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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by g_g_g_unit on November 4, 2011, at 2:49:37
So my psychiatrist returned from vacation this week. He'd read over the report from the professor he referred me to and decided to take up his suggestions, i.e. increasing the Lexapro to 20mg and switching out Depakote for Zyprexa.
I suppose I'm still hesitant about being on an AP, but don't want to be termed non-compliant because I have no concrete reasons for rejecting a trial. What eased my reluctance was the first that I was more firmly able to voice my insecurities about our therapeutic relationship - namely the fact that, over time, I've grown increasingly more terrified of giving my own input regarding medication. My psychiatrist suggested that I carry around two conflicting images of him: one as a benevolent, sage-like elder (who I'll often have OCD-inspired mental dialogues with when anxious) and the other as someone cruel, close-minded and denying. In other words, a classic case of splitting. Neither, he claims, are accurate.
Anyway, I feel a bit more at ease, but I still have an unfortunate tendency of hiding side-effects from him. Maybe it's his training as a psychotherapist at work, but there'll often be a silence or lag in his responses after I tell him something. In the case of reporting side-effects, I'm overcome by this terrifying feeling that I'm being judged, that he thinks I'm crazy or neurotic or just making stuff up. In the case of Lexapro, I said that it is inspiring a "slight" (to ease the impact) feeling of unreality. I don't know why, but he seemed to detect my reluctance and asked if I was sure the feeling was in fact only "slight". For some reason, I couldn't bring myself to say no.
Posted by jono_in_adelaide on November 4, 2011, at 7:35:00
In reply to a little progress (sort of), posted by g_g_g_unit on November 4, 2011, at 2:49:37
Hey GGG. did you get a chance to ask about an NARI (reboxetine, nortriptyline) ?
(excuse typos, I've had about 7 gin and tonics tonight)
Posted by Phillipa on November 4, 2011, at 10:38:54
In reply to Re: a little progress (sort of), posted by jono_in_adelaide on November 4, 2011, at 7:35:00
I have to wonder why I don't even get side effects anymore nor any improvement. Just more knowing that more or less doesn't change how I feel. I also have dialogue now with this new guy who I dispise. No eye contact no nothing. But how does this doc see your behavior as spitting? I don't hear black and white thinking? So are you going to take the lexapro 20mg? Did you benefit from the lower dose in anyway do you feel? Phillipa
Posted by Phidippus on November 4, 2011, at 19:57:50
In reply to a little progress (sort of), posted by g_g_g_unit on November 4, 2011, at 2:49:37
>decided to take up his suggestions, i.e. >increasing the Lexapro to 20mg and switching out >Depakote for Zyprexa.
What are you treating?
> I suppose I'm still hesitant about being on an >AP,What is your hesitation? APs can be powerful adjunct treatment for a variety of mental illness.
>don't want to be termed non-compliant because I >have no concrete reasons for rejecting a trial.
What's the big deal about being termed 'non-compliant'. Its not going to go on your record.
>I've grown increasingly more terrified of giving >my own input regarding medication.Do you know why this is? I'm going to assume you have OCD and challenge you with the question, could it be the OCD that's causing this terror?
>(who I'll often have OCD-inspired mental >dialogues with when anxious)
What are these dialogues like?
>In the case of reporting side-effects, I'm >overcome by this terrifying feeling that I'm >being judged, that he thinks I'm crazy or >neurotic or just making stuff up.
Is there a possibility you may be confusing anxiety for perceived side effects?
>In the case of Lexapro, I said that it is >inspiring a "slight" (to ease the impact) >feeling of unreality.
Well, now, case in point-the feeling of 'unreality' could easily be attributed to anxiety about the medication.
Reading your post, I am surprised at the level of anxiety you have over medication and medication related issues. You really need to be more open with your psychiatrist about what your feeling on these drugs. If you open a dialogue with your doctor he may be better able to assuage the medicines impact on you. You need to let him know about your fears so he can educate you on the medication, tell you what to expect and confront you on your paranoia. There is nothing to fear in having a completely open relationship with your doctor. The biggest roadblock I see is your own anxiety, which may be fueling misperceptions.
Eric
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Posted by g_g_g_unit on November 5, 2011, at 7:37:55
In reply to Re: a little progress (sort of) » g_g_g_unit, posted by Phidippus on November 4, 2011, at 19:57:50
> >decided to take up his suggestions, i.e. >increasing the Lexapro to 20mg and switching out >Depakote for Zyprexa.
