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Re: An update tensor

Posted by SLS on February 17, 2023, at 21:25:04

In reply to Re: An update SLS, posted by tensor on February 17, 2023, at 4:28:18

Hi, Tensor.

> > Nardil (phenelzine), an irreversible monoamine oxidase inhibitor (MAOI). It is perhaps the best treatment available for social anxiety / phobia. It is also effective to various degrees to treat GAD, Panic Disorder, and OCD.
> >
> > Would you describe your anxiety as being the result of social phobia or social anxiety? If not, under what circumstances do you experience anxiety?
> >
> > Some people use propranolol as a PRN to be taken before being exposed to an anxiety-provoking situation. It is sometimes used by people who engage in public speaking.
> >
> > Which benzodiazepines have you tried? Your doctor is absolutely right with the way he portrays Lyrica (pregabalin). My experience with it was pretty bad. After my first few doses, it made me feel less depressed and somewhat calmer. However, after a few more days, I felt dysphoric and smothered by severe brain fog. I became numb to the world around me. After discontinuing Lyrica, it took three weeks for these mental aberrations to dissipate. The drug is unpredictable. I am going to suggest another unpredictable drug - Gabitril (tiagabine). Gabitril is a GABA reuptake inhibitor - the only drug of its type available. GABA is the most ubiquitous inhibitory neurotransmitter found in the brain, and offsets overactivity - anxiety. Some people report a positive outcome with Gabitril. However, it can also produce what is likely to be a disinhibition phenomenon that manifests as anger, irritability, agitation, hostility, and rage. Given your dwindling alternatives, I think Gabitril is worth a try. If you react badly to it, you will know quickly.
> >
> > - Scott

> Hi Scott! Always nice to see a reply from you!

You have no idea how good your timing is to say that.

> I have tried Parnate which worked for my depression and also had anxiolytic properties, esp for panic. That first golden week is possibly the closest I have been feeling "normal". But dose escalation and afternoon crashes rendered it useless over time. I have thought about Nardil and it's likely the most efficacious med out there for anxiety. However, MAOIs tend to lose efficacy over time and they are not without s/e. It's an option that remains on the table though.

I would say that MAOIs can stop working, but not nearly as often as SSRI do - "SSRI poop-out". In my estimation, Nardil is more likely to stop working than Parnate. However, there are plenty of people who continue to respond to Nardil for decades, or indefinitely. I'm into my third year of remission with the addition of Nardil to my treatment regime. I'll give some thought as to what you can do pharmacologically to help lower the risk of relapse while taking Nardil.

One absolutely crucial non-pharmacological treatment that will both make one more likely to respond to a medication and less likely to relapse while taking it is to REDUCE STRESS ON THE BRAIN. Most people are born with a brain that is mostly resilient to physiological stress. The grief that comes with the loss of a loved one does not usually precipitate a prolonged mental illness. One must be pre-disposed to a mental illness in order for normal challenges and psychosocial stress to trigger it. Brain function becomes persistently altered, although not always irreversibly. The dynamics of one's internal psyche is as much responsible for the severity of the stress placed on the brain as are the challenges encountered in the external environment. Given the same challenge, three people might demonstrate three different reactions, depending on how their psyche interprets the challenge. One gets happy. One gets sad. One gets anxious. This is the domain of psychotherapy.

1. Reduce psychosocial stress = Increases the probability of a treatment response.

2. Reduce psychosocial stress = Reduces the risk of a relapse.

* Tip: A trick that the first two generations of psychopharmacologists used when a patient relapsed while taking Nardil was to discontinue it temporarily - a "drug holiday" for a minimum of three months. Upon restarting Nardil, an antidepressant response can be "recaptured".

> What makes me anxious about being away from home most likely (if not certainly) stems from panic disorder, I remember having panic attacks as a kid. Felt like I couldn't breathe and thought I was going to die and also had vertigo. Never told anyone, just kept it to myself, with the "logic" being, don't want doctors to find something is wrong with me, didn't know about panic disorder and thought it was something physiological and dangerous.
> I regret this, it could have saved me from a lot of pain growing up. My social phobia, which appeared when I hit puberty, is still kept under control with clonazepam, I will never speak in front of people but I have no problems going to the grocery store for instance. In my late teens my SP was so bad I couldn't sit in a class room, clonazepam really fixed this. It's interesting and intriguing that other benzos were virtually useless for this (of the ones I have tried).
> I do use propranolol, it's in my arsenal :)
> I have tried at least :
> oxazepam
> diazepam
> alprazolam
> lorazepam (Ok, IV after surgery so doesn't really count)
> chlordiazepoxide
> clonazepam
> temazepam
> nitrazepam for sleep
> (zopiclone, zolpidem)
> I must be one of quite few people that prefer 30mg of oxazepam over diazepam and Xanax. I have a slight paradoxical effect from latter two. Some residual (or added?) anxiety that I don't feel on oxazepam or clonazepam. Maybe they are slightly activating? IIRC Xanax does something to NE.
> Sorry to see you had a bad experience with Lyrica, it's really unpredictable as you said. I have read about people taking it for SP and GAD and had a really difficult time coming off it, one person had withdrawals for nine months. It's a shame it's such a poison (as my doc called it), its anxiolytic properties for me are great short-term. With short-term being the keyword here.
> When I talked to my pdoc yesterday, she said she would arrange for me so that I could get a second opinion (more like 14th, but anyway) from another senior psychiatrist that I haven't met before. Will bring up Gabitril with him for sure, thanks for the tip. Could Trileptal be useful?

- Trileptal: A "cleaner" version of Tegretol. It is not sedating the way Tegretol is and does not have the propensity to produce agranulocytosis. I don't know that it helps with a true anxiety disorder, but I haven't researched it. I would definitely look at any untried treatment as being a potential miracle. I liked Trileptal. I found it to be clean and somewhat energizing. If Trileptal were to work, it wouldn't be because it acts as a sedative or an anxiolytic. It would be because it helped to remodulate dyregulated systems upstream. It has the potential to produce hyponatremia as a side effect. It is not common, though. Unlike Tegretol, Trileptal can be combined with Lamictal without affecting each other's metabolism.

- Depakote: Has a mild anxiolytic effect in addition to its anticonvulsant, anti-manic, and mood stabilizing properties. It acts to increase GABA neurotransmission by blocking sodium channels. GABA inhibits and dampens excitatory tracts, and can reduce anxiety. I would use the word "smoothing" to describe how Depakite affected me. This smoothing effect always remained in the background, regardless of how it altered my mood and cognition. Depakote wouldn't be my first choice, but I wouldn't want to dissuade you from trying it. It might be your miracle.

- Lamictal: Is most often recommended to treat bipolar depression. I have a vague recollection that the rate of response to Lamictal was higher for bipolar depression than to unipolar depression. You'd have to check me on that. For depression, most people respond to 200 mg/day. For me, 300 mg/day is ideal.

> So there may still be changes done to my regime before this is all said and done. My current psychiatric regime is:
> fluoxetine 60mg for depression and anxiety
> clonazepam 2mg (will increase to 3 or 4mg for traveling) for SP, also GAD.
> mirtazapine 7.5mg + nortriptyline 25mg, these two mainly to offset sexual s/e.
> melatonin 5mg for sleep


Nardil - 90 mg/day
Nortriptyine - 100 mg/day
Lamictal - 300 mg/day
Lithium - 300 mg/day

Good luck.

- Scott

Some see things as they are and ask why.
I dream of things that never were and ask why not.

The only thing necessary for the triumph of evil is that good men do nothing.




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