FutureDoc1: SSRI Post-Withdrawl Akathisia - sertraline / Zoloft

[FutureDoc1]

Hello, I am currently a 28 year old male who took Zoloft for about 6 years from 2016 until 2021 where I tapered from a dose of 100mg to 0 over the course of about 3 months. The sertraline was great for me for a long time and very well tolerated. I decided to come off because I had felt like therapy, tandem with years of practicing to manage my OCD would allow me to continue life without the crutch of Zoloft anymore. Final dose was around half way through September 2021. I had minor withdrawal symptoms like brain zaps and mild aggitation but nothing major. Felt the best i'd ever felt for about 3 months from mid-September to mid-December 2021. Then, one day out of nowhere, there was a day that a major stressor of student loan debt sent me into an unbearable and sustained spiraling episode of inner restlessness, pacing for hours, inability to sit still, and I was and still am worried that I will never feel better and that the SSRI for years has done permanent damage to me. I have been diagnosed clinically with OCD by my Psychiatrist and ruled out for psychosis, schizophrenia, and Bipolar/mood disorders. I do have occasional panic attacks, but this feeling is like one long-sustained panic attack without the resolution and feeling better after 20 minutes or so. I have a great Psychiatrist but he doesn't believe me that what I am feeling is different from the OCD, and is in-fact much more intense and alarming. I have been reinstated on Sertraline and titrated back to 75mg again as of a few days ago, with the addition of 1mg daily clonazepam to relieve the symptoms of what my doctor calls "titration discomfort". I feel marginally better with some good days and some bad days, now with about 4 weeks of a zoloft reinstatement under my belt, but my fear is that the sertraline (Zoloft) has left me with a permanent damage. I am a medical student studying for my board exams coming up over the summer and have recently married my beautiful wife. I cannot imagine a world where I do not get better and get back to my dream of becoming a doctor and sustaining a manageable state of mental health. The term i've been finding recently is "tardive akathisia" coming 3-6 months post the termination of an SSRI and I was wondering if anyone might be able to weigh in with their own experiences or provide advice on how I may get better and eventually get off these meds for good. I am a HUGE proponent of CBT and ERP and managing my OCD with therapy rather than pharmacology, but I was reassured by my physician that SSRIs are safe long-term and that I could be on them for life without ever having an issue. I apologize for the length of the post, I am just a very thorough person and my background in medicine as a medical student has taught me to provide full case details 🙂 I hope there is someone out there who has been in a similar situation as me and overcome these feelings because at present, I feel like I will have to deal with this for the rest of my life, and I am questioning whether the reinstatement of the very source of my issues will eventually make another attempt at a slower taper in the future worse than this previous initial attempt. Thanks!

[FutureDoc1]

Quick note: The akathisia I describe is a sensation of intense restlessness like it is a ball of massive anxious energy in my chest that at times can make me feel like I want to crawl out of my skin. I get an intense burning sensation like a bad sun burn on my arms and neck, and my legs will constantly want to tap, flex, curl, or my foot will bounce on my ankle. I can consciously resist the urges so move and the movements are mostly if not always voluntary. The pacing and symptoms are a waxing and waining occurance with windows of where i'm feeling great and like my "old self", and a return with insidious onset to the previously mentioned symptoms. I am better from the first initial episode of these feelings late december 2021, but I would like to know if anyone has succesfully reinstated, tapered again more slowly, and if the feeling of delayed-onset akathisia returned to them or not. Thanks!

[Onmyway]

Dear @FutureDoc1

Welcome to SA. I'm so sorry that you're going through akathisia. It is one of the most uncomfortable feelings that I've had to deal with as well. Let me reassure you, it does get better. Mine resolved with the reinstatement of 2.5 mg of citalopram within a month of stopping and have not returned with slow tapering from 2.5 to 0.8 though I do get an 'on edge', muscle jerks feeling when I cut my dose but at a level 10x less than what I had and perfectly tolerable.