>
> What are you treating?inattentive ADD, OCD and Major Depression.
>
> > I suppose I'm still hesitant about being on an >AP,
>
> What is your hesitation? APs can be powerful adjunct treatment for a variety of mental illness.Two reasons: a) the fact that most meds I've tried so far have worsened my attention and I didn't think APs would be any different in that respect.
b) My depression is primarily characterized by anhedonia, amotivation, social withdrawal etc. and (correct me if I'm wrong) I figured APs would only worsen those symptoms .. the way Lexapro already has. Unfortunately, while stimulants are reasonably effective, they ratchet up my anxiety to unmanageable levels.
I'm aware then that the logical thing to do would be to combine an SSRI, AP and a stimulant but I was under the impression the former two might render the stimulant reasonably ineffective?
>
> >don't want to be termed non-compliant because I >have no concrete reasons for rejecting a trial.
>
> What's the big deal about being termed 'non-compliant'. Its not going to go on your record.
>
>
> >I've grown increasingly more terrified of giving >my own input regarding medication.
>
> Do you know why this is? I'm going to assume you have OCD and challenge you with the question, could it be the OCD that's causing this terror?Maybe. I didn't have the most stellar upbringing - I was never physically abused, but dissent really wasn't encouraged in my house. My dad was particularly liable to snap at me and it's left me terrified of dealing with male authority figures. When I ask myself "what's the worse that could happen?", I immediately leap to the thought that they might physically strike me (which is what would occasionally happen with my dad); I figure that's the OCD at work. But I'm also just very anxious around older males in general ..
>
> >(who I'll often have OCD-inspired mental >dialogues with when anxious)
>
> What are these dialogues like?Since I'm currently in psychotherapy with him, they usually just involve me spontaneously engaging with him in issues that have arisen that week, or elaborating on points from our last meeting.
>
> >In the case of reporting side-effects, I'm >overcome by this terrifying feeling that I'm >being judged, that he thinks I'm crazy or >neurotic or just making stuff up.
>
> Is there a possibility you may be confusing anxiety for perceived side effects?
>
> >In the case of Lexapro, I said that it is >inspiring a "slight" (to ease the impact) >feeling of unreality.
>
> Well, now, case in point-the feeling of 'unreality' could easily be attributed to anxiety about the medication.Maybe, but I haven't been feeling terribly preoccupied with Lexapro. In fact, 15mg has done quite a good job of quelling my anxiety (pending I stay away from stimulants), but I'm often struck by a vague, dreamlike sensation while on it. It is causing a lot of anhedonia and sleep disturbances and it's my understanding that both can contribute to DP/DR. I often notice that the sense of unreality dissipates when my anhedonia does (typically as a rebound effect of Ambien).
> Reading your post, I am surprised at the level of anxiety you have over medication and medication related issues. You really need to be more open with your psychiatrist about what your feeling on these drugs. If you open a dialogue with your doctor he may be better able to assuage the medicines impact on you. You need to let him know about your fears so he can educate you on the medication, tell you what to expect and confront you on your paranoia. There is nothing to fear in having a completely open relationship with your doctor. The biggest roadblock I see is your own anxiety, which may be fueling misperceptions.
>
> Eric
>Thanks. I'm surprised it's reached this point too, though it is my first ongoing relationship with an older male psychiatrist (I usually don't stick around long), which may be why these issues have all finally boiled up. The alienation brought on by immigration has also left me with a more concrete sense that "I don't count".
I have done my best to be open with my psychiatrist so far - in fact, our last session was quite an accomplishment. But I am overcome by the sense that I'm being judged, looked down upon, etc. which is fueled by his bouts of silence. By contrast, my GP will usually offer immediate sympathy in relation to a complaint. Maybe it is just a panacea, or mollycoddling, but I am extremely sensitive and I find those displays of warmth helpful.
Posted by g_g_g_unit on November 5, 2011, at 7:41:28
In reply to Re: a little progress (sort of), posted by jono_in_adelaide on November 4, 2011, at 7:35:00
> Hey GGG. did you get a chance to ask about an NARI (reboxetine, nortriptyline) ?
>
>
> (excuse typos, I've had about 7 gin and tonics tonight)Not yet. I figured I'd seen if the addition of Zyprexa helps control my stimulant-induced anxiety and then ask for an NRI trial based on the result.
