GoldFoilJ - How to know if you should reinstate meds v. white-knuckling symptoms?

[GoldFoilJ]

Hi, this is my first post, and I'd like to ask for some advice.  As can be seen from my signature below, I have been on many types of psychotropic meds over the last 21 years for depression and anxiety (OCD, GAD, Social anxiety) starting when I was in college.  I started on antidepressants for a few years, and when I wasn't doing well on them, they would add an antipsychotic and a benzo or anti-seizure med.  Now that I look back and after having read more about other people's experiences with meds, it's my belief that a couple of them did some damage, as I remember having bad withdrawal symptoms after taking Geodon, for instance, for only a day or two.  After I started taking Ativan, I'm not sure if this might have masked other bad side effects that were occurring under the radar from successive antipsychotics or antidepressants that I've tried.  

 

So, I've been taking Celexa (~8yrs) and Ativan (~15yrs) and have recently come off of them this summer: Ativan in May, and then Celexa, a month and a half later.  After I stopped Ativan, I felt extreme muscle tension and pressure in my head and neck, more so in stressful situations, which would make me kind of homebound.  The immense tension has dissipated a little.  After stopping Celexa, I felt more of my feelings, especially anger, crying easily, anxiety.  The intensity of the feelings has dissipated a little I think.  But I'm still suffering from my overactive mind, intrusive thoughts, plus a lot of anxiety in the home and outside the home.  Low self esteem, self loathing, indecisive, stressed.  I have to make money to move out of the house I live in because it makes me anxious to stay here, but I can't really function well enough to make money.  I've been trying to eat well, exercise, go outdoors, but I don't seem to be improving much.  I was thinking of reinstating or maybe getting on a small dose of Prozac or something.  However, I feel like medications blunted my emotions, intuition, and thoughts so that I wasn't really healing from any deeper issues - but then again, I'm just not sure about that either.  I'm also afraid of a repeat of the withdrawal if starting and stopping in the future, although I would approach it more carefully now that I've read more about it on this site.  Any advice?  Thanks so much.

[Catwoman73]

Hi @GoldFoilJ, and welcome to SA!  We are a community of volunteers providing peer support in the tapering of psychiatric medications, and their associated withdrawal syndromes.  

 

Thank you for completing your drug signature.  You've been through quite a lot!

 

Given that you stopped both your Ativan and your celexa within such a very short time, and tapering at least your celexa much too quickly, it's hard to say if the withdrawal symptoms you are experiencing are from the Ativan, the celexa or, as I suspect, a combination of both.  Here at SA, we recommend tapering at a rate of no more than 10% of your current dose, no more often than every four weeks.  So, as an example, with your celexa, your first few dosage drops would be 10mg-9mg-8.1mg, 7.3mg.  This is known as hyperbolic tapering, and is designed to release the receptors in the brain from the effects of the drug slowly, allowing your body to slowly reverse the biochemical and genetic changes that have occurred as a result of the drug usage.  You can read more about hyperbolic tapering here:

 

Why taper by 10% of my dosage?

 

I think that reinstatement in your case might be worth trying.  You should never be white-knuckling it through this, if you can avoid it!  The question becomes which drug to reinstate?  Since you have stopped both in the last three months, either one would be a candidate.  Typically when tapering, we recommend tapering the most activating drug first, which in your case would be the celexa.  Does it follow that reinstating the least activating drug- the Ativan- would be a good choice?  That's a pretty tough question to answer.  Perhaps knowing a bit more detail about your Ativan usage might be helpful- did you take it every day, or was it on an as needed basis?  How did you taper from it?  

 

Here is some info on reinstatement, regardless of which drug you choose.  A very low dose of one of the drugs that you have recently come off of is a much better choice than trying to play around with a new drug.  And very low dose is the key here- overshooting can be disastrous.  With the number of drugs you have been on and off of over the years, trying anything new can be very risky, and lead to a hypersensitivity reaction, or it's more serious cousin, kindling.  I will link below.

 

Hypersensitivity and kindling

 

The idea with reinstatement is to reduce the severity of your withdrawal symptoms, and taper hyperbolically down the road, when you are stable and prepared to do so.  Reinstatement does not always work for everyone, and it does not necessarily eliminate the withdrawal symptoms altogether.  I'll link you below our advice on reinstating.  I am happy to help you with decisions about dosing, and how to get these oddball super small doses that we are taking about here, if you decide to go that route. 

 

About Reinstating and Stabilizing to Reduce Withdrawal Symptoms

 How long does it take to stabilize after reinstating or updosing?

