinephrine.
I wish you all the best as well as you try to find a suitable treatment for your own social anxiety.
Take care.
Tamara
> Hello Tamara
> I hope the surgery went well and that you are recovering. I think surgery and just being in hospital can be traumatic especially if you suffer from social anxiety. All that questioning, constant interaction, sounds, smells etc not to mention the physical stresses of the surgery are stressful and anxiety provoking.
>
> I can't offer any medication solutions for SA. I was reading a study yesterday that said the strongest evidence for treatment of SA was with SSRIs http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495010
> I don't see a lot of support for their effectiveness in Babble posts. Maybe all the success stories don't need to post?
>
> I hope it goes well for you. If I find the SA answer the first thing I'll do is post it here!
>
> Best wishes
> sabre
>
Posted by jujube on January 7, 2005, at 0:20:53
In reply to Re: Some advice needed (hopefully last time) » jujube, posted by zeugma on January 6, 2005, at 19:51:53
I appreciate the information. I realize that hypotension would also be an issue with Nortriptyline, but, from a chart comparing the side effects of the TCAs, it would appear that it may not be as severe as that caused by Anafranil. So, maybe I would be able to better tolerate the Nortriptyline (with continued use of the salt tablets). Provigil would probably be preferable, if I can convince the pdoc to let me try it. I think I am going to do a Psychobabble search to gather more information on people's experiences with Provigil.
Thanks again.
Tamara
> Hi Tamara. I'm sorry about your medical difficulties. Psych meds complicate things enormously, especially the TCA's.
>
> Nortriptyline was a painfully slow titration process for me, because of the hypotension- I was pouring salt on everything and eating soups, pickles, etc., to get my blood pressure up. So nortriptyline is not free of hypotensive properties, either. the difference is that dosages of nortript are lower, so 50 mg would be a plausible therapeutic dose. You'd still need those salt tablets though!
>
> provigil is unlikely to cause hypotension. I think it also has antidepressant/anxiolytic effects.
>
> -z
>
>
Posted by KaraS on January 7, 2005, at 22:30:03
In reply to Some advice needed (hopefully last time), posted by jujube on January 6, 2005, at 14:32:23
> Ok, I am, no doubt, beginning to seem like a pain in the butt with my indecision and insecurities about my meds, but I am in need of some advice and guidance again. I'll try to keep this brief.
Don't be ridiculous! That's what we're here for. And you of all people, who is always there for everyone else, should not think twice about asking for some advice.
> Since last Friday, I have not been able to take anything. This is really because of how my body reacts to aneastetic (had unplanned surgery on Friday) which results in, among other things, my already low blood pressure really dropping, my temperature remaining low, my skin feeling like a block of ice, and it taking days and days for things to get back to normal. Then there is the effect that pain killers, which I had to take, have on me after a few days of use.
>
> Anyways, I had been taking Anafranil for the past 7 weeks, and had managed to go up to 75 mg for a few days before my accident by taking salt tablets to increase my blood pressure so that I could tolerate the higher dose. However, after 7 weeks (mostly at 50 mg), there has only been a modest improvement in mood, general and social anxiety relief and motivation. I was to have continued taking Celexa with the Anafranil, but kept forgetting to take it. I was happy to have experienced some increased energy and motivation and what I thought (hoped) was the beginnings of a return to my old self prior to Christmas after adding some natural supplements (Vitex, NADH and DMAE), but, since the surgery, those are not helping as much and I am feeling empty, scared and anxious. I feel like such a hopeless loser, and have been on the verge of tears all day.You are not a hopeless loser. You're just going through a really difficult time. You were making some progress (albeit incomplete) and then you suffered a terrible setback. No wonder you're upset. This can all turn around again soon when you get on something you can tolerate that will work for you better. Once all of the pain medication is out of your system you will probably respond better to your supplements as well.
> Anyways, it has become increasingly obvious to me that I will not be able to tolerate a high dose of Anafranil. So, I was hoping to get some suggestions on what to try next. I could restart the Celexa at a low dose (for anxiety relief) and ask my pdoc for Provigil if that sounds like it may be effective. Or perhaps I could see if the pdoc is willing to prescribe Nortriptyline to combine with the Celexa. Or . . . I just don't know anymore.Unfortunately this usually comes down to trial and error. You discuss with your doctor. You make educated guesses and then you try them out. Fortunately your guesses are very educated. You do your research and you come to the right places for advice. You can't do much more. I wish I could tell you whether you should go with Celexa or nortriptyline. I don't know whether they can be combined, but if so, that might be an option to consider. You may find that nortriptyline is more easily tolerated than Anafranil. I couldn't say that with any scientific certainty but I do know of several people who were on it for years and tolerated it very well. Provigil is also a good choice as an augmenting medication if your doctor will prescribe it.