Posted by Phidippus on November 5, 2011, at 18:15:45
In reply to Re: a little progress (sort of) » Phidippus, posted by g_g_g_unit on November 5, 2011, at 7:37:55
> inattentive ADD, OCD and Major Depression.
You have a spectacular chance to treat all three issues with three medications: an SSRI, Dextroamphetamine and an AAP. Treating the ADHD with a dextroamphetamine, Adderal or Vyvanse also helps to treat the OCD-dextroamphetamine has been studied as a treatment for OCD. The mainstay of the treatment of OCD will always be an SSRI or Clomipramine. At 20 mg, your Lexapro is on the low end for treating OCD properly. You really need about 40 mg. Now, because dopamine levels tend to be on the high side for people with OCD, augmenting SSRI treatment with an AAP is a logical step. Zyprexa is a good choice, I used it a while to great effect.
I'm treating ADHD/OCD/Bipolar NOS. I treat the ADHD with Vyvanse, which also diminishes my OCD. My main treatment for the OCD is Clomipramine and I augment it with Latuda. I take Lithium for the bipolar part of me and I also take Lyrica for chronic headaches and to augment my OCD treatment.
> Two reasons: a) the fact that most meds I've >tried so far have worsened my attention and I >didn't think APs would be any different in that >respect.
Have you trialed drugs long enough to see if cognitive effects might pass within weeks? APs can sap your attention, but it really depends on which ones. Zyprexa helped me to concentrate (remember, we're aiming to reduce the clutter OCD creates), Seroquel made me feel stoned, Abilify helped with my attention. Latuda so far has improved my cognition. Invega dimmed me a bit...
I guess I'm saying it takes time and trial to get on the right mix of medications.
> b) My depression is primarily characterized by >anhedonia, amotivation, social withdrawal etc. >and (correct me if I'm wrong) I figured APs >would only worsen those symptomsHow much of your OCD is mixed up in all that depression? What a terrible combo, trying to sort out the OCD thoughts from the depressive thinking. The right AP will calm the OCD thoughts and the depressive thinking. With the right balance of SSRI, an AP is not likely to cause worsening of symptoms.
> while stimulants are reasonably effective, they >ratchet up my anxiety to unmanageable levels.
I had the same problem with stimulants until I discovered Vyvanse. Have you tried it? I experience no anxiety on it.
Perhaps you'll need some Clonazepam or Lyrica for the anxiety.
>I was under the impression the former two might >render the stimulant reasonably ineffective?
This is not true. Most stimulants work on D1 receptors, where as most APs hit the D2 receptor. Stimulants also tend to alter glutamate levels in the prefrontal cortex, where most executive funtion is rendered. Most SSRIs compliment this action while APs don't touch it or are 5ht2c antagonists, which actually causes a release of dopamine in the prefrontal cortex as well.
> My dad was particularly liable to snap at me >and it's left me terrified of dealing with male >authority figures.Do you have a counselor? One who specializes in treating OCD?
> Since I'm currently in psychotherapy with him, >they usually just involve me spontaneously >engaging with him in issues that have arisen >>that week, or elaborating on points from our >last meeting.
I'm always calling my doctor to give him updates on how my meds are making me feel. Haha.
> Maybe, but I haven't been feeling terribly >preoccupied with Lexapro.
Why don't you try something else?
>But I am overcome by the sense that I'm being >judged, looked down upon, etc. which is fueled >by his bouts of silence.
This is clearly the OCD talking and you know it.
Eric
Posted by g_g_g_unit on November 7, 2011, at 6:38:10
In reply to Re: a little progress (sort of) » g_g_g_unit, posted by Phidippus on November 5, 2011, at 18:15:45
> > inattentive ADD, OCD and Major Depression.
>
> You have a spectacular chance to treat all three issues with three medications: an SSRI, Dextroamphetamine and an AAP. Treating the ADHD with a dextroamphetamine, Adderal or Vyvanse also helps to treat the OCD-dextroamphetamine has been studied as a treatment for OCD. The mainstay of the treatment of OCD will always be an SSRI or Clomipramine. At 20 mg, your Lexapro is on the low end for treating OCD properly. You really need about 40 mg. Now, because dopamine levels tend to be on the high side for people with OCD, augmenting SSRI treatment with an AAP is a logical step. Zyprexa is a good choice, I used it a while to great effect.Why did you stop taking Zyprexa?
