aphex: duloxetine and Ritalin / methylphenidate reinstatement?

[aphex]

Hello there, 

I had taken 60 mg Duloxetine since January 2018. I started tapering in Jan. 2021 down to 18.5 mg in summer and held that dose. It was a bit rough at times but I got through the year and more and more stable until December 11 2021 when I cut down to 4.7 mg for about two weeks and then down to 0 mg on December 27 2021.
I also took 60 mg Methylphenidate since Sep. 2013 and tapered to zero from September to December 2021. I really don't want to be on stimulants anymore only to be functionaly and able to work (doing things I am not interested in). They also raise my blood pressure and have so many adverse effects.

 

I had paid time off and much time with my family in December and actually felt pretty good. Had no duloxetine withdrawal symptoms at all except some dizziness when looking to the side (I guess like a pre-stage to brain zaps) that subsided both times after and tinnitus one night. Was only slightly sluggish on some days. (Since I also quit my ADHD med.)

 

Had to work again in January this year and still did well emotionally/mentally at first. But I noticed that I really cannot (or want not?) focus on work and that it's definitely not the same without ADHD meds. I used to be that talented programmer but I wonder what is left without stimulants. After one week that turned into real frustration...
On January 13 I was so stressed that I abused some 2C-B (short-acting psychedelic and aphrodisiac) nasally after work and found out that even then I have PSSD. The following day I tried a microdose of LSD to see if that could help with my focus as an alternative to conventional ADHD meds. It didn't really help. I have to say that I have a history of multiple substance abuse disorder but actually I am clean and in the direction of a much healthier life since 2020/2021. I really regret that accident that seemed to trigger the withdrawal/HPPD wave I am currently in...

 

Symptoms I have/had:

• anxiety and agitation (no panic attacks so far but 'anxious breath' and constant worrying)
• thinking about and re-imagining negative experiences in the past from childhood until now
• occasional suicidal thoughts (never had that before in my life actually)
• body/muscle aches
• PSSD
• HPPD
• loss of all interests, indecisiveness
• unable to focus, can't think clearly, mind wandering
• procrastination
• earworm of the same tune since two weeks or so
• voices, words and sentences racing through my mind when going to bed (like the tetris effect)

I also really regret that I CTed the duloxetine in December. Did all the hard work in 2021 and did the disciplined taper for the whole year despite what everyone else (not here) says regarding SSRI 'discontinuation'. I really wanted to use vacations as much as possible as a 'shortcut' and thought to give a complete withdrawal a try (and didn't notice any issues for a while). And I actually wanted what my psychiatrist and a friend says to be true even if I knew better and know SA since spring last year. And I neglected or didn't know of the possibility of delayed withdrawal syndrome.

 

I think it could be much worse when I read some of the other posts in this forum. For example I can sleep without problems, although I get the intense cortisol wakeup and don't want to get out of bed when I wakeup because it is like I don't want or cannot tackle life at the moment.

I really fear losing my job or crashing my career as a software developer. Can't really work right now (4 weeks in WD) because it's so mentally taxing (for me right now) and I cannot focus. So I procrastinate and fake all the time so far. Can't go well for too long. I am constantly worrying about my withdrawal situation and whether I should take Methylphenidate again.

On the other side my current job gets worse and worse, many people are leaving the company and I would like to apply for something better, too. But then I need to be stable. My current job or situation prevents me to be stable and needs me to be stable at the same time. A vicous circle...

I really need a solution and think that I cannot ride this out. Maybe I can and it's just willpower but I doubt it. On some days I feel better but it's not consistent.

I used low doses of methylphenidate on some days last week and this week. They didn't really help. I cannot focus and procrastinate all the time. That also makes me more anxious.

 

I run 10 - 12 km every other day since a few months, take some multivitamin, fish oil and magnesium. Bright light in the morning. No recreational drugs except said accident. Daily meditation since withdrawal/HPPD began. 

 

So I am thinking about reinstatement of duloxetine. What dose would you suggest? 1 mg? 5 mg?
I tried 1 mg this monday and felt better after a few hours. The only really unacceptable drawback was insomnia: I could get to sleep fairly well but woke up after one hour of sleep and could not sleep again. Insomnia really destroys my work performance and makes everything worse.

Sorry for that lengthy post. I really struggle to filter out what's important and what not and am so desperate now.

 

TL;DR:
CTed 18.5 mg duloxetine. (two-weeks taper) Quit methylphenidate. Delayed withdrawal syndrome. Need help
 

[aphex]

Some updates: 

 

I said that I can sleep fairly well... That did change now. I have occasional sleepless nights now. (Waking up after about one hour of sleep. Or unable to fall asleep at all.)

