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Discussion Starter · #1 ·
Sorry in advance for making this a book rather a forum post.

Okay, current diagnoses (by doctors - not self-diagnosed) include social phobia, generalized anxiety disorder, major depression, panic disorder, and avoidant personality disorder. My psychiatrist and I agree for the most part that a mix of the social phobia and anxiety are pretty much the foundation of all my problems.

Doing a bit of reflecting lately, and I'm pretty sure I have inattentive ADHD. I think growing up as a kid in a gifted class, with the same group of kids every single year, might have contributed to my social phobia because it's very difficult to fit in with a group of kids like that when everybody is super-focused and devoted to their schoolwork and you're the odd one out.

I've been seeing my psychiatrist for almost a year now. Before I started seeing her, my GP had me on a daily dose of Lexapro and Wellbutrin, with a failed attempt at Effexor. The first two drugs I stayed on for a while... and although they didn't do much except that the wellbutrin helped my energy a bit, they weren't giving me any negative side effects.

My psychiatrist switched me off both to find something that works better (and worried that the wellbutrin would contribute to anxiety.) For anxiety/depression/sleep she's had me try the following (I may be forgetting some):

  • Zoloft (SSRI)
  • mirtazapine (tetracyclic)
  • trazodone (triazolopyridine anti-depressant)
  • seroquel (anti-psychotic)
  • zyprexa (anti-psychotic)
    [*]nortriptyline (tricyclic)
    [*]zopiclone (z drug)
    [*]klonopin (benzo)

The ones in bold are the ones I'm currently on. She's only recently put me on klonopin because I've suddenly started having much worse panic attacks.

The klonopin has been helpful, 2mg as needed. In some instances it doesn't seem to curb my anxiety at all, but in others I notice a big difference. I was able to successfully negotiate for a new car this weekend (for a family member... I've never had a job and have had to put university on hold because of my problems.) That was a huge achievement though because normally I'm a huge pushover and probably even trembling. Although like I said, it doesn't help ALL the time, and my mood and motivation are still rock bottom. So while I'm able to handle some situations better with the klonopin, I'm still pretty avoidant and find myself lacking the energy and the desire to do anything.

She wants me to try another anti-psychotic, risperdal, which I'd really rather not go through after trying seroquel and zyprexa. Most drugs I seem to be a bit insensitive to, but the anti-psychotics have had major effects on me, and I just feel dumb and restless on them. She also mentioned Cymbalta, which to my understanding is much like Effexor, with a slightly worse side effect profile, and Effexor was the only drug out of the bunch I had to stop taking after a week because the side effects were just horrible. I don't want to go through that again.

More importantly though, I feel now like we're just going in circles. Up until this point I've been pretty open to taking the new medications she's thrown at me. But now it seems like we're going back to the same old thing, and to me, that feels like she's given up on me. We've tried the conventional way of doing things for a while now, and it's obvious it's not really improving my situation.

So basically I'm wondering if anybody has some out-of-the-box solutions for this that I can discuss with my psychiatrist. As of now I've been thinking of suggesting modafinil to her, as it's somewhat of a stimulant and energy-boosting, but far less likely to drive my anxiety up than something like ritalin or adderall.

I should also mention that I've been doing CBT therapy for just as long now... and I find it helps me with anger and frustration, but when I'm anxious, particularly in a social situation, it's like my mind is too crowded to really take any control of my thoughts. When I'm anxious like this, it also makes it difficult to talk to people because I'm switched into a completely reactionary mode. If I'm asked a question that requires some thought, for example, it's pretty much impossible for me to give an answer that hasn't been previously thought out.

So yeah... like I said, I feel like she's kind of giving up on me now and I just don't feel like I'm able to take control of my own progress anymore. If anybody can add some insight to my situation it would be really appreciated.
 

