mccallways: From Paxil to Lexapro. Thoughts?

[mycallways]

Hello,

 

I am new to the forum.

 

Long story short...

I have been on Paxil for 15+ years now.  I was started on it after developing anxiety/depression after acquiring visual snow syndrome vs persistent migraine symptoms at age 18.   It seems the visual may have been triggered by panic after illicit drug experimentation.  Prior to starting the Paxil, I had developed trails off of moving objects, a feeling of depersonalization/derealization, and the illusion of objects wavering if I stared long enough.  My psychiatrist placed me on Zoloft to start along with as needed clonazepam.  I eventually switched to Paxil and most of my symptoms came under very good control.  At least, my anxiety about the visual phenomena was well controlled.  Eventually, I stopped clonazepam alltogether.  

 

Things went relatively well for the following 15 years.  I graduated from college, had plenty of friends and enjoyed my life, rarely thought about the visuals, eventually went to grad school,  met a great girl, and have been practicing in medicine for the past 3-4 years.  All the while, I remained on Paxil at ~ 15 mg daily.  

 

Unfortunately, there was a period of extreme emotional stress 2-3 years ago when the girl and I were "on the rocks".  It was an awful time as we were living in separate states and were seeing other people.  I couldn't sleep, couldn't focus at work, wasn't eating, etc.  I ended up increasing my Paxil dosage to 20 mg and taking a clonazepem nightly to get some sleep.   During that turmoil, I stupidly smoked some pot with friends to try and forget things. I hadn't done that in like 8 yrs so it was a shock to the system.  On one occasion, I experienced a sort of panic attack and had a migraine the following day.  About 1-2 months later, I started to notice severe photophobia, followed by prolonged afterimages, trails, and a constant daily headache that seemed to stem from my palate/jaw.  Ironically, the girl and I worked things out and are now engaged to be married!!  We have been doing relatively well except all the sxs have continued to worsen. 

 

These recurrences of symptoms reminded me of those I had experienced from 15 yrs earlier, but much worse.  They have persisted for the past 2+ years!!  It seems that in moments of heightened stress, the visual symptoms become much worse.

I have tried a few treatments, mainly targeting the headaches (Lamictal, Nadolol, Verapamil, Nortriptyline), none of which helped.  I have even tried slowly tapering the Paxil, thinking it may be the culprit.  I have only made it from 15 down to 10 mg.  This brings me to my question...

 

I have started Gabapentin 300 mg at night in hopes that it will ease the facial pain/headaches.  I have been on it for 1 month now and only experiencing worsening visual symptoms including longer trails/afterimages and now significant blurred vision.  I have grown MUCH more anxious over the worsening of symptoms and general despair of the situation.   I am not sleeping well and fear things will continue to worsen.  My neurologist wants me to switch from Paxil to Lexapro in hopes that it may help with the pain and facilitate coming off the Paxil once and for all.  

She is certain that it is safe to do a sudden switch, dropping 10 mg of Paxil and starting 10 mg of Lexapro in the same night.  My fear is that I will go into an awful w/d from the Paxil while the Lexapro is ramping up.  She is certain this won't happen since they work on similar receptors so the Lexapro should't take 6 weeks to get into the system.

 

Is this true?  Is it wiser to cross-taper?  Should I continue to taper Paxil completely before starting Lexapro?  Should I stop the Gabapentin as it may be worsening the visuals?  I fear that I will develop worsening visual symptoms regardless.  I am aware go the horror stories about SSRIs causing visual snow, etc.  I just know from my history that the Paxil HELPED the visual symptoms initially.  

 

Thanks for any and all advice.

Edited May 29, 2017 by scallywag
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[Altostrata]

Welcome, Mccallways.

 

The kindest way to switch drugs is a cross-taper. A cold switch from Paxil to Lexapro, such as suggested by your neurologist, is very risky.

 

The risk is elevated by your apparent history of adverse reactions to various psychiatric drugs and recent drug changes, which are wearing on the nervous system.

 

You should also know that milligram for milligram, Lexapro is several times stronger than Paxil. The Lexapro dosage should be reduced accordingly.

