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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by g_g_g_unit on January 26, 2012, at 5:36:19
Sorry for posting again (I've probably expounded on this in the past anyway), but I was inspired to write after reading a thread a little further up about difficulty tolerating serotonergic meds.
I've been noticing something strange. While on Lexapro, if I slept 7 hours or less, I would feel really wired and anxious, like I was overdosing on adrenaline; if I slept more than 7 hours, I'd feel depressed and foggy. On 20mg, I never experienced any substantial relief from suicidal thoughts, depression or irritability.
I've noticed that anything that acts on noradrenaline will have an undesirable effect. clomipramine made me feel totally wired and agitated; same with Strattera, Ritalin and also Dexedrine (when I wasn't sleepy and dazed on it).
Technically I have inattentive ADD, but anything that acts on noradrenaline will just have the tendency to make my mind feel way too constricted and weird to actually focus and concentrate. I can read, sort of, because I'm more alert, but my mind just feels too 'boxed in' to really process stuff.
The only thing I ever recall actually improving my focus in an uncomplicated fashion was low-dose Prozac (10mg), which I'm aware will act on the prefrontal cortex via 5-ht2c antagonism. However, I tried it before I was diagnosed with ADD, so I can't recall the *exact* extent of its benefits, but there were definitely some from memory. Same with low-dose nortriptyline - which I was prescribed for sleep prior to my ADD dx., but which proved too stimulating for that purpose .. though I did retrospectively notice improved ability to stick to a task, which has completely dissolved during depression.
Conversely, anything inhibitory - benzos, gabapentin - will technically help me 'focus' by shutting down ruminative thoughts, but they make my attention span 1000x worse and affect my reading comprehension, which is by far the most depressing aspect of my condition .. things were always difficult with ADD, but since become depressed 3 years ago, I've just been in this constant fog. Like I say, stimulants lift the fog, but don't actually help me read stuff like books.
I donno what's going on. Am I just really sensitive to stimulants/noradrenaline? Does it sound like bipolar+ADD?
I really wish I, or my pdoc, had some idea of what's going on. I mean, he's great, but it feels like we're just shooting in the dark at this point. I've stopped Lexapro in preparation to start Parnate next Friday, but now I'm getting hesitant .. I just can't waste more and more time on these trials that go nowhere.
Posted by SLS on January 26, 2012, at 16:03:14
In reply to Do these symptoms/reactions sound familiar?, posted by g_g_g_unit on January 26, 2012, at 5:36:19
What about using guanfacine for ADD and as an anti-noradrenalin drug - NE alpha-2 agonist?
- Scott
Posted by phidippus on January 26, 2012, at 19:51:25
In reply to Do these symptoms/reactions sound familiar?, posted by g_g_g_unit on January 26, 2012, at 5:36:19
I think your suicidal thoughts are part of the OCD. You don't seem suicidal.
How do you want to feel? Do you have a concept of what normal should feel like?
Eric
Posted by g_g_g_unit on January 26, 2012, at 21:45:56
In reply to Re: Do these symptoms/reactions sound familiar? » g_g_g_unit, posted by phidippus on January 26, 2012, at 19:51:25
> I think your suicidal thoughts are part of the OCD. You don't seem suicidal.
Maybe you're right, but I do (or did) have a defined plan and did overdose once while on Lexapro as a cry-for-help. I suppose my behaviour is closer to nihilism in that - in the absence of any way to self-actualize - I refuse to engage with life at all.
> How do you want to feel? Do you have a concept of what normal should feel like?
Um, well, I would like my OCD to magically vanish, but that obviously isn't going to happen.
I would like to experience reward and a desire to engage with things, like I used to prior to depression. I would like to be able to think clearly. I would like to be able to read and concentrate and pay attention without feeling like I'm either viciously overstimulated or drowning in brain fog.
Posted by g_g_g_unit on January 26, 2012, at 21:47:34
In reply to Re: Do these symptoms/reactions sound familiar? » g_g_g_unit, posted by SLS on January 26, 2012, at 16:03:14
> What about using guanfacine for ADD and as an anti-noradrenalin drug - NE alpha-2 agonist?
