AdviceNeeded: introduction - mirtazapine and zopiclone

[AdviceNeeded]

Hi All,

 

I had quite a severe bout of depression and anxiety towards the end of August and was diagnosed with depression. I was prescribed 15 mg of mirtazapine daily. I felt like it worked quite well over the course of 3 weeks, felt the sedation but still needed the odd zopiclone for sleep, got on well at work, etc. I mentioned I still wasn't sleeping brilliantly on 15 mg to my doctor (I'd wake up with night sweats) and he suggested going up to 30 mg. I tried it once and didn't like it - felt very ropey. From then on I decided to take 7.5 mg to help with sleep and it worked a treat, then 3.75 mg - still good. Then I started questioning whether I'd done the right thing and started upping it again.

 

Basically, after 3 weeks of 15 mg and 3 weeks of either 7.5 mg or 3.75 mg I started getting really anxious, ridiculously so at points. The doctor suggested going back up to 15 mg which is what I've done - I sleep okay on it, but only okay (I've actually started splitting it and doing 7.5 mg before bed for the sedation, and 7.5 mg when I wake up to try and chill me out), and my anxiety is through the roof, verging on panic sometimes. I've felt so desperate at times I've briefly considered doing the worst - usually during the early hours of the morning when I 've woken early and the panic has set in.

 

I've spoken to the doctor about this and he's suggested I can just stop it - it doesn't feel like I can to me. I'm guessing I've messed my serotonin levels around or something and my brain doesn't know whether it's coming or going. I'd like to do whatever I can to stabilize and then take it form there.

 

Any suggestions, or reassurance would be greatly appreciated.

 

Thank-you.

[Gridley]

Welcome to SA, AdviceNeeded. Thank you for completing your drug signature.

 

It's very important that you remain at a stable dose.  Jumping up and down in dose is very destabilizing to your nervous system, accounting for the symptoms you're experiencing. 

 

How are you doing on the current dose of 15mg?  If you're doing all right, I'd remain at 15mg (taken at the same time each night and not splitting the doses) until you stabilize.  Then, when you've stabilized on that dose, which can take several months, you can, if you wish to come off the drug, you can begin a slow taper.  We recommend tapering by no more than 10% of your current dose every four weeks.  

 

Why taper by 10% of my dosage?

 

We strongly do not recommend just stopping the drug, as your doctor suggested, known as cold turkey.  That puts you at risk of some very unpleasant and long-lasting withdrawal symptoms.

 

What is withdrawal syndrome.

 

This link is specifically about tapering Mirtazapine, including how to get the non-standard doses you'll need the the time comes for your 10% taper.  A recommended method of tapering is making your own liquid, and the link contains instructions on how to to that.  But that's for the future.  Right now you need to stabilize.

 

Tips for tapering off mirtazapine (Remeron)

 

 

We don't recommend a lot of supplements on SA, as many members report being sensitive to them due to our over-reactive nervous systems, but two supplements that we do recommend are magnesium and omega 3 (fish oil). Many people find these to be calming to the nervous system. 

 

Magnesium, nature's calcium channel blocker 

 

Omega-3 fatty acids (fish oil) 

 

Add in one at a time and at a low dose in case you do experience problems. Get supplements that ae single ingredient (not mixed with other types of supplements).

 

This is your Introduction topic, where you can complete your drug signature, questions and connect with other members.  We're glad you found your way here.

 

 

 

 

 

 

[AdviceNeeded]

Thanks for the reply.

 

I was quite shakey yesterday, not sure how much of it was psychological - fearing worse case scenarios, etc. But I’ve calmed down a bit today. I’ve had the odd moment but again, I’m not sure how much of this I’m creating with my own thoughts.

 

I’m sticking with the 15 mg for the time being. I was in a mess before I started on these so it is hard to distinguish what’s the drug and what’s my old symptoms. I’ll keep you all posted either way.

 

Thanks again.

[AdviceNeeded]

Just a quick update, 

 

Things have stayed pretty much the same, heart rate feels a bit high and shakey, and I have a non-existent libido. I generally don’t feel me either, really struggling to connect with things. I think I may have screwed myself up.

 

These drugs shouldn’t be handed out as readily as they are. Granted, I shouldn’t have played around with it but I had no idea something so easily given out could do so much damage at such low dosages. 
 