 

From your history, it sounds to me like your use of clonazepam might have caused the original bout of adverse reactions. Physiological dependency can occur within 2 weeks of consistent use. Breakthrough anxiety, rebound anxiety, paradoxical reactions, and panic attacks are not uncommon. We see them all the time.

 

It could very well be that your current symptoms are adverse reactions or drug-drug reactions. What drugs are you taking now, at what times of day and dosages?

 

Please keep notes on paper about your symptoms, when you take your drugs, and their dosages to see if there are any regular daily patterns that can be traced back to the drugs.

 

You might also put your drugs in the Drug Interactions Checker and copy and paste the results in this topic.

 

Paradoxically, minimizing your drug burden may reduce your symptoms. This is a site for going off drugs. Are you interested in doing this?

[mycallways]

Altostrata, thank you for your kind reply...

 

I am certainly interested in coming off of all medications as soon as possible.  My fear is that my anxiety is very poorly controlled due to these visual symptoms and headaches.

I felt very stable on Paxil 15 mg for the 5 or so years prior to the onset of headaches and visual symptoms 2 years ago.

I had attempted to taper a few times here and there with no real success, so I just stayed on 15 mg thinking it was doing no harm.

 

In regards to the clonazepam that I was taking in my times of high stress prior to symptoms onset, I was taking low doses of 0.25 mg-0.5 mg once every night/every-other night, to help with sleep.  I probably took a total of 10-12 doses.  That was 2.5 years ago.  Would that minimal of use set into motion such a drastic issue with these headaches/visual disturbances??  I have not taken the clonazepam since these awful headaches started 2 years and 2 months ago.  

 

When the symptoms onset, I initially attempted to increase the Paxil to 20 mg, but was having worsening visual symptoms, so I stayed at 15 mg.  I was placed on Lamictal by a headache specialist in Boston as he suspected I was having persistent migraine aura due to the visual symptoms (photophobia, palinopsia, trails, floaters, etc.).  I worked up to 50 mg bid over ~ 2 months, but this seemed to again worsen my symptoms, so I weaned off and was started on Verapamil 120 mg daily, again, in hopes to treat a migrainous condition.  I had no real adverse effects at that time, but the headaches and visuals stayed.  I came off it after 2-3 months.  It was around then that I relocated from Boston to Dallas and found a new headache specialist who again changed my regimen to Nadolol 40 mg daily for migraine therapy.   Again, there was no positive effect and I stopped after 2-3 months.  All along this time, I was still on Paxil 15 mg.  I had also experimented with multiple herbal/non-pharma supplements to attack headaches, most of which I have since d/c.  

 

I opted for anther opinion from a general neurologist recommended by my PCP.  She agreed that this all sounded migrainous, likely due to stress/anxiety, and placed me on Nortriptyline 10 mg along with the Paxil.  She advised that I d/c the Paxil over the course of a few weeks, but I knew better, so I asked her for the liquid suspension.  I slowwwwwly tapered form 15 mg to 10 mg (over like 6-8 months).  I continued to go up on the nortriptyline to 30 mg daily.  This was ~ 1 year ago.  Again, I saw no positive effects on the visual/headaches.  I saw a headache guru at the big university here in Dallas and she advised that I have a nerve block (no help), and that I wean off Nortripyline as it wasn't working.  I have done so and remained on Paxil 10 mg daily.  I also tried Botox with no relief.  

 

Most recently, ~ 1 month ago, the headache specialist advised I start gabapentin and titrate up to try and treat the pain.  She does NOT think this is chronic migraine, but is unsure what it might be.  Visual snow syndrome with associated headache is her unofficial diagnosis.  The neurologist, who I saw most recently, realizes that my anxiety and depression have come back with a vengeance (mainly due to the constant headaches/visuals) and advised that I either increase my Paxil or go on a different SSRI at a higher dose to get the anxiety better controlled.  The anxiety is at a point that I'm waking at 4-5 AM every morning with chills and nausea associated with headaches and racing thoughts.  I have become depersonalized as well.  The worst new symptom, which I think started after gabapentin use, is the blurred vision.  

 

So, now, my regimen is as follows...

10 mg Paxil at night.  300 mg Gabapentin at night.  1500 mg Omega-3 at night.  5,000 units Vit D at night.  Finasteride 1 mg at night.  I have recently stopped Magnesium Citrate 400 mg nightly, but will restart soon.  