>
>
> - ScottUnfortunately, guanfacine isn't available in Austraia .. only clonidine.
Posted by SLS on January 27, 2012, at 6:27:50
In reply to Re: Do these symptoms/reactions sound familiar? » SLS, posted by g_g_g_unit on January 26, 2012, at 21:47:34
> > What about using guanfacine for ADD and as an anti-noradrenalin drug - NE alpha-2 agonist?
> >
> >
> > - Scott
>
> Unfortunately, guanfacine isn't available in Austraia .. only clonidine.
Well, you certainly know your stuff. I'll be very interested to know what you come up with.Check out prazosin as an anti-noradrenergic. It was developed as an antihypertensive that has shown efficacy in PTSD and may also exert therapeutic effects for ADHD as monotherapy. Adding a stimulant to prazosin actually reduces its efficacy.
I am currently experiencing an improvement in bipolar depression by adding prazosin to my treatment regime.
- Scott
------------------------------http://www.medscape.org/viewarticle/457175
* [There is a typographical error: Prazosin is a alpha-1 antagonist, not a alpha-1 agonist].
Prazosin
Taylor Fletcher, MD[3] conducted a clinical trial of prazosin in order to explore the role of norepinephrine in the pathophysiology of ADHD and the potential mechanism of action of dextroamphetamine. Prazosin is an alpha-1 agonist. Stimulant medications operate through feedback loops that have secondary effects on both alpha-1 and alpha-2 receptors. Alpha-1 receptor activity has been shown to alter activity in the prefrontal cortex, an area of the brain involved in planning and organization. The authors conducted a double-blind, placebo controlled study with 16 adults with ADHD. Nine of the adults were receiving d-amphetamine and 7 were not. Prazosin used alone was effective in reducing ADHD symptoms. However, when prazosin was given to adults who were also taking dextroamphetamine, there appeared to be a negative interaction, implying that the prazosin actually interfered with the stimulant effect. This study suggests that noradrenergic alpha-1 receptor activity may be important in the pathophysiology of ADHD and the mechanism of action of d-amphetamine medication.
-------------------------------
http://www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/2006/september/director-report.pdfBlood Pressure Medication Relieves Daytime PTSD Symptoms
Current treatments for post-traumatic stress disorder (PTSD) are reported to be only minimally effective in reducing both nighttime and daytime re-experiencing and intrusion symptoms; many people with PTSD self-medicate with drugs or alcohol. Recent studies have demonstrated that prazosin (Minipress), a generically available alpha-1 adrenergic antagonist, can reduced night time PTSD symptoms.
A new study by Fletcher B. Taylor, of the Veteran
Health Care System and University of Washington, and colleagues suggests that daytime administration of prazosin also may bring relief from anxiety, nervousness, and fear. The results suggest that daytime administration will not interfere with routine daytime tasks and skills, indicating that prazosin may be an effective addition to current treatments. Taylor FB, Lowe K, Thompson C, McFall MM, Peskind ER, Kanter ED, Allison N, Williams J, Martin P, Raskind MADaytime prazosin reduces psychological distress to trauma specific cues in civilian trauma posttraumatic stress disorder. Biol Psychiatry. 2006 Apr 1;59(7):577-81.
Posted by SLS on January 27, 2012, at 6:43:03
In reply to Re: Do these symptoms/reactions sound familiar? » g_g_g_unit, posted by phidippus on January 26, 2012, at 19:51:25
> I think your suicidal thoughts are part of the OCD. You don't seem suicidal.
>
> How do you want to feel? Do you have a concept of what normal should feel like?Good question.
How do you separate out OCD versus the ruminations that often occur with depressive disorders?
- Scott
Posted by phidippus on January 27, 2012, at 18:19:44
In reply to Re: Do these symptoms/reactions sound familiar? » phidippus, posted by SLS on January 27, 2012, at 6:43:03
>How do you separate out OCD versus the ruminations >that often occur with depressive disorders?