I’m guessing it’s just a waiting game now. Any further advice or suggestions welcome.

 

Thanks.

[AdviceNeeded]

Hi @Gridley

 

I’m taking the 15mg mirtazapine with a 40 mg propranolol at 10 pm each night. I’m sleeping poorly for around 5 hours.

 

I’d say the anxiety (bit of a tame term for what I’ve been experiencing) is easing off. I’m finding it easier to sit (I’m less restless) and a bit easier to concentrate. My hearts not pounding as much either.
 

Still struggling with feeling any positive emotions, got constant song snippets playing in my head, no sexual response or desire. I hate to say it but I get suicidal ideations as well.

 

I’m due to see the doctor in a couple of weeks, I’m guessing he’s going to suggest upping the dose or switching. I’m guessing it’s probably wiser to hold for longer and stabilise. 
 

Could I ask what your thoughts are please?

[Gridley]

54 minutes ago, AdviceNeeded said:

 

Could I ask what your thoughts are please?

It sounds like you're showing improvement on many fronts, which is a very encouraging sign that you're beginning to stabilize. I would recommend that you stay at the same dose and continue to stabilize.  You had a lot of dose changes since September and what your system needs now is stability.  I definitely would not recommend changing your dose or your drug, the latter being a pig-in-a-poke situation (do they have that expression in the U.K.?), meaning you never know what you're going to get or how you'll react to it.   

 

As we say here, keep it simple, keep it slow, keep it stable.

The rule of 3KIS: Keep it simple. Keep it slow. Keep it stable.

I've very happy you're showing improvement.  To repeat, I would hold steady where you are for several months and then, if you wish, we can talk about tapering.

 

[AdviceNeeded]

 

Yea, it’s not a common saying but it does occasionally get said.

 

Thanks for the reply - I think I’ll be taking your advice 👍🏼

[AdviceNeeded]

Hi @Gridley

 

So, after speaking with my doctor and explaining both the positive improvements and the many negatives, he’s prescribed citalopram to be taken in the morning as an add on. I’ve not taken it, and I don’t intend to tbh.

 

Overall I’d say a lot of general discomfort has settled down. My biggest areas of concern are now sleep (it’s really patchy, short, or non-existent), the complete lack of sexual desire or response, feeling unnaturally awake despite a lack of sleep and a general feeling of weakness (like I’ve lost my mojo).

 

So, I’m guessing I stay put for the time being? Any tips or advice for dealing with any of the above are very welcome (I’ve started a magnesium supplement but am only 2 days in).

 

As always, thanks.

[Gridley]

3 hours ago, AdviceNeeded said:

Overall I’d say a lot of general discomfort has settled down. My biggest areas of concern are now sleep (it’s really patchy, short, or non-existent), the complete lack of sexual desire or response, feeling unnaturally awake despite a lack of sleep and a general feeling of weakness (like I’ve lost my mojo).

 

I definitely agree with your deciding not to add Citalopram.  Stability (which means not changing anything) is very important right now.

 

I have a few links on sleep that I'd like t give you.  I've found that a very small dose of Melatonin .3mg helps me get to sleep, then when I wake up around 2:00 I talk 100mg magnesium glycinate (I'd start lower to see how your system tolerates it) then when I yet again wake up around 5:00am I take another magnesium.  It doesn't work perfectly but many night it allows me to get 1 or 2 or even 3 extra hours sleep, which as you know in our situation is a lot.

 

Relaxation exercises, guided meditations, calming videos, sleep hypnosi

 

Tricks and tips to fall asleep faster

 

http://articles.mercola.com/sites/articles/archive/2017/02/16/tips-tricks-fall-asleep-faster.aspx?utm_source=dnl&utm_medium=email&utm_content=art1&utm_campaign=20170216Z1&et_cid=DM133787&et_rid=188974895

 

This link contains helpful information, including insomnia and also non-drug coping skills.

 

 Important topics about symptoms, including sleep problem

 

Some members have found Melatonin helpful with insomnia.   

 

See Melatonin for sleep   It's best to start at a very low dosage, such as .25mg, and gradually increase if needed to the lowest effective dose.  

 

I found this post by Apace41, one of or moderators, to be helpful with not only tips but attitude about sleep.