 

The plan per the neuro is to abruptly discontinue Paxil 10 mg and switch to Lexapro 10 mg.  I realize this is not the comparable dosage, but her idea was to get on a higher doe at first and once more stable, try to taper slowly.  I think it wiser to switch to Lexapro 5 mg and see how I do.  If anxiety poorly controlled, consider increasing that dose, but I would ultimately love to be off Paxil.  

 

My issue with a cross taper is that I have no idea how best to do it!  Also, I don't want my anxiety to spike any more.  

 

PS.  ~ 3 months ago, I purchased an engagement ring and proposed to my fiancee.  We are now planning a wedding.  I assume this is contributing to the anxiety.

[snostorm]

Just to  chime in here.  Generally switching to another SSRI is not recommended here and bridging to another is risky.  That being said I am in the process of bridging to Prozac from a 15 year exposure of Paxil.  I tried to taper multiple times failed and reinstated.  What I did not know was that even though I was following the advice of my doctor I was tapering way too fast and destabilized my nervous system.  I suffered significantly.  It came to the point where upping my dose of paxil seemed to make matters worse. I feel extremely lucky to have found relief from introducing Prozac. I am almost done with my cross taper and although I do have some discomfort and sleep issues, I am functional.

 

It is best to do a methodical slow taper from the AD you are on.   Its going to take me a long time once I fully transition to Prozac assuming I have ultimate success.

[mycallways]

So, in your opinion, if you had just switched abruptly from Paxil to Prozac, it would have been hell??

[ShadowMan]

Well, about switching, I bridged from Paroxetine 40mg to Escitalopram 15mg without major problems, was just annoying.
Recently I tried bridging from Escitalopram to Desvenlafaxine, and damn, it was HELL! ( I decided to give myself another chance, and stop taking ADs ).

Both times was cold switch! So I think that theres no right answer when it comes to switch ADs this way. But please, do yourself a favor, take the safer way and listen to what Altostrata said: "The kindest way to switch drugs is a cross-taper."

This can save you from very very bad days! I wish I would have found SA earlier, and was given to me this advice.


Just for curiosity, these visual symptoms only appear during you migraines?

[snostorm]

I think it takes time to build Prozac into your system. I was on low dose Paxil when I started Prozac so it was more introducing Prozac then removing the low dose of Paxil. I know some have done a straight switch I think it's very risky.

[mycallways]

Shadowman.

 

I have the visual symptoms at all times.  The issue is, I always have headache too.  24/7 pain in my jaw, face, teeth.  So I can't tell if I'm stuck in a constant migraine with aura, or that the visuals are unrelated.  I think they are totally related though.  Look into visual snow syndrome.  

 

I wish someone could just write out a plan for me to switch from Paxil to Lexapro.  Nobody has been able to give me a clearly plotted course for switching.  

Do I take 5 mg Lexapro one day and cut there Paxil to 5 mg immediately?  Stay on that for 1 week and cut the Paxil to 2.5 and so on???

[KarenB]

In case you didn't see this thread:  The Prozac switch and in particular: 

 

• For a "normal" dose of Effexor (150mg per day or more) or Paxil (20mg) or Cymbalta (20mg), he would switch to 10mg Prozac with a week of overlap. In other words, take both medications for a week and then drop the Effexor. Lower doses of Effexor or other antidepressant require lower doses of Prozac as a "bridge."
• The lower dose of Prozac reduces the risk of excessive serotoninergic stimulation from the combination of the two antidepressants during the overlap period.
• Do not stay on the combination of the first antidepressant and Prozac for more than 2 weeks, or you run the risk of your nervous system accommodating to the combination and having difficulty tapering off both antidepressants.

 

So you'd take both drugs for 1 week, then drop the Lexapro.

[Altostrata]

Very interesting. 
 
You were not taking the clonazepam regularly. But after a while, it is possible you had rebound reaction or breakthrough anxiety from the benzo. They are very treacherous drugs. 
 
Or, you may have accidentally skipped a dose or two of Paxil, and that withdrawal reaction wore out your nervous system's tolerance for the drugs.
 