 

The 1 mg (6 granules) reinstatement trial on last Monday (Jan. 24) was a bit late (13:15 PM) so that might be the reason that I could not sleep. Btw, I had used 9 mg Pipamperone then because I really did not want a sleepless night before work. (Bad idea - destabilization)

Last Saturday (Jan. 29) I tried 1 mg again but at about 6 AM. I had some side effects (adverse reactions?) like a feeling of pressure in the left side of my brain/skull und was feeling really dull. But I could fall asleep really easy and early and slept at least from 9/10 PM until 3/4 AM without interruptions. Though I had a sleepless night before. 

 

Looking back over the last weeks, the inconsistency is really bad. It seems like I was destabilized further and further. I hope that I was not kindled.

 

I prepared dosages of 0.83 mg (5 granules) for this week and took the first one today at about 6 AM. Will see how it goes...

[getofflex]

Hello, and welcome to SA.  We are a volunteer-run community of people who have been or are getting off of psychiatric drugs.  I'm sorry it has taken us so long to get back to you.  I can see why you are having trouble.  You have tapered off 2 neuroactive drugs simultaneously, and faster than what we suggest on this forum.  No judgment, as there is very little information out there on how to get off these drugs safely.  You have come to the right place.  

 

Can you please give us specific information about your drug history for all drugs you are on and have been on, especially for the past 18-24 months in your signature box?  It would be especially helpful to have the details of your drugs in a concise vertical list (no symptoms), only drug names, specific dates (as best you can say for example early March if you don't recall the day) and dosages of each medication decrease or increase.  Use this format:

 

Drug name: date, dose, date, dose, date, dose…

Drug name: date, dose, date, dose, date, dose…

Etcetera

 

Please read the link below for instructions.  This will allow us to give you the best guidance.  

 

How to List Drug History in Signature

 

Here is some information about how these drugs actually work.   This explains why we get symptoms from going off of these medications, and why it's so important to taper slowly and carefully, and be very cautious about changing our doses: 

 

How Psychiatric Drugs Remodel Your Brain

 

 

This helps you understand what withdrawal syndrome is: 

 

Video on Recovery from Psych Drugs

 

Windows and Waves Pattern of Stabilization

 

 

Also, as we are recovering, we suggest keeping things slow, simple, and stable.  Therefore, I would suggest that you stop trying out the LSD, other psychedelics, pipamperone, and any other substance that is mind altering.  This will tend to further destabilize your nervous system, and may worsen your withdrawal symptoms.  Even if it helps in the short term, in the long run it could further confuse and throw your nervous system into disequilibrium.  

 

Keep it Simple, Slow, and Stable

 

Here is a link with checklists of common WD symptoms: 

 

Dr Joseph Glenmullen Withdrawal Symptom Checklists

 

 

Here are some techniques to cope with symptoms: 

 

Non Drug Ways to Cope with Withdrawal Symptoms

 

 

We don't suggest many supplements, but 2 that many of us find helpful are magnesium and omega-3 fish oil. Here are the links for info about those. It is suggested to add one at a time, and start with a low dose to see how it affects you. 

Magnesium

 

Omega 3 Fish Oil

 

If it were me, I continue with your reinstatement of 1 mg of Duloxetine early in the day, since it seems to have affected your sleep. Take this every day, a precise dose, (1 mg) at the same time each day.  It is important to be consistent, and keep you dose exactly 1 mg each day.  Don't skip doses, or vary doses.  Give it a week, and see how you feel.  It takes a week for the drug to get into your system and register with your brain.  This is best done very carefully.  This is temporary, and after stabilizing you would then taper gradually off of this.  There is some risk involved. Here is some information about reinstatement.  

 

About Reinstating and Stabilizing to Reduce Withdrawal Symptoms

 

Please let me know what you decide to do.  I would not reinstate the Methylphenidate yet.  We only suggest making 1 drug change at time, so we know what is causing what. 

 

This link will explain how to correctly administer your dose.    

 

Tapering and Dosing Duloxetine

 

Q: What adverse effects did you have to the methylphenidate?  

 

I've given you quite a bit of information here.  Please read through it, and mull it over, and we will take it from there. In the meantime, take care of yourself, and take heart.  We in this forum have been through this, and we understand first hand the pain and discomfort you are going through.  Please know that the brain is amazing in it's healing abilities.  It takes time, but healing can and will happen. 

