Question:
Dear Doctor,
A brief history: depression, suicidal
thoughts, anxiety by age of 15. First
suicide attempt: 16. In and out of
hospitals a lot until my twenties. I
seemed to get by in my twenties, but
had chronic masturbation to ease
anxiety, and lots of depression, crying
spells, and two day sleeping
marathons. I went on Paxil when I was
34. I'm now 44. I seemed to be
surviving. I could work, but that was
all. Spent most weekends sleeping.
When I got laid off three years ago, I
isolated myself, and it led to a drug
overdose. I was put on Effexor 300 mg.
I spent the last three years yo-yo' ing
between Paxil 60 mg. and Effexor
150-300 mg. I am in a wonderful
relationship, but now I cannot seem to
hold down a job. I get anxiety attacks
or rage, and I end up bolting. Since
finding your website, I took a list of
meds. to my doctor.
He put me on Prozac 40mg., Tegretol 200
meg., and Risperdal .25 mg. The
problems I am having seem to have
started with the Prozac. I was so itchy
I couldn't sleep and very hyper, but I
felt mentally good. I decided to take
the Risperdal daily, and then I slept
whole days away. Right now I'm awake,
but tired, yet hyper, if that's
possible. Do you have any suggestions
on the meds? I have a doctors'
appointment in a week. Desperately
seeking a middle ground.
Answers to screening test:
* Are you nervous more than you're not?
* Do you always feel scared?
* Does your mind never shut off, and has been that way
since you were a child?
* Did Prozac make you feel very hyper and/or ill?
(Generalized Anxiety Disorder - GAD)
A huge yes to all, especially the third one. It
takes hours to fall asleep because as
soon as I lay down, my brain decides to
wake up. On the Prozac, I am more
anxious, sweaty, and itching all over
when I try to sleep. I stayed up until
noon yesterday. Going to my doctor
today.
Dr. Heller's Answer:
If the borderline personality disorder
(BPD) is present, it sounds a lot like
the BPD made worse by SSRI'S. It's
unfortunately common, and complicates
BPD treatment as they are usually
intolerant of increased anxiety.
The cognitive GAD (genetic worry) is a
genetically heightened serotonin 1A
receptor. Individuals with this
diagnosis are "cave guarders" -- their
ancestors would sit vigilantly outside
the cave all night looking for danger.
SSRI'S increase the activity of this
receptor, so the fear and vigilance
seem worse. To an individual with the
BPD, this makes the dysphoria (anxiety,
rage, depression and despair) much
worse. BuSpar (buspirone) is the key
medication here, as it effectively
shuts off the gene. It's a genetic
imbalance that is worsened by
stimulants and medications that raise
serotonin. Whether or not the BPD is
present, BuSpar (buspirone) remains
a safe medication to use for the
generalized anxiety disorder.
When I see a person with your story
I'll generally:
1) Skip the Prozac (fluoxetine) for a
day, then resume it at 20mg daily. The
Prozac dose can be adjusted later once
the individual is more level.
2) Begin Buspar (buspirone) 7.5mg (1/2
pill) twice daily for 7 days, then 15mg
twice daily. Take with food! Avoid
grapefruit juice!
3) Stop the Risperdal, since it
doesn't seem to work well chronically
for most BPD patients
4) Begin Zyprexa: 5-10mg nightly for
usually 6 nights. This will usually
stop the mind racing and anxiety, but
can cause significant weight gain.
5) Stop the Tegretol and resume it a
week later, although usually a higher
dose because BPD patients with chronic
dysphoria (anxiety, rage, depression
and despair) usually do much better
when they take the Tegretol after being
off it for a week.
If PTSD (post traumatic stress
disorder) is present, the BuSpar
(buspirone) may worsen the symptoms. I
usually temporarily add Remeron
(mirtazapine) to the regimen in these
cases.
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