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There are lots of other SSRI's you could try like fluoxetine, there's also monoamine oxidase inhbitiors like selegeline, tranylcypromine and phenelzine. Less conventional drugs aisde from dextroamphetamine would be opioids, barbiturates and GHB though a psychiatrist won't pescribe them for anxiety.
 

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Equilibrian Epicurius
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I recommend trying a nonselective MAOI like Nardil or Parnate next. They can be used to treat a wide range of psychological disorders, and are most likely the best single-drug option available for treating all the diagnoses you listed. The only downsides I can think of are the diet restrictions and potential (more like guaranteed) side effects, but from my experience with Nardil both were mild enough where I would take them in a heartbeat over having to deal with SA.
 

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I've been on Nardil (MAOI) for about 2 weeks. I already feel a pretty big difference. I wonder if you would have the same results? I have been on both Cymbalta and Effexor, and there is some fatigue with Nardil but, not as severe as with the SNRI's. Also, I haven't noticed any side effects from anything I've eaten.

Before getting on Nardil, I went off all meds for months. They put me on Klonopin a month ago and I haven't taken one for a few day now. I was in your same boat with the other stuff not working, so this was like a final "try". As I've taken the gamut of drugs out there...

I hope this helps :)
 

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Nortriptyline is a muscarinic antagonist, which could decrease intelligence, concentration, memory, and more -- pretty bad for ADD I'd say. This is a big reason why TCAs aren't used much any more. It is also a noradrenaline reuptake inhibitor (more strongly than serotonin), which could increase anxiety for the same reason Wellbutrin can. The favourable properties of nortriptyline in anxiety/depression can be obtained with an SNRI like duloxetine, without anywhere near as bad side-effects.

Zyprexa and Seroquel are antipsychotics, and should only be used for psychotic disorders unless in exceptional cases; they block dopamine receptors which is extremely bad for ADD and social anxiety, and may result in irreversible movement disorders (such as twitching), which anyone can see would be the last thing a SA patient needs. Do you suffer from paranoia or other symptoms of psychosis? If not, there are better tolerated agents available for sleep, anxiety, etc. If your psych wanted the serotonin 2 receptor effects of those antipsychotics, mirtazapine is clearly a better choice.

Zopiclone could be increasing your daytime anxiety & depression due to its short half-life. This is very common if it's used on a long-term basis, but probably not noticeable to you because of Klonopin.

Klonopin could be contributing to your ADD in a major way, as it's proven to negatively affect various functions of the brain for the duration of its effects, such as concentration, and is also linked to depression.

This is just the internet, and maybe there are reasons for the meds your psych chose (I am no expert), but really it sounds like he/she is completely ****ing clueless and just wasting your money. Your GP appears to have been going in a better direction.

If it was me, I'd definitely stop the nortriptyline and avoid antipsychotics. You could replace the serotonin effects of nortriptyline with an SSRI, or an SNRI if you wanted the noradrenaline, and lose a lot of the sides. Mirtazapine may also be useful in combination, and together could reduce the need for your current sleep (zopiclone) and anxiety (Klonopin) meds -- Klonopin isn't exactly ideal for someone with university prospects.
 

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provided the problem falls within the depression/anxiety disorder spectrum, then for sleep problems and/or antidepressant augmentation, mirtazapine or trazadone are probly a good place to start, much more preferable to say Nortriptyline or antipscyhotics, or Zopiclone.
 

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Discussion Starter · #9 ·
Nortriptyline is a muscarinic antagonist, which could decrease intelligence, concentration, memory, and more -- pretty bad for ADD I'd say. This is a big reason why TCAs aren't used much any more. It is also a noradrenaline reuptake inhibitor (more strongly than serotonin), which could increase anxiety for the same reason Wellbutrin can. The favourable properties of nortriptyline in anxiety/depression can be obtained with an SNRI like duloxetine, without anywhere near as bad side-effects.