 

Edited February 4, 2022 by getofflex

[aphex]

Hi @getofflex, 

thank you for reply! Very helpful and informative. I am a bit late, but I updatet my signature and have some updates:

 

Week 1:

I took a week off (sick leave) and continued my reinstatement since 2021-01-31 at 1.16 mg (7 granules). It almost immediately (same day) took the sense of anxiety, dread and the 'flooding negative past life memories'. I was still very negative and was ruminating intensively and could not sleep through on most days. No anxiety in the morning, but woke up after 6 hours sleep and could not get back to sleep.

 

Week 2:

Last week (since 2022-02-07) I started to feel better, though I noted some mild side effects (agitation and jaw pain, probably because of sleep bruxism). But really felt okay otherwise or even good sometimes that I thought to myself: 'Wow, incredible, such a change from such a small dose!' I even texted some friends that I am feeling better and would be up to meet. My sleep did improve, but also thanks to an eye mask. Even stopped ruminating so badly, like it was too much effort. I felt good/okay for about the whole last week. 

I have to add that I also reinstated the methylphenidate at a low dose (10 mg max. per day) because I feel I really need it to be productive/focussed at work.

 

Week 3:

This week (since 2022-02-14) is really bad again. I feel like I have to cry but cannot (lump in my throat). Really negative thoughts come up again and I my mind is scattered. I have to admit that I think it might be related to the methylphenidate reinstatement. I read that it increases cortisol and can worsen depression. Might be especially bad when you're sensitized by WD. Maybe I should discontinue it again, but that would inconsistent... I really don't know. 

 

Regarding your question about the adverse effects of the methylphenidate: The biggest issue is hypertension which is why I started tapering in September last year. Other than that I had issues with blurry vision, anxiety (rare) and agitation (of course since it's a CNS stimulant). I really don't like the effects anymore, the sense of being wired and the sense that it has cardiovascular effects. But I think I might need it, at least for some time.

 

Another question I have: When should I consider a Duloxetine updose? It's been nearly three weeks now with one good week (last week). Guess it's waves and windows. I know it is like there is a window of opportunity for reinstatement. But does the same apply to an updose after RI? I fear that I am losing time. But I also don't know if I should updose at all or continue waiting...

 

Sorry for that overly verbose text, I have some struggle focussing on the details...

 

Thank you very much! 🙂

[getofflex]

On 2/17/2022 at 3:56 PM, aphex said:

Week 1:

I took a week off (sick leave) and continued my reinstatement since 2021-01-31 at 1.16 mg (7 granules). It almost immediately (same day) took the sense of anxiety, dread and the 'flooding negative past life memories'.

I assume you meant to say "took away" instead of "took"?  

Six hours of sleep is pretty good for someone in withdrawal from psych meds.  

 

On 2/17/2022 at 3:56 PM, aphex said:

This week (since 2022-02-14) is really bad again. I feel like I have to cry but cannot (lump in my throat). Really negative thoughts come up again and I my mind is scattered. I have to admit that I think it might be related to the methylphenidate reinstatement.

Yes, an activating drug could certainly cause more WD symptoms.  We suggest only 1 drug change at a time, and you've made 2.  (reinstating both duloxetine and methylphenidate). Personally, if it were me, I would discontinue the methylphenidate.  

 

On 2/17/2022 at 3:56 PM, aphex said:

Another question I have: When should I consider a Duloxetine updose? It's been nearly three weeks now with one good wee

I wouldn't want to add yet a 3rd drug change to an already destabilized nervous system.  I would suggest that you drop the methylphenadine, and stay on the current dose of duloxetine 1.16 mg for a while, and allow your nervous system a chance to stabilize and find equilibrium.  Then, you could consider an updose.  We discourage making multiple changes to your drug in a short period of time because 1) if you have problems, we don't know which drug changed caused it, and 2), our nervous systems need and crave stability so that they can heal and recover.  Please read:  

 

Considerations About Stability - Stop Jumping Around

[aphex]

I am a bit late... 

 

Unfortunately I am not really doing better and am unable to work (software development) due to cognitive issues. I have a new job that starts in August and I really want to get better. 

I am on long-term sick leave, living with my parents again and am waiting for a stay in a rehabilitation center as my psychiatrist (who doesn't know anything about WD) suggested. I am really worried about that. That they will put me on medication again. And that it will interfere with my low-dose reinstatement etc. On the other side it seems like the only option to increase my time off work but still being paid. Maybe a good opportunity to relax and to heal w/o meds, too. I don't know...