 

So this will get better. In terms of CBT you're catastrophizing and fortunetelling  Also remember to not disqualify the positive - improvement of some of the symptoms.

 

I'm going to send you links to more resources tomorrow but wanted to reassure you that you will be ok and you can eventually taper once stabilized. 

 

Two things to be cautious about right now

1) Clonazepam - try not to get dependent on that in the process  as you will then have to slow taper that as well. If you can handle not being on it you might wish to stop it either with a very quick taper or cold turkey. 

 

2) your reinstatement dosage is higher than what we recommend -we suggest 1-2 mg as a trial in case you have become too sensitive. But if it hasn't made things worse you can stay on this dose and stabilize. I would not increase further.

 

Here you can find out more about what we have learned. 

https://www.survivingantidepressants.org/topic/7562-about-reinstating-and-stabilizing-to-reduce-withdrawal-symptoms/

 

This will get better but it may take some time to get there, you're not permanently damaged (it's a common concern).

 

Take care of yourself. You've found the right place to get support.

 

OMW

Edited January 18, 2022 by Onmyway
Autocorrect Typos

[Onmyway]

Hi @FutureDoc1, 

a few more important links if you haven't seen them yet. Please update us how you are feeling. It might help to separate your clonazepam and sertraline doses and see whether the sertraline is having side effects which the clonazepam might mask. 

 

WHAT’s HAPPENING AND WHAT TO EXPECT

The Windows and Waves Pattern of Stabilization - Symptoms and self-care - Surviving Antidepressants

What is happening in your brain? - Symptoms and self-care - Surviving Antidepressants

How psychiatric drugs remodel your brain - Symptoms and self-care - Surviving Antidepressants

 

WHY TAPER SLOWLY

Why taper by 10% of my dosage? - Tapering - Surviving Antidepressants

Why taper? SERT transporter occupancy studies show importance of gradual change in plasma concentration - Tapering - Surviving Antidepressants

 

 

SUCCESS STORIES

Success stories: Recovery from psychiatric drug withdrawal - Surviving Antidepressants

 

SUPPLEMENTS

In WD many of us are sensitive to psychoactive substances and so we recommend that you don't take them - alcohol, pot etc. We are also sensitive to some supplements - some in the vit B family and vit D as they tend to be activating (make us feel anxiety/on edge). You might want to limit those if you are not deficient.  Most of us, however, find magnesium calming. So magnesium and Omega-3 we recommend you take. Below is our experience with them. 

https://www.survivingantidepressants.org/topic/15483-magnesium-natures-calcium-channel-blocker/

King of supplements: Omega-3 fatty acids (fish oil) - Symptoms and self-care - Surviving Antidepressants

 

FROM THE MEDICAL LITERATURE

As a medical student, you may find this section interesting 

From journals and scientific sources - Surviving Antidepressants

 

This one is based on the learnings from Surviving Antidepressants

 

[FutureDoc1]

Thank you @Onmyway so much for the excellent post and encouraging response. Reading this gave me a new spark of hope!

 

While I have an excellent psychiatrist, and he is very conservative (relative to most) when it comes to drug prescription, he advised me to reinstate and at the regular schedule at which one would begin the drug again, at the classic initial dosages and increase intervals. Hence the 25 to 50 to 75mg sequence at 2 week intervals. I do not plan on increasing from 75mg, and had I known about this site I would have trialed a small dose reinstatement. Life doesn’t always have the best timing but what can we do, gotta just move forward. Also, on the topic of Clonazepam, my doctor has already made it abundantly clear that this will be the first, last, and only course of Benzos that I get from him with a 30 day max and a taper imminently soon. Rest assured that I am well aware of the dangers of benzodiazepines long-term, and other drugs for that matter. As a future physician they will play an important role in the management of some of my patients, and when used correctly in short course can even be lifesaving, but I will certainly be a highly conservative provider nonetheless. I constantly struggle with my thoughts and the evidence behind the therapeutic index of benzos and opioid pain killers, but this would be a different post for another day!