Thinking in OCD involves a lot of self-testing, with negative thoughts being weighed in a 'what if?' manner.
For instance, when I have OCD driven suicidal ideations, I am more apt to argue with myself about the thoughts, then draw a conclusion that I want to kill myself.
Depressive thinking on suicide is often dependent on low self-esteem and negative thinking, with no real arguing about the thinking. Simply put, depressive thinking is merely 'life sucks, I suck, I should kill myself'. I'm simplifying, but I think I'm getting my point across.
Eric
Posted by phidippus on January 27, 2012, at 18:23:21
In reply to Re: Do these symptoms/reactions sound familiar? » g_g_g_unit, posted by SLS on January 27, 2012, at 6:27:50
>I am currently experiencing an improvement in >bipolar depression by adding prazosin to my >treatment regime.
Interestng, I experienced a similar lift when I was taking Prazosin.
Prazosin raises dopamine levels in the prefrontal cortex and reduces dopamine transmission in the nucleus accumbems. I wonder if the raised dopamine in the prefrontal cortex may account for the improvement in affect.
Eric
Posted by phidippus on January 27, 2012, at 18:31:49
In reply to Re: Do these symptoms/reactions sound familiar? » phidippus, posted by g_g_g_unit on January 26, 2012, at 21:45:56
>I would like to experience reward and a desire to >engage with things, like I used to prior to >depression. I would like to be able to think >clearly. I would like to be able to read and >concentrate and pay attention without feeling like >I'm either viciously overstimulated or drowning in >brain fog.
I am certain that the severity of your OCD is probably causing problems in all areas of concentration, focus, mood and motivation.
Once you gain control of the OCD, you will be able to concentrate better without all the mental static and intrusive and recurrent thoughts.
You are overwhelmed by anxiety and can't think straight, I believe.
Eric
Posted by g_g_g_unit on January 28, 2012, at 5:41:43
In reply to Re: Do these symptoms/reactions sound familiar? » g_g_g_unit, posted by phidippus on January 27, 2012, at 18:31:49
Hmm. I find your stipulation kind of reductive. Yes, there can be little doubt that OCD is affecting all of the aforementioned areas, but that still doesn't explain why my cognitive problems are proving so difficult to resolve, which was the point of my post.
I was speaking to Dr Ken Gillman earlier, and told him that psychiatrists who refuse to treat me for ADD will always claim that anxiety is the root of my concentration problems. But when I am treated for anxiety, it fails to improve my attention span, reading comprehension etc. His reply was that "anxiety obviously isn't the sole cause of your attention problems. Simple as that."
I have experienced a meaningful reduction in anxiety/OCD on drugs like benzos, SSRIs and anti-convulsants. But they either fail to improve my attention or make it worse. Adding a stimulant, however, just results in the symptoms of "noradrenaline overdose" I describe.
I was "overwhelmed with anxiety and OCD" since 19, but still managed to think straight enough to finish college and embark on a vaguely successful career as a writer.
Your hypothesis would make sense if anxiolytics brought me anywhere back to a functional state, but they don't.
> I am certain that the severity of your OCD is probably causing problems in all areas of concentration, focus, mood and motivation.
>
> Once you gain control of the OCD, you will be able to concentrate better without all the mental static and intrusive and recurrent thoughts.
>
> You are overwhelmed by anxiety and can't think straight, I believe.
>
> Eric
Posted by SLS on January 28, 2012, at 6:18:44
In reply to Re: Do these symptoms/reactions sound familiar? » phidippus, posted by g_g_g_unit on January 28, 2012, at 5:41:43
> Yes, there can be little doubt that OCD is affecting all of the aforementioned areas, but that still doesn't explain why my cognitive problems are proving so difficult to resolve, which was the point of my post.
What do you experience that indicates to doctors that you have OCD?
If you have not done so already, you might want to compare and contrast OCD to ruminating in depressive disorder. Ruminating can even occur in the absence of depression.