Zyprexa and Seroquel are antipsychotics, and should only be used for psychotic disorders unless in exceptional cases; they block dopamine receptors which is extremely bad for ADD and social anxiety, and may result in irreversible movement disorders (such as twitching), which anyone can see would be the last thing a SA patient needs. Do you suffer from paranoia or other symptoms of psychosis? If not, there are better tolerated agents available for sleep, anxiety, etc. If your psych wanted the serotonin 2 receptor effects of those antipsychotics, mirtazapine is clearly a better choice.

Zopiclone could be increasing your daytime anxiety & depression due to its short half-life. This is very common if it's used on a long-term basis, but probably not noticeable to you because of Klonopin.

Klonopin could be contributing to your ADD in a major way, as it's proven to negatively affect various functions of the brain for the duration of its effects, such as concentration, and is also linked to depression.

This is just the internet, and maybe there are reasons for the meds your psych chose (I am no expert), but really it sounds like he/she is completely ****ing clueless and just wasting your money. Your GP appears to have been going in a better direction.

If it was me, I'd definitely stop the nortriptyline and avoid antipsychotics. You could replace the serotonin effects of nortriptyline with an SSRI, or an SNRI if you wanted the noradrenaline, and lose a lot of the sides. Mirtazapine may also be useful in combination, and together could reduce the need for your current sleep (zopiclone) and anxiety (Klonopin) meds -- Klonopin isn't exactly ideal for someone with university prospects.
I've already given mirtazapine AND trazodone a shot (both in combination with zoloft), and they only did 2 things for me: made me wake up feeling hung over, and gave me an endless appetite. I've been taking zopiclone for a while now, whereas the klonopin just recently, and haven't really noticed any rebound anxiety from the zopiclone. In fact, I've cut my dose in half from what I was originally taking so I don't think I've developed too much of a tolerance/dependence to it... yet. What I do know is that the zopiclone has given me the best quality sleep I've ever had, I find it easier to get out of bed in the morning than ever before, which used to be a huge problem for me. So far that's the only real progress I feel I've made.

You're right Klonopin isn't really ideal for my goal of going back to school. It helps with the anxiety but, while it doesn't sedate me, it does sometimes make it noticeably harder to focus. The antipsychotics are much much worse though in this regard though, and I have no idea how my psychiatrist thinks that's in any way compatible with my goals.

Going the benzo route was really a last resort choice for both of us, and while klonopin is doing only good things for me right now, I definitely agree it's not something I would ideally be going to school with. If a benzo is absolutely necessary (I don't know yet), although I realize it probably has the worst dependence issues, I think Xanax on an infrequent, as-needed basis would be better suited for me. Because it's shorter acting but potent, I'd be able to take it when I feel I need to, without losing the ability to focus for the rest of the day, like Klonopin seems to do. But... my psychiatrist says she doesn't ever prescribe it so it's a moot point anyways.

As for the nortriptyline, the only noticeable side effect for me is dry mouth. I also had pretty much no side effects with the SSRIs. But I haven't really seen any of the positive, intended effects either from any of the drugs.

Now that people are bringing up the idea of Nardil though, she actually mentioned that before when I brought up the possibility of an MAOI, and that was actually the plan for what I was going to take after tapering off from the zoloft, but instead she changed her mind and gave me a TCA. One with (I believe) particularly strong dopamine and noradrenaline reuptake inhibition as compared to its serotonergic effects, but I have always been under the impression that TCAs are particularly ineffective with stuff like social phobia, atypical depression, etc.

So I don't know. Last night I wrote her a 3 page letter re-examining my problems and why I felt the current direction of my treatment isn't going to lead to anything sustainable, even if it "works". I never seem to be able to communicate the way I'd like to, and anxiety usually pushes out any other thoughts from my head anyways, so I think putting it down on paper is probably my best bet. I think my inability to really express my problems, or even answer the most straightforward of her questions, has probably caused her to peg my situation as something very different from the way I see it.