> I also have a prescription for Xanax, which I use as needed. I am wondering if Klonopin might be better for social and anticipatory anxiety.
Supposedly Klonopin is the best of the benzos for social anxiety. The only problem is that it tends to cause depression with regular usage. For that reason you might want to wait until you're on an antidepressant that is working well for you before trying it. Then again, once you're on something that works well for you, you might not need it - or at least not very often.
> Well thanks all for reading and sorry for the long-winded message. Any advice would be greatly appreciated.
>
> Tamara
Remember - this is a temporary setback based on an unfortunate occurence. This too shall pass!!Luv ya,
Kara
Posted by jasmineneroli on January 7, 2005, at 23:26:02
In reply to Re: Some advice needed (hopefully last time) » jujube, posted by KaraS on January 7, 2005, at 22:30:03
Hey Tamara:
Hope you are on your way to a speedy recovery....must be heard to type, huh???I feel for you,in your setback and indecision. It's SOOOO hard when a plan you have finally set upon, seems to stop working. :(
I just wanted to recommend the Celexa/Klonopin combo I was on all spring & summer. I have GAD, that does come with social anxiety in my severe moments, but not usually a feature of my condition.
Of all the drug combo's I've tried, a low dose of Celexa (10mg) and low dose of Klonopin (.25 to.5mg) was the most effective. However, as you may recall, I had miserable side effects to Celexa and ended up coming off it. I still take the Klon. because it's the only thing that helps my anxiety. I take .25mg daily (I'm still fiddling around with tryptophan augmentation, + magnesium, niacinamide...not too bad, but not as effective as Celexa & Klon. combo).
I disagree that Klonopin inevitably causes depression. I have not found so.
My daughter has social anxiety and dysthymia. She's on a much higher dose of Celexa and can tolerate it, but she went through some extreme anxiety attacks and complete social phobia recently (bad enought to stop her from accepting a great new job offer!). There was a lot of crap going on in her life. She was in a highly stressed state and worried me a great deal. I could see her heading into a major hole.
I gave her some of my Clonazepam. (BTW, not recommended to share your meds, without medical advice, but Mom's tend to jump in with quick help!). She used it for a couple of weeks and found it to be a wonderful help at only .125mg x 2 per day!!!! (.25mg made her too drowsy).
She said it lifted a weight off her shoulders - she had an "I don't care about this situation" feeling. The worry and fear of humiliation dissipated. As a result she applied for a different job, got it, started it, and with the help of Klon., got through the steep learning curve of the first 2 weeks, amongst strangers.That's my 2 cents. Hope you find your answer soon.
Take care
Jas
Posted by zeugma on January 8, 2005, at 0:05:05
In reply to Re: Some advice needed (hopefully last time) » jujube, posted by KaraS on January 7, 2005, at 22:30:03
> > Ok, I am, no doubt, beginning to seem like a pain in the butt with my indecision and insecurities about my meds, but I am in need of some advice and guidance again. I'll try to keep this brief.
>
> Don't be ridiculous! That's what we're here for. And you of all people, who is always there for everyone else, should not think twice about asking for some advice.
>Of course not.
>And (not to be a long-winded bore myself) these meds are serious and should be taken seriously. The Prozac mythology fostered by Peter Kramer has given the world the false idea that psych meds are harmless toys that should be added to the water supply. (Since I don't want to get banned I'm not going to say any more about Peter kramer.I'm the pain in the butt around here...)
> > Since last Friday, I have not been able to take anything. This is really because of how my body reacts to aneastetic (had unplanned surgery on Friday) which results in, among other things, my already low blood pressure really dropping, my temperature remaining low, my skin feeling like a block of ice, and it taking days and days for things to get back to normal. Then there is the effect that pain killers, which I had to take, have on me after a few days of use.
> >
> > Anyways, I had been taking Anafranil for the past 7 weeks, and had managed to go up to 75 mg for a few days before my accident by taking salt tablets to increase my blood pressure so that I could tolerate the higher dose. However, after 7 weeks (mostly at 50 mg), there has only been a modest improvement in mood, general and social anxiety relief and motivation. I was to have continued taking Celexa with the Anafranil, but kept forgetting to take it. I was happy to have experienced some increased energy and motivation and what I thought (hoped) was the beginnings of a return to my old self prior to Christmas after adding some natural supplements (Vitex, NADH and DMAE), but, since the surgery, those are not helping as much and I am feeling empty, scared and anxious. I feel like such a hopeless loser, and have been on the verge of tears all day.