>
> > Two reasons: a) the fact that most meds I've >tried so far have worsened my attention and I >didn't think APs would be any different in that >respect.
>
> Have you trialed drugs long enough to see if cognitive effects might pass within weeks? APs can sap your attention, but it really depends on which ones. Zyprexa helped me to concentrate (remember, we're aiming to reduce the clutter OCD creates), Seroquel made me feel stoned, Abilify helped with my attention. Latuda so far has improved my cognition. Invega dimmed me a bit...Well, I've been on Lexapro for 3+ months now and the attention-difficulties have persisted. I suppose that since attention is already so compromised in ADD, it takes very little to impair it further. You're right, though, that OCD is also a major focus-drainer.
> I guess I'm saying it takes time and trial to get on the right mix of medications.
>
> > b) My depression is primarily characterized by >anhedonia, amotivation, social withdrawal etc. >and (correct me if I'm wrong) I figured APs >would only worsen those symptoms
>
> How much of your OCD is mixed up in all that depression? What a terrible combo, trying to sort out the OCD thoughts from the depressive thinking. The right AP will calm the OCD thoughts and the depressive thinking. With the right balance of SSRI, an AP is not likely to cause worsening of symptoms.I have mainstay obsessive preoccupations which persist whether I'm depressed or not, but I find that while depressed, I become obsessively jealous of the fact that other people aren't mentally ill, which I guess accounts for that overlap you describe ..
>
> > while stimulants are reasonably effective, they >ratchet up my anxiety to unmanageable levels.
>
> I had the same problem with stimulants until I discovered Vyvanse. Have you tried it? I experience no anxiety on it.I'm in Australia. The only stimulants available here are Ritalin, Ritalin SR, Concerta, Dexamphetamine IR, Strattera and Reboxetine.
>
> Perhaps you'll need some Clonazepam or Lyrica for the anxiety.
>
> >I was under the impression the former two might >render the stimulant reasonably ineffective?
>
> This is not true. Most stimulants work on D1 receptors, where as most APs hit the D2 receptor. Stimulants also tend to alter glutamate levels in the prefrontal cortex, where most executive funtion is rendered. Most SSRIs compliment this action while APs don't touch it or are 5ht2c antagonists, which actually causes a release of dopamine in the prefrontal cortex as well.
>
> > My dad was particularly liable to snap at me >and it's left me terrified of dealing with male >authority figures.
>
> Do you have a counselor? One who specializes in treating OCD?Yeah I'm currently seeing a therapist who specializes in OCD.
>
> > Since I'm currently in psychotherapy with him, >they usually just involve me spontaneously >engaging with him in issues that have arisen >>that week, or elaborating on points from our >last meeting.
>
> I'm always calling my doctor to give him updates on how my meds are making me feel. Haha.
>
> > Maybe, but I haven't been feeling terribly >preoccupied with Lexapro.
>
> Why don't you try something else?Hmm, well, to date I've tried:
Prozac - too much anxiety/insomnia/akathisia
Zoloft - too much anxiety/worsened OCD
Luvox - pretty similar to Lexapro
Mirtazapine - dysphoria, severe anxiety
Clomipramine - anxiety/insomnia/weird movement problems
Nardil - helped depression, but caused insomnia .. possibly worth revisitingThere's not much else, other than Pristiq (my psych isn't really a fan of Effexor, other than as a last resort).
>
> >But I am overcome by the sense that I'm being >judged, looked down upon, etc. which is fueled >by his bouts of silence.
>
> This is clearly the OCD talking and you know it.
>
You know, I have to thank you for saying that. The past couple of days I've turned your words into a kind of catchphrase because I'm so prone to getting caught up in whether a problem is 'real' or OCD-based, to the point where I sometimes end up deluding myself.
Posted by Phidippus on November 8, 2011, at 20:47:42
In reply to Re: a little progress (sort of) » Phidippus, posted by g_g_g_unit on November 7, 2011, at 6:38:10
> Why did you stop taking Zyprexa?
In short, Diabetes. I became hyperglycemic on Zyprexa.
> Well, I've been on Lexapro for 3+ months now >and the attention-difficulties have persisted.