 

My symptoms are as follows:

• rumination, regrets, worries. The constant rumination interferes with my thinking. I have trouble reading texts, following conversations etc. because I am always somewhere else mentally. 
• flashing memories from the past (childhood, youth until now), emotional, mostly 'negatively colored', like this
• sleep issues. I can fall asleep pretty well but wake up several times and can't sleep more than 6 hours.
• premature ejaculation (PSSD)
• blood pressure issues (new) when standing (feels like too much blood in my head), came up in March when I had to stop running.
• loss of interests, low motivation. Waiting for the day to get over, everyday, not really doing anything. 
• indecisiveness
• flat affect, not sad, not happy, nothing
• bad focus/concentration, unordered thinking (also due to rumination and mind wandering)
• suicidal ideation (no real intentions, just thoughts about the topic popping into my mind), rare

My symptoms are pretty constant and stable. No waves and windows pattern yet (after about 4 1/2 months). Evenings are better though and feel like a slight relief. 

The only symptom that is gone now is the acoustic hallucination or tinnitus: I was hearing sirens in the background when there was some noise like from a shower.  

I am so glad that I have no issues with anxiety at all. Even when waking up. 

 

I try to meditate everyday but am not getting any better. My focus is so bad that I cannot count my breath to ten without my mind wandering. Feels like just sitting there ruminating. 

I had to stop running because of pain in my ankle and am doing less exercise now. 

I am doing nothing most days. Sitting around, watching TV and most of the time I am obsessively using my phone to search for stuff related to SSRI withdrawal etc. I can't stop and its related to my rumination, I think. 

 

My issues are mostly cognitive/mental and seem like a typical depressive episode. But different from and more intense than anything I experienced before. I never had that early waking before in my life though. And premature ejaculation is definitively a WD symptom. Sometimes I wish I could just go back on 18.5 mg Duloxetine. 

 

After some weeks I increased my Duloxetine dose to 1.5 mg.

 

I stopped the Methylphenidate like you suggested. But it would be good to go back on a low dose in the future to be able to work again. But I don't tolerate it yet. 

 

I am worried that my reinstatement was much too low. Would you suggest to increase to maybe 2 mg? Isn't it too late for that? I fear that it could make things worse. I read that SSRIs make rumination (main problem) worse during the adjust period. I also fear that I am doing it wrong taking the full dose in the morning. Maybe interdose withdrawal? Duloxetine has a half life of only 12 hours. But I can't tolerate late doses (sleep). Do you have any info on that issue? Seems like some people here on low doses of Cymbalta doses split their doses, some others not... 

 

Sorry for that lengthy post. I have so much trouble w/ details and structure.

 

Thank you for your help. This forum is so great!

[getofflex]

On 4/20/2022 at 6:28 AM, aphex said:

After some weeks I increased my Duloxetine dose to 1.5 mg

Q: After you increased your duloxetine to 1.5 mg, did you feel overall 1) better, 2) worse, or 3) the same, as you did before you increased it to 1.5?  

 

I'm sorry that you are going through this.  When you answer my question above, I can tell you whether it would be good to increase your reinstatment.  I don't think it is necessarily too late to increase your reinstatement dose.  If duloxetine messed with your sleep, then I'm not so sure about splitting the dose.  I will confer with the other mods, and one of us will get back to you on that.  

 

[aphex]

It might be better or worse but actually I didn't experience any definitive change besides the initial two weeks or so (adjustment side effects). So I would say 'no change'.

 

Thank you for your quick reply.

[getofflex]

So if you have experienced no change since you increased duloxetine to 1.5, you might consider increasing your dose to 2.0 mg, and see if this helps.  I wouldn't split the dose if it messes with your sleep.  

[aphex]

Okay, I increased to 2 mg this morning and will see how it goes. 

I regret it so much that I didn't updose earlier, wasted so much time. Would be good to be symptom free thanks to reinstatement before I go to the rehabilitation center (basically mental institution) soon. But I cannot change that...

[aphex]

Unfortunately, there was no real improvement in symptoms with 2 mg.

I updosed to 3 mg on May 2 and still do not experience any improvement. If anything its actually making things slightly worse as I start to notice the typical emotionally numbing SSRI effects. 

 

The most debilitating symptom is the rumination and cognitive impairment. 

I could live with the other symptoms I think. 

 

Btw, what is strange that I did not notice any side effects when updosing from 1.5 to 2 and not even from to 2 to 3 mg. Really strange, before it was like I was really sensitized: intense tiredness and headache when going from 1.16 to 1.5 mg. But now nothing. 

 

Would you try something else or leave it at that?

[aphex]

I hope it's not a problem that I updosed to 3 mg on my own and that I did not come off as an askhole...

 

[aphex]

So is there anything wrong?