>
> You are not a hopeless loser. You're just going through a really difficult time. You were making some progress (albeit incomplete) and then you suffered a terrible setback. No wonder you're upset. This can all turn around again soon when you get on something you can tolerate that will work for you better. Once all of the pain medication is out of your system you will probably respond better to your supplements as well.That's a good point, which I wasn't sharp enough to pick up myself. Pain medications make people feel awful.
And nortriptyline is definitely much better tolerated than anafranil. Anafranil, by common consent, is one of the least well-tolerated meds out there. It's a coin toss as to whether nortriptyline is less well tolerated than Peter kramer's favorite drug- do you prefer anorgasmia and flattened emotions, or dry mouth and a good night's sleep?
Nortriptyline is reasonably safe to combine with celexa. I have Lexapro samples sitting on my kitchen table which my pdoc gave me in response to my own request for Anafranil. it was his opinion that the combination of nortrip and lex is safer and less side-effect ridden than Anafranil. By the way, he also said that a mg for mg swap of nortrip for anafranil was feasible, so presumably it would work the other way around too. It's something you could mention to your pdoc which would eliminate the necessity of a long titration, since you'd start with a dose in the therapeutic range.
It's also possible to combine Provigil with nortriptyline. I had a lot of side effects, but if you want to talk about motivation, I was running five miles a day on 100 mg of both nortriptyline and Provigil. Now I can't even make it up the stairs without seeing stars, but that's another issue entirely. I'll give you a link to an article on provigil augmentation:
http://jrnlappliedresearch.com/articles/Vol4Iss2/Bransfield-Jar-spring.pdf
My experience tallies with the gist of the article, and I wish I could be on Provigil instead of lots of ritalin right now. I notice that the article mentions combos with citalopram and desipramine (very similar to nortrip), so maybe you could also think about augmenting with desipramine and Provigil instead of nortriptyline, since the s/e I experienced may not have occurred if I'd been on desip.
Sorry I've gone on so long myself! I hope some of this will be useful to you.
-z
Posted by jujube on January 8, 2005, at 1:16:35
In reply to Re: Some advice needed (hopefully last time) » jujube, posted by KaraS on January 7, 2005, at 22:30:03
> You are not a hopeless loser. You're just going through a really difficult time. You were making some progress (albeit incomplete) and then you suffered a terrible setback. No wonder you're upset. This can all turn around again soon when you get on something you can tolerate that will work for you better. Once all of the pain medication is out of your system you will probably respond better to your supplements as well.
>
-- Thanks Kara. It seems that for months now I have been taking two steps forward and one and a half steps back. I usually refuse to take pain medication (I have a relatively high tolerance for physical pain), but the surgeon said it was to my benefit to take something for a few days at least. It's weird, but at first the pills were almost like "happy" pills, not in the least bit sedating for me. But, after a few days, I started to get an almost oppressive feeling. It was so bad at times that I had to turn on all kinds of lights, even during the day, and have not been able to go to sleep without the t.v. and a hall light on. I end up on the verge of tears, but am afraid that if I start crying, I won't be able to stop. Now that I have stopped the pain meds, I think I will restart Celexa.> Unfortunately this usually comes down to trial and error.
-- I am so hoping that my next trial will be the one for me. I am leaning toward Provigil as of today. I have read about the experiences of others with it both here and on Remedyfind, and it sounds like it would be a good choice. I will just have to try to be assertive with the pdoc when I see him again in the next couple of weeks. And, I will raise Klonopin with him as well, although I am not as concerned about that since I do have Xanax which does help me quite a bit. I have to pick my battles, and Provigil is more important to me at this stage.
> Remember - this is a temporary setback based on an unfortunate occurence. This too shall pass!!-- Thanks Kara. I will do my best to keep those words in mind.
Take care.
Tamara
Posted by jujube on January 8, 2005, at 1:37:33
In reply to Re: Some advice needed (hopefully last time), posted by jasmineneroli on January 7, 2005, at 23:26:02
> Hey Tamara:
> Hope you are on your way to a speedy recovery....must be heard to type, huh???-- Thanks Jas. It is hard to type. I have been reduced to the one hand hunt and peck technique. Very slow. Perhaps I should try to train myself to type with my feet - it would probably be just as fast!