I don't really blame her, but it's probably worth a shot. I guess I can also resurrect the idea of Nardil, although the dietary requirements seem very extreme for me. Honestly, reading the list of foods containing tyramine is nearly identical to reading a list of everything I like! But still, if there's a chance it might help me out, there's no question in my mind it's worth having to avoid all those foods.
 

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I've already given mirtazapine AND trazodone a shot (both in combination with zoloft), and they only did 2 things for me: made me wake up feeling hung over, and gave me an endless appetite.
Mirtazapine's sedative effects (including the "hangover") should mostly disappear after several weeks of treatment. I've been on mirtazapine for a while and it barely even sedates me at night any more, let alone the morning.

I've been taking zopiclone for a while now, whereas the klonopin just recently, and haven't really noticed any rebound anxiety from the zopiclone. In fact, I've cut my dose in half from what I was originally taking so I don't think I've developed too much of a tolerance/dependence to it... yet. What I do know is that the zopiclone has given me the best quality sleep I've ever had, I find it easier to get out of bed in the morning than ever before, which used to be a huge problem for me. So far that's the only real progress I feel I've made.
Hmm... It's important to note you're on Klonopin which acts on the same receptors as zopiclone (and lasts a lot longer), so it could be too soon to speak about tolerance -- Kpin will be suppressing any rebound/withdrawal in the daytime.

The only other thing I'd say about the two would be: if you plan to stop taking them, start doing it as soon as possible. The longer you use them, the harder withdrawal will be.

You're right Klonopin isn't really ideal for my goal of going back to school. It helps with the anxiety but, while it doesn't sedate me, it does sometimes make it noticeably harder to focus. The antipsychotics are much much worse though in this regard though, and I have no idea how my psychiatrist thinks that's in any way compatible with my goals.

Going the benzo route was really a last resort choice for both of us, and while klonopin is doing only good things for me right now, I definitely agree it's not something I would ideally be going to school with. If a benzo is absolutely necessary (I don't know yet), although I realize it probably has the worst dependence issues, I think Xanax on an infrequent, as-needed basis would be better suited for me. Because it's shorter acting but potent, I'd be able to take it when I feel I need to, without losing the ability to focus for the rest of the day, like Klonopin seems to do. But... my psychiatrist says she doesn't ever prescribe it so it's a moot point anyways.
Sounds like you know the score with benzos. What reason did your psych give for not prescribing Xanax? S/he shouldn't be avoiding it because of its bad reputation, when a clear indication is present for a short-acting benzo.

As for the nortriptyline, the only noticeable side effect for me is dry mouth. I also had pretty much no side effects with the SSRIs. But I haven't really seen any of the positive, intended effects either from any of the drugs.
Some of the focus problems you attributed to the Kpin may be at least in part caused by the nortriptyline. I guess it depends on dosage though.

Now that people are bringing up the idea of Nardil though, she actually mentioned that before when I brought up the possibility of an MAOI, and that was actually the plan for what I was going to take after tapering off from the zoloft, but instead she changed her mind and gave me a TCA. One with (I believe) particularly strong dopamine and noradrenaline reuptake inhibition as compared to its serotonergic effects, but I have always been under the impression that TCAs are particularly ineffective with stuff like social phobia, atypical depression, etc.
I don't think nortriptyline has any significant effect on dopamine whatsoever. It's primarily a noradrenaline reuptake inhibitor, with weaker effects on serotonin (and is an anticholinergic).
 

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Discussion Starter · #11 ·
Mirtazapine's sedative effects (including the "hangover") should mostly disappear after several weeks of treatment. I've been on mirtazapine for a while and it barely even sedates me at night any more, let alone the morning.
I was on it for about two months, wasn't helping anything :(

Hmm... It's important to note you're on Klonopin which acts on the same receptors as zopiclone (and lasts a lot longer), so it could be too soon to speak about tolerance -- Kpin will be suppressing any rebound/withdrawal in the daytime.
I've been on klonopin maybe 3 weeks now, and zopiclone for over 4 months, so I think I would have noticed it before. Besides, I'm taking the klonopin PRN, often 3-4 days apart, so even now I should be noticing something.