 

Regardless of whether or not you choose to reinstate, it is very obvious that living life with such challenging emotional symptoms is not something you wish to do.  We have many, many threads here on learning to cope with our symptoms without the use of psychiatric drugs.  I will link some of them below.  You will likely find some of your own as well.  On a personal level, I have found that practicing mindfulness each and every minute of every day has been helpful in preventing me from thinking catastrophically, or ruminating too much.  Meditation/yoga Nidra is super helpful for sleep.  I do a lot of challenging my negative thoughts, and thought transformation as well.  I also engage in many, many distractions, such as painting, swimming, walks in nature, etc.  It's important to develop a whole toolbox to help get you through this.  What works one day may not work so well the next, so having multiple strategies is very helpful.  A good therapist can help with this, if you can find one/afford one, but you can also work on this stuff yourself as well.   Not only will these things help with your withdrawal journey, but they help for years to come, as you continue to encounter challenging situations throughout your life.

 

Non-drug techniques to cope with emotional symptoms

 Easing your way into meditation for a stressed-out nervous system

Music for self-care: calms hyperalertness, anxiety, aids relaxation and sleep

Ways to cope with daily anxiety

"Change the channel" - dealing with cognitive symptoms

Dealing With Emotional Spirals

 

It sounds like you are already doing some of this, which is great.  I want to assure you that, while it may not feel like it is doing much, constantly practicing these techniques will start to rewire your brain over time.  Nothing happens overnight though- it takes patience!

 

As you proceed through your journey, you will notice periods where you feel better and periods where you feel worse.  This is known as the windows and waves pattern of stabilization, and it is a wonderful sign of healing.  You may wish to start a symptom journal, rating each of your symptoms on a scale of 1-10 each day.  This can help you identity your windows and waves, and can help you identify whether or not you are improving with reinstatement, if you choose to go that route.  Here is a list of typical withdrawal symptoms that you can use as a template for a symptom journal, and some more info on windows and waves:

 

Daily Checklist of Antidepressant Withdrawal Symptoms (PDF) 

Windows and waves pattern of stabilization

 

There are many things you can do to assist with healing, and it sounds like you have already started doing some of this stuff.  Eat a balanced, whole foods diet, stay adequately hydrated, get gentle exercise (overdoing it can cause symptoms to worsen), and get adequate rest/sleep.  Avoid neurologically active substances like caffeine, nicotine, alcohol and recreational drugs, as these things can destabilize you further.  Avoid taking other new psychiatric medications to mitigate the withdrawal effects of psych meds- their effects are not predictable (as it looks like you've discovered in the past), and it only creates a situation where you have to taper another drug in the future, thereby prolonging your withdrawal journey.  We only recommend two supplements here at SA- magnesium and omega-3 fatty acids.  Do be mindful though- it is common to develop hypersensitivities to all sorts of things in withdrawal, including medications, supplements and even foods!  So if you choose to start a supplement, even our recommended ones, start with a low dose to see how you fare, and slowly increase over time. 

 

In summary, review the info provided, and make an informed decision about whether or not you want to try to reinstate.  Replying with answers to the questions I asked above may help provide a bit more clarity for me in assisting you.  Start working on a symptom journal, and incorporating those non-drug coping mechanisms.  Doing this will be helpful no matter what path you choose. 

 

Most of all, don't lose hope.  You're in very good company here.  And humans are designed to heal.  Give your body and brain what they need, and you will heal.  Be patient, take things very slowly, and you will get there.

 

This is your introduction topic- each member gets one intro topic.  Please post updates, questions, concerns here, on this thread.  But keep exploring the rest of the forum- there's lots of good info here!  And if you feel up to it, don't hesitate to read the intro threads of others, and drop a word of support.  This can be a lonely journey, and many find it helpful to create a community of like-minded people to share it with.  There's lots of great support here, if you would like to take advantage of it. 

 

 

[GoldFoilJ]

Hi Catwoman73,

 

Thanks so much for your thoughtful reply; it's really informative and gives me a bit of hope, as I just keep going with the lifestyle changes and incorporate new techniques as well.  And I will definitely be a frequent visitor to this forum.

 

As to your questions...

8 hours ago, Catwoman73 said:

Does it follow that reinstating the least activating drug- the Ativan- would be a good choice?  That's a pretty tough question to answer.  Perhaps knowing a bit more detail about your Ativan usage might be helpful- did you take it every day, or was it on an as needed basis?  How did you taper from it?  