 

Something that stood out to me the most is the windows and waves that you mentioned in your post. I’ve found myself having days where I felt like my normal self for as long as 2 days straight, followed by days where the restlessness and inability to sit still feel overbearing. At the pinacle of a wave I even experience intense intrusive thoughts or a feeling like I’m unsafe in a perfectly safe environment most, likely due to the distress of the physiological symptoms. I am now getting used to the feeling and have less distress about the occurrence, but the initial onset was definetly a truly horrifying feeling of “I think I’m losing my mind!”

 

I can also appreciate the catastracizing and forecasting component you mentioned, as this is a difficult issue I struggle with from the OCD. What is frustrating about all of this is that for the 3 month window from drug free to withdrawal/Akathisia, I had been able to remain in control of the intrusive obsessions and ‘doom and gloom’ thoughts that I had experienced prior to therapy and SSRIs. What I take this to mean, however, is that I now know I am completely capable of living a life without the drugs and I will remember that feeling throughout my new journey of however long it takes to once again become drug free.

 

I am going to do my best to go day to day, and just focus on the small victories and let the setbacks come as they will. My plan is to stay the course and take as long as my system may need to return to a consistent steady state, and then eventually use the guideline for a much slower taper.

 

I do, however, have another question for those who have tried to taper again after reinstatement. Does Akathisia following the first trial of tapering (following years of being in an SSRI) predispose to future Akathisia? As you had mentioned, my fear of permanent damage or altered brain chemistry still lingers, and I am doing my best to believe it is not the case. In time, I’m sure this thought will pass too. But my new fear is that I will stabilize on 75mg sertraline, slowly taper, have another window where I feel great for months, and then slam back into Akathisia… the future is uncertain to all and I completely understand that, but if anyone was successful in tapering again after reinstatement without a recurrence or Akathisia (not the brain zaps or other classic symptoms which I can much more easily live with) I would appreciate the insight!

 

P.S. I will absolutely review the resources you have provided over the next few days. Thank you onmyway for the amazing response, and I am glad to have found SD!

[FutureDoc1]

@Onmyway forgot to tag you in the post above, still learning the lay of the site!

[Boris]

Mine would always come 3months after each taper (very fast first 2 attempts). No one would believe me either and I always use to point out the 3 month time frame and be told it was my original condition coming back. I never had it before going on paroxetine, I went on for stress concerning RSI.

 

I added fuel to the fire with reading and convincing myself it was permanent. I decided no more and held everything at its current dose and found some stabilising windows over the months. I stopped reading or researching anything. I only came here after I finally got off and it had subsided and some other issues that started.

 

So any way my point is I finally stopped nearly 5 years ago with paroxetine that originally caused my akathisia and I’m just over 4 years since I last experienced it. I slowly tapered over 5 years that last 5mg with flares of akathisia and an episode that came and went after finally stepping off. I was really obsessive and still are on other subjects in life.

 

Basically I had to make sure I added no more meds, wait for stability, slowly taper and try to avoid stress. Avoiding stress didn’t really always happen with the way I am.

 

It is such a cruel side effect but it really is time and acceptance. I did have one gp who said me it doesn’t matter how you got to this point now but we need to look forward. I use to go over and over my same story at times.
 

I rarely think about it now but I’m always on the guard for anything that could set it off.