Is there any chance that your medication is producing cognitive impairments? Lamictal at dosages above 200 mg kicked my butt.
Speaking only for myself, my cognitive impairments are so profound that they can be considered a form of dementia (non-Alzheimers). These impairments dissipate when my depression improves. As one ages with major depressive disorder, cognitive effects can become more prominent than depressed mood such that the term "pseudodementia" was coined to describe the common mistake made of misdiagnosing MDD as being Alzheimers Dementia.
- Scott
Posted by g_g_g_unit on January 28, 2012, at 6:38:26
In reply to Re: Do these symptoms/reactions sound familiar? » g_g_g_unit, posted by SLS on January 28, 2012, at 6:18:44
>
> What do you experience that indicates to doctors that you have OCD?I would prefer not to go into too much detail, but the presence of OCD is an indisputable aspect of my condition and has been diagnosed by multiple OCD specialists. Typically, I experience intrusive thoughts (e.g. being accountable for my parents' death) or sensations (such as fixating on my breath), which will provoke avoidance/reassurance-seeking strategies.
>
> If you have not done so already, you might want to compare and contrast OCD to ruminating in depressive disorder. Ruminating can even occur in the absence of depression.
>
> Is there any chance that your medication is producing cognitive impairments? Lamictal at dosages above 200 mg kicked my butt.It was easier to determine what was doing what prior to depression. When I just had OCD+ADD symptoms, SSRIs would reliably diminish my concentration, alertness and reading comprehension. Discontinuing them would always allow me to return to a baseline where I was highly anxious but more functional than on medication. Stress has played a huge factor in my illness - I find it improves alertness and motivation, which my psychiatrist said would be consistent with catecholamine release.
Now, since my attention etc. is so bad, I find SSRIs neither improve it nor diminish it.
>
> Speaking only for myself, my cognitive impairments are so profound that they can be considered a form of dementia (non-Alzheimers). These impairments dissipate when my depression improves. As one ages with major depressive disorder, cognitive effects can become more prominent than depressed mood such that the term "pseudodementia" was coined to describe the common mistake made of misdiagnosing MDD as being Alzheimers Dementia.
>
I'm really sorry to hear that. I don't think I'm quite at that stage .. I'm typically struck by mental and physical anergia, which, like I say, will improve with stimulating agents, but I just can't seem to reap any kind of consistent or stable effect.Anyway, I wonder if I'm just highly sensitive to noradrenaline-effecting drugs.
Posted by SLS on January 28, 2012, at 11:44:34
In reply to Re: Do these symptoms/reactions sound familiar? » SLS, posted by g_g_g_unit on January 28, 2012, at 6:38:26
> Anyway, I wonder if I'm just highly sensitive to noradrenaline-effecting drugs.
I don't know how well targeted it would be for your illness, but propranalol might make a good drug to test your theory.This would make an interesing antiadrenergic cocktail:
clonidine
propranalol
prazosin
Also worth a look for anxiety and ADHD:mecamylamine (Inversine) - ACh nicotinic receptor antagonist.
Of course, reserpine would deplete stores of NE.
- Scott
Posted by phidippus on January 28, 2012, at 16:06:29
In reply to Re: Do these symptoms/reactions sound familiar? » phidippus, posted by g_g_g_unit on January 28, 2012, at 5:41:43
>still doesn't explain why my cognitive problems >are proving so difficult to resolve
Again, I think the OCD is 'clouding' your thinking. I know I can't concentrate under a barrage of intrusive and recurrent thoughts and endless rumination.
Trying to treat your ADHD with rampant OCD is going to be difficult simply because one cannot weed out which of the two is causing concentration problems. You need to get the OCD under control then assess the remainder of your attention problems.
Hopefully the parnate will help with the OCD and be more effective then tthe SSRIs you have been treated with. Just keep in mind MAOIs are not well studied in the treatment of OCD.
Concentrate on getting your OCD under control, then tackle the attention difficulties.
Eric
This is the end of the thread.
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