 

There is, unfortunately, no "silver bullet" to withdrawal or any of its symptoms, including insomnia.  If there were, SA would be a much smaller site than it is at this point.  Sadly, it continues to grow as more and more people get caught in the psychiatric medication "web."

 

insomnia and disordered sleeping is a hallmark of psychiatric medication withdrawal.  It starts earlier than that with many studies making it clear that SSRIs (and other psych meds) frequently suppress REM sleep for those who take the meds.  https://www.sleepio.com/articles/sleep-aids/antidepressants-and-sleep/  Given this as a backdrop, it should be no surprise that coming off the meds can wreak havoc on sleep.  The good news, however, is that the brain works hard to achieve homeostasis and, all other things being equal, the brain will return to a place where sleep becomes, as it should be, a matter of routine.  How long that takes for any one person is impossible to predict.  

 

So, what do you do?  In no particular order, some of the things to try:

 

• Don't place too much significance on sleep.  Rest should be the key and when your body absolutely needs to sleep it will.  The anxiety that comes with lying awake and saying "I must sleep" is far worse than the not sleeping.  It's hard but it can be done.
• Try a journaling practice before bed -- get out the things that are on your mind and add 3 things you are grateful for from the day
• Get a sleep ritual in place so that you do the same thing day after day and start to repair your circadian rhythms
• Take a warm bath with epsom salts few hours before bedtime and add in a cup of chamomile tea
• Use lavender essential oils in a diffuser at bedtime
• Exercise early in the day so that you aren't activated near bedtime
• Get outside and get some sunlight early in the day so that your rhythms are reestablished
• Make sure you have a consistent bedtime 
• Try not to be too activated in the couple of hours before bed and, of course, no caffeine
• Add a meditation practice
• Try yoga
• Go for walks in nature

Most insomnia is the result of the body being "hyperstimulated."  It is very hard to calm down an overstimulated body, especially when it is the result of chemical cascades that come as a result of medication use and withdrawal.  But, it can be done to a certain degree and the skills learned will provide valuable as your body improves over time.  

 

From my own perspective, my sleep is still not great, but it it better than it was.  I went through many stretches of 2 or 3 days with zero or an hour or two a night of sleep.  At this point, I have the occasional sleepless night, but most nights I'm good for at least 5 and usually closer to 6 hours.  By "normal" people standards that's not great, but it feels pretty good when compared to 0 or 2-3 hours a night.  As the saying goes, "in the land of the blind the one-eyed man is king!"

 

Try not to let it become the dominant factor in your life.  Over time, it will get better and you will heal.  Just do your best to continue to live your life what your brain is repairing itself.

 

--

 

With the sexual situation, the only cure I know is time.

 

Weakness and losing your mojo is another typical WD symptom.  I'd relate it, at least for me, with the WD symptoms of apathy and anhedonia.  If you can manage to do a gentle 30-minute walk in nature, that would be helpful.

 

 

 

 

[AdviceNeeded]

Thank-you @Gridley, some really useful stuff in there 👍🏼

[AdviceNeeded]

Hi @Gridley and/or @Altostrata

 

Sorry to be a pest. I think I know the answer but would starting a micro taper in the next week be complete folly?

 

There are a few symptoms (such as elevated heart rate, general wiredness, anhedonia) that aren’t abating and I wasn’t sure if these could be an adverse reaction to the mirt. And I think I’m probably paranoid that the longer I have elevated levels of the drug in my system, the more damage it’s doing. 
 

You guys obviously have a wealth of experience and I just wanted to float the idea for my own peace of mind. Thanks.

[Gridley]

21 minutes ago, AdviceNeeded said:

would starting a micro taper in the next week be complete folly?

 

It's very good that your symptoms have settled down, but it's only been a month since your last dose change.  I'd continue to hold to let things settle.

[Altostrata]

6 hours ago, AdviceNeeded said:

elevated heart rate, general wiredness, anhedonia

 

What times of day do these symptoms occur? How do you feel before and after taking mirtazapine?

[AdviceNeeded]

Hi @Gridley & @Altostrata

 

Thanks for the replies.

 

The elevated heart rate is permanent compared to pre mirt but is worse in the morning.

 

The anhedonia is constant throughout the day. 
 

The general wiredness is fairly constant but does occasionally  abate in the evening.

 

I take the mirt at 10pm, usually asleep by 11, and awaken at either 2am or 4am. 
 