In a nutshell, these drugs are hard on our nervous systems. Many people experience a honeymoon of x years on the drug, then things start going wrong. The nervous system adapts and changes over time; chronic exposure to psychiatric drugs may change it in ways that are dysfunctional. Drug changes and inadvertent skipping of doses adds to the stress on the nervous system.

 

Finally, there's withdrawal syndrome. See What is withdrawal syndrome?
 

The anxiety is at a point that I'm waking at 4-5 AM every morning with chills and nausea associated with headaches and racing thoughts.  I have become depersonalized as well.  The worst new symptom, which I think started after gabapentin use, is the blurred vision.

 
Well, of course you're depersonalized. You're taking a bunch of drugs. The gabapentin alone is enough to make people feel like zombies.
 
Please get a report from the Drug Interactions Checker -- use it to reduce your drug burden
 

10 mg Paxil at night.  300 mg Gabapentin at night.  1500 mg Omega-3 at night.  5,000 units Vit D at night.  Finasteride 1 mg at night.  I have recently stopped Magnesium Citrate 400 mg nightly, but will restart soon.

 
Suggestion: Vit D is a daytime prohormone, you might take it in the morning. The D3 form is the one that's effective. Please read
 
King of supplements: Omega-3 fatty acids (fish oil)

Magnesium, nature's calcium channel blocker
 
Did you feel better on the lower dose of lamotrigine?

[mycallways]

I really don't remember how I felt on the Lamictal.  

I do know that while on it, I first noticed intense afterimages in opposite colors of the original stimulus.  I.e. If I looked at the blue chat bubble on my phone and looked away, it would appear clearly in yellow.  That problem has worsened over the past 2 years.  

I may have had slightly less headaches on the Lamictal, and maybe the photophobia wasn't as bad, but when I look back at my journals, there's no sign that things were any better.  

I've read so many accounts of people developing this phenomenon (palinopsia) due to SSRIs or after tapering off of them.  I fear that changing my meds will worsen it.  

 

I will try to change my Vitamin D3 to AM.  

 

In regards to Paxil, I would really like to keep tapering slowly.  I guess I will hold out for as long as possible before adding a new SSRI.  I have the liquid and will keep dropping by 10% monthly.  I just wish I could control the anxiety and get some sleep.  

[Altostrata]

If the anxiety and sleeplessness arose from tapering Paxil, continuing to taper it will make it worse.

 

When did the sleeplessness start? What is your sleep pattern?

[mycallways]

Those symptoms honestly did not arise in correlation with any recent tapering.  I had been down to 10 mg and remained there for at least 6 months prior to the sleeplessness, chills, cold hands, etc.  

 

I have been able to fall asleep fine, but noticed that ~ 2-3 months ago, I started to wake up with the anxiety, chills at 5 AM-6 AM daily.  I noted my hands grow more and more cold and painful soon afterwards.  Over the past 2 months or so, I have experienced significant blurred vision and nausea.  

 

The other variable involved are as follows...

Just prior to those symptoms starting, I had seen an upper cervical (NUCCA) chiropractor and underwent a gentle adjustment.  I also saw a trigger point/myofascial release expert.  I cannot be sure there is definite correlation, but figured it may be pertinent.  I asked the chiropractor if the adjustments could have caused these symptoms and he said no.  I had also seen a dentist who placed me in an NTI device in attempts to treat TMJD.  He also had me trial cyclobenzaprine (Flexeril) nightly for 2 weeks.  I started using this ~ 4 weeks prior to the new symptoms started.  He also doesn't think there is a correlation.  

 

I've stopped using the NTI device, Flexeril, chiro/PT, and any other new therapies.  Despite this, the blurred vision etc have continued to worsen :-(

[Alpha23]

I would be very careful about switching to Lexapro. I tried switching from Prozac to Lexapro at the start of this year and it made me a lot worse. My doctor did not advise a cross-taper so I stopped Prozac, waited 5 days, and then started Lexapro. I soon developed really bad side-effects and had to go back on Prozac. Unfortunately, I feel a lot worse now than before the failed switch. If you do decide to switch, monitor any side effects very carefully. I developed palpitations and tinnitus while switching and still have these long after switching back to Prozac. I naively thought I could try switching and return to my previous state if it didn't work out. Sadly, it doesn't work like that.