[Onmyway]

Dear @FutureDoc1, 

 

we can't predict with certainty that akathisia will never return while you are tapering but if you do it after stabilization and very slowly, it is very likely that it won't. If it seems like it is coming back, you will hold at that dose or you may updose a bit. You will learn how to manage it. You now have more resources than you did and we will help you. Once you have read all of the materials earlier, things will start making more sense. I had akathisia in the beginning, reinstated, it went away and I have been tapering very slowly now for 3 years since then (with long breaks) and it has not returned. I do sometimes get an on-edge feeling or RLS or muscle jerks but not akathisia. What I have done and what you can do is that once you feel withdrawal symptoms coming on, you can hold at that dose until your nervous system settles. Basically, with tapering you are in charge and ready to intervene - you are allowing for the nervous system to adjust to each small change and not letting it into a full blown disequilibrium where lots of other parts of the system are disturbed. I like to think of it as the system is changing but within the bounds of its tolerance level sort of like jenga. 

 

Now on the topic of whether you can live without the SSRIs. The evidence, after having read quite a lot of the medical literature, is that the SSRIs are working as a glorified placebo albeit with side effects and potential for cruel withdrawal. The chemical imbalance theory is a myth with no backing and it is not supported by empirical data. The theory came after people started observing that the drugs made some people happy and then they reasoned that it must be because these drugs work in XYZ way and if they work then you might have an imbalance in XYZ. It is as idiotic as saying that if you take MDMA and you feel empathy then I must have had oxytocin deficiency. The brain is complex, the neurotransmitters (the ones that we know about) work interdependently with lots of other chemicals and hormones so to claim that one chemical is not in balance is silly esp since we can't actually measure neurotransmitters in the brain. 

 

Psychiatrists claim that they never promoted the chemical imbalance myth but that is not true (my psychiatrist at the time told me of it) and this misinformation can easily be proven. Here is, at last, the former head of the APA distancing himself from it. 

Debunking the Two Chemical Imbalance Myths, Again (psychiatrictimes.com)

 

Here's a summary of the research on ADs and the placebo effect 

Antidepressants and the Placebo Effect (nih.gov)

 

This is really hard to learn about for people for whom the drugs 'worked' and/or did not cause horrible side effects. I had a crisis of faith when I found out because I believed in my ADs. The question then becomes - what will happen to my original disorder. First of all, the fact that you had OCD does not mean that you will always have OCD - it is treatable. Second, OCD can be managed through cognitive restructuring and therapy (various kinds - I'm a fan of IFS recently but CBT, ERP also have success). I have had OCD 3 times in my life. First time as a teenager where it went away in a few months. Then in college (when I got the SSRIs) and it was the result of a very big decision I had to make. And then while on the SSRIs - that one lasted for over a year - longest episode while on citalopram. All of these resolved with or without SSRIs. In my case they were due to childhood trauma. I have friends for whom OCD became activated after they had their babies but in all cases it was manageable and eventually lessened or went away.

 

It is important to know that during withdrawal OCD-like symptoms are common - rumination/obsession. They are common also for people who have NEVER had such symptoms before withdrawal. This does not mean that your OCD is back. This is now brain chemistry not some disorder - you had flooded your brain with serotonin while on the SSRIs. Your receptors downregulated. Now you withdrew the serotonin and the receptors are still downregulated so by the time they adjust you have a deficiency of that neurotransmitter which work sort of like a brake on the system - hence the emotional spirals about which you may have read on the site and the ruminations/obsessions.

 

You need to remember that this is not an indication that your symptoms are returning. This will pass with withdrawal. Try not to feed it with reassurance seeking or avoidance behaviors. You will notice how the symptoms disappear in windows (like they did for you) and how they may be bad during waves. All this tells you is that this is your brain healing, going through this predictable process of waves and windows - sort of like how a wound heals, first you get swelling, then a scab, then itching, then discoloration then eventually it's healed. You may have a scar as in you may be for a while sensitive to psychoactive substances or you may be traumatized by this process but you will heal. Your brain is plastic. 

 

This is my favorite article on the site - it's about benzo withdrawal but SSRI withdrawal is similar too. 

What is happening in your brain? - Symptoms and self-care - Surviving Antidepressants

 

Please keep us updated on how the reinstatement is progressing and take good care of yourself. 

OMW