I normally feel quite calm in the evening prior to taking my dose, and then about half hour after taking it I get drowsy and chilled out prior to sleep.

[Gridley]

9 minutes ago, AdviceNeeded said:

awaken at either 2am or 4am. 
 

When you awaken, you might want to try taking a bit of magnesium, such as magnesium glycinate, maybe 50mg to start.  It doesn't always work for me when I wake up in the middle of the night but sometimes it does and I get a bit more sleep.

[Altostrata]

4 hours ago, AdviceNeeded said:

The elevated heart rate is permanent compared to pre mirt but is worse in the morning.

 

When did this symptom start? Did you have the elevated heart rate when you were taking 15mg mirtazapine August 25--September 15?

 

On 10/24/2020 at 3:08 AM, AdviceNeeded said:

I've actually started splitting it and doing 7.5 mg before bed for the sedation, and 7.5 mg when I wake up to try and chill me out

 

What times o'clock do you take these two doses? What is your symptom pattern before after the second dose?

 

Are you drinking any alcohol? Taking any other drugs?

[AdviceNeeded]

The elevated heart rate began 16th October, along with the anhedonia and general wiredness. 
 

Heart rate during 25th August - 15th September was normal.

 

I only did the dose splitting once as it didn’t seem to make much difference.

 

No alcohol or any other drugs (I was advised by the doctor to take propranolol as needed but only took it a handful of times as it didn’t seem to make much of a difference).

[AdviceNeeded]

Hi @Altostrata

 

I just wondered what your thoughts where as to the above? (I’m trying to make sense of what’s happened)

 

Also, do you think splitting the dose and taking half at 10 pm and the other half when I wake in the early am has an credence? Wondered whether it might help me get a few more hours of sleep. I didn’t want to make the gamble without your advice.

Thanks.

 

[Altostrata]

If the elevated heart rate occurred after you increased mirtazapine to 15mg, it's most likely an adverse effect of the drug. You may have become hypersensitive to it.

 

I might decrease mirtazapine 10% to 13.5mg to see if that helps. Tips for tapering off mirtazapine (Remeron) explains how to make a liquid for taking small doses.

 

Please let us know how you're doing.

[AdviceNeeded]

Hi @Altostrata

 

I've been on the 13.5 mg for a couple of days now, probably too early to make an assessment but things aren’t any worse thus far.

 

I really don’t think the Mirt is agreeing with me (the increased heart rate, anhedonia, etc). I’m full of regrets at the minute, but looking at it objectively I can only move on from where I find myself now. So, going forward... do you think stay on the 13.5 mg for the next 4 weeks and then continue to taper at 10% (symptoms permitting)? Get some daily light exercise and stay relatively busy? Act like I’m not emotionally numb (fake it)? Stick to a bedtime routine and hope sleep sorts itself out (I’m pretty certain the high heart rate is impacting sleep quality and duration)?
 

I think just having a rough plan is going to make me feel a little better, I just wanted to run it past you.

[Altostrata]

7 minutes ago, AdviceNeeded said:

the increased heart rate, anhedonia, etc

 

Are you getting this after you take 13.5mg mirtazapine? Has this changed since you lowered the dosage?

 

8 minutes ago, AdviceNeeded said:

Get some daily light exercise and stay relatively busy? Act like I’m not emotionally numb (fake it)? Stick to a bedtime routine and hope sleep sorts itself out (I’m pretty certain the high heart rate is impacting sleep quality and duration)?

 

Yes, do these things for the duration.

[AdviceNeeded]

Hi @Altostrata

 

Since taking the 13.5 mg I’d say the anhedonia is slightly (and I do mean only slightly improved), heart rate is generally the same (although I do think I caught it at the lowest it’s been for weeks earlier today) and I even felt the slightest of stirrings in my gentleman’s area while I was half asleep this morning (only mentioning as I figure it could be linked to the anhedonia).

[Altostrata]

Mirtazapine has a long half-life. A reduction you made 2 days ago will need a couple of weeks to take full effect. Since you've seen slight improvement, this should get a little better each day. Please let us know how you're doing.

[rupa]

On 11/26/2020 at 11:12 AM, AdviceNeeded said:

The elevated heart rate began 16th October, along with the anhedonia and general wiredness. 
 

Heart rate during 25th August - 15th September was normal.