> I just wanted to recommend the Celexa/Klonopin combo I was on all spring & summer. I have GAD, that does come with social anxiety in my severe moments, but not usually a feature of my condition.
-- It I will restart Celexa in the next few days, and ask the pdoc for Provigil to augment when I see him next.
> Of all the drug combo's I've tried, a low dose of Celexa (10mg) and low dose of Klonopin (.25 to.5mg) was the most effective. However, as you may recall, I had miserable side effects to Celexa and ended up coming off it. I still take the Klon. because it's the only thing that helps my anxiety. I take .25mg daily (I'm still fiddling around with tryptophan augmentation, + magnesium, niacinamide...not too bad, but not as effective as Celexa & Klon. combo).
-- I would like to eventually try Klonopin, but may have a hard enough time getting Provigil. So, I will continue to use the Xanax for now as needed.
> I disagree that Klonopin inevitably causes depression. I have not found so.
-- That's good to know. It really is so true that no two people will react the same way to a med. I have heard of some people experiencing a dampening of mood and others not being affected in that way at all.
>
> That's my 2 cents. Hope you find your answer soon.
> Take care
> Jas-- Thanks again. Your 2 cents are greatly appreciated!
Tamara
Posted by jujube on January 8, 2005, at 1:55:21
In reply to Re: Some advice needed (hopefully last time) » KaraS, posted by zeugma on January 8, 2005, at 0:05:05
Thanks so much Zeugma for all the great and useful information. It is appreciated more than you will know. The link to the article on Provigil augmentation will be particularly useful and, I am sure, will certainly help bolster my argument for Provigil when I see the pdoc in the next couple of weeks.
Take good care of yourself.Tamara
Posted by KaraS on January 8, 2005, at 16:53:16
In reply to Re: Some advice needed (hopefully last time) » KaraS, posted by jujube on January 8, 2005, at 1:16:35
> -- Thanks Kara. It seems that for months now I have been taking two steps forward and one and a half steps back.
I know the feeling... but that can change.
>I usually refuse to take pain medication (I have a relatively high tolerance for physical pain), but the surgeon said it was to my benefit to take something for a few days at least. It's weird, but at first the pills were almost like "happy" pills, not in the least bit sedating for me. But, after a few days, I started to get an almost oppressive feeling. It was so bad at times that I had to turn on all kinds of lights, even during the day, and have not been able to go to sleep without the t.v. and a hall light on. I end up on the verge of tears, but am afraid that if I start crying, I won't be able to stop. Now that I have stopped the pain meds, I think I will restart Celexa.Very bad timing unfortunately to have go through all of this when you were already in a precarious state. I can imagine how the whole experience could really overturn the apple cart. I don't like having to take pain medication either but you really had to. I hate that scared panicky feeling. If keeping the lights and the tv on helps you now, then so what. You just have to do what helps you get through this.
Celexa sounds like a good relaxing choice for you now.
> > Unfortunately this usually comes down to trial and error.
>
> -- I am so hoping that my next trial will be the one for me. I am leaning toward Provigil as of today. I have read about the experiences of others with it both here and on Remedyfind, and it sounds like it would be a good choice. I will just have to try to be assertive with the pdoc when I see him again in the next couple of weeks. And, I will raise Klonopin with him as well, although I am not as concerned about that since I do have Xanax which does help me quite a bit. I have to pick my battles, and Provigil is more important to me at this stage.Good luck convincing him on the Provigil. It's sad we have to battle to get these things that can help us, isn't it?
I'm sure that Jas is right about the Klonopin not causing depression for everyone who takes it - especially if you're taking a small dosage. My concern was that you don't know up front though which way it's going to effect you, so if you're already depressed, is it worth the risk? (I'm a bit afraid of benzos in general though so you have to keep that in mind. I'm definitely not against them though.)
> > Remember - this is a temporary setback based on an unfortunate occurence. This too shall pass!!
>
> -- Thanks Kara. I will do my best to keep those words in mind.
>
> Take care.
>
> Tamara
Ok, keep us posted.Kara
Posted by jujube on January 9, 2005, at 18:35:25
In reply to Re: Some advice needed (hopefully last time) » jujube, posted by KaraS on January 8, 2005, at 16:53:16
Kara,
I just wanted to thank you for your reassuring words. You are so nice and very kind.
Take care.
Tamara
This is the end of the thread.
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