You've got so many things going on at once, it is really hard to pinpoint Lexapro as the cause of your innattention. ADHD, OCD and depression all confer difficulties with attention. To say its the Lexapro alone might be a bit presumptious.
> I become obsessively jealous of the fact that >other people aren't mentally ill
Interesting, as most people experience some kind of psychiatric problem some time in their lives.
> I'm in Australia. The only stimulants available >here are Ritalin, Ritalin SR, Concerta, >Dexamphetamine IR, Strattera and Reboxetine.
Have you tried Dexamphetamine?
>they usually just involve me spontaneously >engaging with him in issues that have arisen >>that week, or elaborating on points from our >last meeting.
Do you work on any exposures?
> Nardil - helped depression, but caused insomnia .. possibly worth revisiting
Its hard to find a good med to treat anxiety. Why not try Nardil again?
> There's not much else, other than Pristiq
Pristiq isn't bad...You might benefit from an SNRI. I take Viibryd and we're getting along famously.
>I'm so prone to getting caught up in whether a >problem is 'real' or OCD-based, to the point >where I sometimes end up deluding myself.That's the cool thing about OCD, you really can't delude yourself, just scare the crap out of yourself and stay painfully aware of what is and isn't reasonable, no matter how loud the OCD gets.
Don't be afraid of the anxiety.
Eric
Posted by g_g_g_unit on November 9, 2011, at 5:46:39
In reply to Re: a little progress (sort of) » g_g_g_unit, posted by Phidippus on November 8, 2011, at 20:47:42
> > Why did you stop taking Zyprexa?
>
> In short, Diabetes. I became hyperglycemic on Zyprexa.Hmm, yeah, diabetes is kind of a buzz kill ..
>> You've got so many things going on at once, it is really hard to pinpoint Lexapro as the cause of your innattention. ADHD, OCD and depression all confer difficulties with attention. To say its the Lexapro alone might be a bit presumptious.
No, sure. But when I presented with anxiety symptoms alone four years ago I was always prescribed SSRIs and found that they worsened my *baseline* attention; because I was so reliant on stress/anxiety in order to focus, SSRIs deprived me of that mechanism. I've always found reading, for example, really difficult on SSRIs .. I just get spacey and can't really process stuff. So I'm not blaming Lexapro for the attention-difficulties, but even in clearing up the depression, it doesn't really restore me to my ADD baseline.
>
> > I become obsessively jealous of the fact that >other people aren't mentally ill
>
> Interesting, as most people experience some kind of psychiatric problem some time in their lives.Sure, but I'd imagine most aren't afflicted to the extent that you (presumably) and I and the rest of the posters here are .. otherwise society would probably collapse =)
>
> > I'm in Australia. The only stimulants available >here are Ritalin, Ritalin SR, Concerta, >Dexamphetamine IR, Strattera and Reboxetine.
>
> Have you tried Dexamphetamine?Yeah, it makes me really anxious :/
>
> Do you work on any exposures?I tried in the past with my previous therapist, but I took on too much at once I think and just became overwhelmed. I find I can grasp OCD on an intellectual level, but that the principles of treatment just never really click for me, so I just end up obsessing over why I'm doing exposures. I'm currently working on cognitive restructuring (there's an excellent book I was recommended called GETTING OVER OCD by JONATHAN S. ABRAMOWITZ, if you're interested) and examining my erroneous beliefs etc. in the hope that I'll be more prepared for ERP this time.
>
> > Nardil - helped depression, but caused insomnia .. possibly worth revisiting
>
> Its hard to find a good med to treat anxiety. Why not try Nardil again?I might, yeah. The only problem is that my doctor wouldn't prescribe a stimulant with it, so I'd have to give up on treating my ADD. What's kept you away from MAOIs?
>
> > There's not much else, other than Pristiq
>
> Pristiq isn't bad...You might benefit from an SNRI. I take Viibryd and we're getting along famously.So you dumped Clomipramine?
>
> That's the cool thing about OCD, you really can't delude yourself, just scare the crap out of yourself and stay painfully aware of what is and isn't reasonable, no matter how loud the OCD gets.
>
> Don't be afraid of the anxiety.
>
> Eric
>
>
Posted by Brainbeard on November 12, 2011, at 16:27:05
In reply to Re: a little progress (sort of) » Phidippus, posted by g_g_g_unit on November 9, 2011, at 5:46:39
This is the end of the thread.
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