 

I only did the dose splitting once as it didn’t seem to make much difference.

 

No alcohol or any other drugs (I was advised by the doctor to take propranolol as needed but only took it a handful of times as it didn’t seem to make much of a difference).

Hi,

All I can advice you to start tapering as per this site instructions,which I did and I achieved almost before meds state of mind.

Please keep a goal to come out of the chaoes.And work towards it ,steadily and slowly.

Give monthly intervals to reduce 10% As per tapering instructions of the site.

Please do not doexperiments.

Experiments would only lead to more choaos in the brain.

Believe the site.

Adopt healthy food habits.

Make a habit of reading story threads here,who did taper and achieved previous state of mind safely.

Time is nothing.

Reaching back to normal is important.

Time flies by.

Read every word of fellow sufferers as they mean it.No need to experiment and then only understand things.

[AdviceNeeded]

Hi @Altostrataand @Gridley

 

Hope you’ve both had a decent week. So, I’m a week into 13.5 mg and everything seems okay. In fact, I’d say there’s a few slight (very slight) improvements. Sleeping is still ropey but it has been for a while.

 

I’m increasingly convinced I’m reacting adversely to the mirt. I’m no expert but I feel like it’s too stimulating (could possibly be due to increased norepinephrine?). As such, would it be beneficial to carry on with a slow taper (such as 2.5% per week) in order to reduce the amount going into my system whilst hopefully avoiding any major withdrawal symptoms?

 

I had a medication review with my GP last week and he reckons all my symptoms are normal side effects and they’ll decrease as I continue on the dose (15 mg as far as he’s concerned). This is despite me explaining that the really uncomfortable effects appeared pretty much at the same time as the updose in mid-October.
 

Would welcome your thoughts and input.

 

Thanks.

[Altostrata]

It's very possible that you are taking too much mirtazapine for your sensitized nervous system. Yes, you might very gradually reduce the dosage. Please keep daily notes of your symptom pattern and let us know how you're doing.

[ChessieCat]

47 minutes ago, Altostrata said:

Please keep daily notes of your symptom pattern and let us know how you're doing.

 

This post explains what is required and why it has been requested:  

 

Keep Notes on Paper

 

Example:

DATE:

 

6 a.m. Woke with anxiety
8 a.m. Took 2.5mg Lexapro
10 a.m. Stomach is upset
10:30 a.m. Ate breakfast
11:35 a.m. Got a headache, lasted one hour
12:35 p.m. Ate lunch
4 p.m. Feel a bit better
5 p.m. Took 2.5mg Lexapro
6 p.m. Ate dinner
9:20 p.m. Headache
10:00 p.m. Took 50mg Seroquel
10:20 p.m. Feeling dizzy
10:30 p.m. Fell asleep
2:30 a.m. Woke, took 3mg Ambien (NOT "took 1/2 tablet Ambien")
2:45 a.m. Fell asleep
4:30 a.m. Woke but got back to sleep

[AdviceNeeded]

Hi @Altostrataand @ChessieCat

 

I’ll start taking notes today. I spoke with my GP yesterday (in the hope of getting some melatonin - it didn’t happen), and he finally acknowledged that I’m probably reacting adversely to the mirt. Apparently this isn’t a real problem... he reckons I can half the dose for a couple of weeks and then drop it - no problems! If only.

 

I have got a quick question with regards propranolol... I’m figuring withdrawal will be a long process... if the propranolol takes the edge off my increased heart rate would it be worth considering? I know the ethos of this site is anti-drug, but as it’s neither an AD or psychotic, what do you think?

 

Thanks. 

[AdviceNeeded]

Hello again,

 

My dearest girlfriend (who really doesn’t deserve any of this) has taken an interest in helping with my taper (she even suggested 10% every 4 weeks so may be a secret SA reader). So starting tonight she’ll be taking note of the dosages. Do you recommend sticking with 13.5 for a bit longer or making another slight decrease? Since dropping to 13.5 there have been a few slight improvements (less anxiety, less anhedonia, less agitation). However, I don’t want to be impatient but at the same time am keen to get down to a level where the (possibly) adverse reactions aren’t too bad. 
 

Thanks for all that you do.