The only other thing I'd say about the two would be: if you plan to stop taking them, start doing it as soon as possible. The longer you use them, the harder withdrawal will be.
That's the plan...

Sounds like you know the score with benzos. What reason did your psych give for not prescribing Xanax? S/he shouldn't be avoiding it because of its bad reputation, when a clear indication is present for a short-acting benzo.
She said she never prescribes it because the dependence and withdrawal issues can be a lot more severe. She also said the same thing about diazepam though which I found a little odd.

Some of the focus problems you attributed to the Kpin may be at least in part caused by the nortriptyline. I guess it depends on dosage though.
I'm on a fairly high dose of nortriptyline, 150 milligrams, and I've been on it for I think at least 3 months now. Like I mentioned before though, the klonopin has only been for 3 weeks. And also like mentioned before, I only take the klonopin as needed, not on a regular schedule (which is what she originally wanted me on) so it's pretty easy for me to tell that I'm having focus issues because of the acute effects of the klonopin. I've seemed to tolerate the nortriptyline okay, but then again it isn't really helping me either.

I don't think nortriptyline has any significant effect on dopamine whatsoever. It's primarily a noradrenaline reuptake inhibitor, with weaker effects on serotonin (and is an anticholinergic).
You may be right. Looking back it seems to me now that she's actually avoided dopaminergic drugs, even pulling me off the Wellbutrin, because she thinks it would contribute to my anxiety. And yet the more I look into people who are successfully treating social phobia (even without ADHD), dopamine boosting or stimulant drugs seem to play a key role. I don't know if modafinil fits the bill exactly, but having been in university a bit I'm no stranger to prescription stimulants, and for the most part I didn't handle them well.

But I've definitely got a lot to chat with her about. Thanks for the help.
 

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You dont need to write off Nardil because of the side effects you read "it" could cause. The side effects do look ugly when looking at them. Everybody is different though, and you should atleast try it and if the negatives outweigh the positives over a good length of time quit it. I suffer just minimal side effects from Nardil.
 

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Discussion Starter · #13 ·
I haven't written it off, it's definitely something to discuss. I'm really starting to buy this whole dopamine thing though (explains why I'm afraid to do pretty much anything... my reward system is fried). I think that's still compatible with the idea of taking an MAOI though, as to my knowledge they are pretty non-selective inhibitors.

Only problem though is, the amount of time that an MAOI takes to try. I've got to taper off of what I'm already on, then once I've tapered completely it's what... two weeks before I can start the MAOI? And then probably another 2 months to determine it's not working.

I just... don't know. I really don't know how much time I'm working with when the days just constantly seem to get gloomier and gloomier and I feel increasingly helpless and hopeless.
 

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The Klonopin can help during the tapering processes. I know it sucks but you've got to be patient with most of these meds. In the grand scheme of things what is 3-4 months if you find an effective medication combo? I've been where you are emotionally and it sucks but don't give up hope, it can feel impossible at times but you've got to keep pressing on. I'd give Nardil a shot if I were you.
 

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The possible reward at the end of your struggles is the best single medication for your SA. But its hard to tell you to tell you to keep taking it as i didnt have to deal with what your going through.
 

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Sounds like your psychiatrist loves to prescribe anti-psychotics. They're really kind of only good for psychotic disorders (duh) and making you really tired (that's what they were originally discovered for, they were medical anesthetics for surgery).
Try an SSRI or MAOI. Some might not work, but others can have that "miracle drug" effect. You might as well try.
 

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Don't want to sound like a broken record on these boards, ......but I completely got rid of my SA, GAD, OCD with Effexor XR and Clonazepam.

But as previous people have said, stick in there mate, .....I've been there. Once I found the right drug cocktail it was like a miracle.

I could write a list of all the meds I've tried, but I think you get the picture.

Hope you get things sorted mate.
 
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