 

I took Ativan everyday.  The way that I tapered was kind of at irregular intervals, so I honestly can't really give an exact timeline.  And my memory has been really bad these past few months.  At the time that I started to taper off of it, I was on 4mg.  I tapered off by deducting 0.25mg (because that was the smallest I could cut the tablet into) about every month or so (maybe less, maybe more) until 2mg, which I held for several months, and then tapered off by 0.25 every 2ish weeks while getting acupuncture treatments and taking herbs that are meant to have a calming effect.  I think I cut down too fast for the later 2mg...    Would it be ok, you think, if I took a small amount as needed, probably for me that's family gatherings, like birthdays and for the holidays (Nov/Dec) that will be coming soon?  I really don't know the best way to go about this, so any advice would be great.

 

[Catwoman73]

What you did there was a linear taper, rather than a hyperbolic one.  Your timeline wasn't bad- it should take a long time to taper from any of these drugs.  But dropping by 0.25mg at a time is most definitely going to lead to some serious withdrawal effects. 

 

Taking Ativan intermittently is only going to continue to destabilize you, and prolong what you are going through.  What I would recommend instead would be to reintroduce a very small daily dose to try to mitigate some of the withdrawal effects you are going through right now.  Give it time to stabilize on that, and then do a proper hyperbolic taper once you are more stabilized. It may take you many months to destabilize on a smaller dose.  And that's ok- none of this is a failure on your part.  It's a failure on the part of the pharmaceutical industry, who continue to state that withdrawal from these types of drugs is 'mild and short lived.'  

 

I would suggest starting with 0.25mg per day, if you have previously taken up to 4mg per day, though you can start a bit lower if you like.  I wouldn't go higher.  In terms of getting accurate dosages, I would strongly recommend purchasing a jewellers scale, and weigh your pills.  Dosage accuracy is important to ensure you don't create any further instability.  Many here use the following scale (link is to Amazon Canada, since that's where I am- but you could find the same one on US amazon):

 

https://www.amazon.ca/American-Weigh-Gemini-20-Black/dp/B077KC8D8Y/ref=asc_df_B077KC8D8Y/?tag=googleshopc0c-20&linkCode=df0&hvadid=706723740630&hvpos=&hvnetw=g&hvrand=14382583256535930990&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9001042&hvtargid=pla-848141135981&mcid=8392183ee8823f2c851c2203e7fd1504&gad_source=1&th=1

 

So if you have 1mg pills, you would weigh the pill, and multiply the weight by 0.25- that will be the weight that you want to take to get an accurate 0.25mg dose.  So you can cut the pill in half, and then carefully shave one of the halves down until you hit the appropriate weight.  An exacto knife or a razor blade is good for shaving pills down. 

 

When reinstating, you need to hold each dose for at least a week to gain a full understanding of whether or not it's working.  I would strongly recommend you keep a symptom journal, as looking back on where you have been can be very helpful in making decisions about next steps. Some people experience immediate relief, some people have to updose a few times before finding that ideal dose- it's all a bit of an experiment.  Taking it very slow is the key.  Overshooting your dose sets you up for an adverse reaction.  If you need to updose, after holding for 1-2 weeks, I would go up by no more than 0.1mg at a time.  This is an ultra cautious approach, since you have been off the Ativan for several months.  We could move faster if you had just come off last week, but moving slowly becomes more important the further out you are. 

 

Reinstating doesn't work for everyone, but it's certainly worth a shot for you.  If you react adversely after starting, you can immediately stop.  An adverse reaction would be increased agitation, hyperalertness- everything described in the Hypersensitivity and Kindling link I provided above. 

 

I also want to caution that reinstating doesn't necessarily mean that the goal is to eliminate all withdrawal symptoms.  The idea is to get to a place where you can tolerate your symptoms, and go about your life, day to day, in spite of them.  So once you hit that point with any necessary slow updosing, it's important that you stop, and hold at that dose.  Like I said, overshooting can be dangerous, and make things much worse. 

 

Of course, whether or not to reinstate is entirely up to you- this is just my recommendation, rather than intermittent dosing, which has been shown to prolong the withdrawal journey.

 

While reinstating, or even if you don't, I would absolutely recommend working very hard on those non-drug coping mechanisms.  It takes time to create a new habit, and for your brain to start responding to these techniques the way we want it to.  I have been working on mindfulness and meditation for years, and I'm still a work in progress.  But I'm at a point where it does help me get through the rough times.  I just need to be consistent with my practice. Once you are more stable, and start tapering again, you can continue to apply these techniques when withdrawal symptoms come up.  Because they will- even with a proper hyperbolic taper.  

 

Please let me know if you have any questions- I'm very happy to help! 

[GoldFoilJ]

Hi Catwoman73, thank you for all the information again and support.  Even though every direction seems kind of anxiety-inducing, at least I'm more equipped with knowledge.  Thank you~