Withdrawal effects
How can I tell the difference between withdrawal problems and relapse?
There are three ways to tell if symptoms are the result of withdrawal, according to one expert, David Healy, who applied it to SSRIs in particular:
- The problems begin immediately after reducing or stopping the drug. (If the original problem has been treated, it should be some time before the symptoms come back, if ever.)
- The symptoms disappear if you go back on the drug, or raise the dose.
- You are experiencing new symptoms as well as some of those that were a feature of your original condition (flu-like symptoms as well as depression, for instance).
These are the kind of withdrawal effects you might encounter:
Minor tranquillisers
Benzodiazepine withdrawal symptoms include: anxiety, depression, panic, agoraphobia, confusion, perceptual disturbances and hallucinations, insomnia, nightmares, suicidal thoughts, memory problems, cold sweats, heart palpitations, breathing problems, high blood pressure, stomach ulcers, nausea, loss of appetite, weight loss, nose bleeds, tremor, muscle spasms, tinnitus, light-headedness, dizziness, detachment, feeling poisoned.
Antidepressants
Withdrawal symptoms for tricyclic antidepressants include:
excessive anxiety, restlessness, hyperactivity, insomnia, disturbing dreams and nightmares, flu-like symptoms (headache, sweating, diarrhoea, stomach ache, bowel discomfort, nausea, vomiting, hot and cold flushes, goosebumps), fast or irregular heart beat, low blood pressure, and increased libido. Psychiatric effects include hypomania and mania, apathy, social withdrawal, depressed mood, panic attacks, aggression, delirium and psychoses.
When describing the symptoms of withdrawal from SSRI antidepressants, David Healy breaks them down into two groups:
- Symptoms ‘unlike anything you have had before’
- Symptoms that ‘may lead you or your physician to think that all you have are features of your original problem’.
The first group include: dizziness (when you turn your head you feel your brain gets left behind); ‘electric head’ (strange brain sensations which have been likened to goose bumps in the brain); electric shock-like sensations, other strange tingling or painful sensations; nausea, diarrhoea and flatulence; headache; muscle spasms and tremor; agitated and vivid dreams; agitation; hearing or seeing things others can’t.
The second group include: mood swings; irritability; confusion; fatigue, malaise and flu-like symptoms; insomnia or drowsiness; sweating; feelings of unreality; disturbed temperature sensations; change in personality.
Many people taking SSRIs, especially paroxetine (Seroxat) and fluoxetine (Prozac), have reported uncharacteristic feelings of violence and suicidal thoughts and actions, and these seem to be particularly associated with changes in dose.
Withdrawal symptoms for Monoamine oxidase inhibitors (MAOIs) are less well known than for other antidepressants, because they are less commonly prescribed. There are conflicting reports on the frequency and severity of withdrawal problems. Reported symptoms include: anxiety, agitation, paranoia, being unusually talkative, headaches, low blood pressure when standing, muscle weakness, shivering and tingling, burning sensations, and mania. Catatonic states have also been reported.
Antipsychotics
Withdrawal psychosis and tardive dyskinesia are two of the most serious problems. (See p. 11, for more information.) There could also be other less severe but still unpleasant effects to contend with: flu-like effects (nausea, vomiting, diarrhoea, headaches, chills, sweating, runny nose); movement problems (involuntary twitches, muscle spasms and tics); psychological effects (insomnia, anxiety, agitation, irritability, and psychosis, including hallucinations, delusions, confusion and disorientation). The psychological effects may be little different from the symptoms of the original problem, and it may be very hard to know for certain which it is.
Neuroleptic malignant syndrome is a very serious condition, which some people have developed on drug withdrawal. It can also occur as a side effect of the drugs. It can be life-threatening and involves changes in consciousness, abnormal movements and fever. It is important to seek medical treatment immediately.
Mood stabilisers
Mood stabilisers behave differently from other psychiatric drugs.
Lithium does not directly affect neurotransmitters, but slows down the normal electrical traffic of brain cells by replacing the sodium and potassium ions involved. There are no problems, therefore, with increased or reduced receptor numbers. Even so, it’s still better to withdraw gradually, because this reduces the risk of depression or mania returning, and allows people to adjust the speed of withdrawal to their own needs. Withdrawal may significantly alter blood flow through the brain, and this could lead to manic states. Slow withdrawal will allow the brain to adjust gradually to changes in blood flow. There is some disagreement among experts about whether the blood flow is returning to normal having been changed by lithium treatment or whether withdrawal leads to an abnormal flow pattern.
Lithium withdrawal may bring common problems such as feeling anxious, irritable, tense, restless and highly emotional or confused. There don’t seem to be any physical ‘rebound phenomena’.
Carbamazepine is an anticonvulsant that can also be used to stabilise moods. (Much of the information about withdrawal comes from people who have taken it for epilepsy.) Withdrawal symptoms include aching muscles, spasms or twitches, walking unsteadily, sleeping problems, no energy or appetite, headaches, tension, weak memory and loss of concentration. It can also make people feel depressed and irritable, disconnected (depersonalised), paranoid and confused. There are reports of some people having low blood pressure with a fast heartbeat.
Valproate and similar anticonvulsants should be reduced gradually to minimise withdrawal symptoms, ‘such as anxiety and restlessness’, according to guidelines on withdrawal for people with epilepsy. Other reported withdrawal symptoms of valproate are anxiety, muscle twitching, tremors, weakness, nausea and vomiting. There is also a small risk of having a seizure, even for those who haven’t had one before.
Source: Making sense of coming off psychiatric drugs
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