[RickyIsHealing]

hello Advice 

i was on the same tablets for around about the same time ..if you check my signature you can see my taper process ..i tapered  rather fast but i had to get off the drug as it was doing nothing but making everything worse!

the whole of this site recommends at 10% or 5% drop depending on how you feel so i guess you have to listen to your body.

I've been off since the 12th of November this year.

current symptoms 

Anxiety ( sometimes severe  )

Spells and days of a really low , sad miserable mood.

restlessness 

and my sleeping is just , meh , sometimes 4 - 5 hours , sometimes 2-3 

i hope it gets easier for you mate ! 

one foot in front of the other , one day at a time 

ALSO one thing that has helped me is to review how you feel every week compared to everyday! 

[Altostrata]

You reduced to 13.5mg about 10 days ago? With no bad effects?

 

Please be sure to keep notes of dosage changes. You might make another 10% reduction (1.35mg) in a few days -- reducing every 2 weeks. If you get withdrawal symptoms, you'll have to slow down. Please let us know how you're doing.

 

12 hours ago, AdviceNeeded said:

if the propranolol takes the edge off my increased heart rate would it be worth considering?

 

Have you tried propranolol already? How did the reduction to 13.5mg affect your heart rate?

[AdviceNeeded]

Hi @Altostrata

Thanks for the reply.

 

I’d say there were a few slight positive effects after the drop to 13.5 mg. Sleeps still extremely poor but it has been throughout so I’m not sure how much of that I can attribute to the drop.

 

I’m not sure the drop had a much of an effect on heart rate, although I do remember catching it at it the lowest it’d been for a while a couple of days later.

 

I tried the propranolol again a couple of days ago and it appeared more effective than previously. I think I’m settling my mind into the fact I’m in this for a while and am trying to make myself as comfortable as possible.

 

Notes will follow.

 

 

 

 

 

[AdviceNeeded]

Hi @Altostrataand @ChessieCat
Daily Notes

 

3am Woke up - couldn’t get back sleep but felt comfortable so stayed in bed.

5:45am - decaf tea and cereal followed by chores.

7:30am - felt fatigued so rested in bed.

10am - 20 mg propranolol

10:30am - still fatigued but went to visit mum. Low mood.

12:30pm - cheese salad sandwich and soup.

1:30pm - fatigued, sense of surreal ness - rested in bed.

4pm - drove home - fatigue and low mood

6:30pm - made dinner: pasta and garlic bread.

7pm - 20 mg propranolol

7:30pm - fatigue turns into tiredness, lots of yawning, mood lifts slightly.

9:30pm - 13.5mg mirtazapine (homemade suspension)

10pm - bed - fall asleep quickly 

2am - wake up very alert, aware of mild tinnitus, busy mind - unable to get back to sleep.

 

The pattern of feeling fatigued yet wired is pretty consistent day on day. As is waking up after 4 hours feeling super alert. My cognition isn’t great at the minute either.

 

People close to me tell me they’ve noticed an improvement over the past few weeks - when I first went back up to 15 mg I was extremely agitated and restless. The consistent 4 hours a night (max - sometimes a lot less) is taking its toll though. I feel like my adrenaline is constantly up.

 

I’m planning on dropping 10% tonight. I really feel like this is an adverse reaction the mirt and am hoping it brings a bit more relief. At the same time I don’t want to rush off it and cause myself more problems.

 

As always, thanks and I welcome your thoughts and comments.

[AdviceNeeded]

Can someone post a link for editing/updating my signature please? I can’t find it. Ta.

[Gridley]

20 minutes ago, AdviceNeeded said:

Can someone post a link for editing/updating my signature please? I can’t find it. Ta.

Account Settings – Create or Edit a signature.

 

[AdviceNeeded]

@Gridleythanks

 

@Altostrataand @ChessieCat

 

Daily notes

 

02:00am woke up, wide awake but stayed in bed to rest, felt low and listless

05:45am breakfast and chores

07:00 felt fatigued so returned to bed to rest

10:00 20 mg propranolol

10:30 drove to mums, felt a little more positive

12:00 lunch

02:00 pm 2 mile walk - felt more optimistic 

06:00 propranolol

06:30 evening meal, mood drops

09:30 12.15 mg mirtazapine

10:00 bed - fall asleep quickly, sleep solidly for 4 hours

 

Main symptoms throughout day - poor sleep duration, anhedonia, mild tinnitus, poor concentration, frustration.