Duncan Double claims withdrawal symptoms are solely psychological

[Altostrata]

Torturing logic, Duncan Double, of the UK's Critical Psychiatry Network, concludes that antidepressant withdrawal symptoms are psychological in nature.

 

What does it mean to say that antidepressants are not addictive?

Monday, September 24, 2012

http://criticalpsychiatry.blogspot.com/2012/09/what-does-it-mean-to-say-that.html

 

The Royal College of Psychiatrists has published a leaflet with the results of a survey about coming off antidepressants, which I mentioned in a previous post. Generally, I think this is a helpful leaflet. However, it ends with a throw-away remark, "We would like to reassure readers that despite some people having symptoms of withdrawal when stopping antidepressants, antidepressants are not addictive".

 

I think what is meant is that there is no evidence that the body gets addicted with antidepressants. However, people can get psychologically addicted and it seems confusing to restrict the use of the term 'addiction' to physical addiction. GlaxoSmithKline, the makers of paroxetine, eventually dropped its insistence that paroxetine is not addictive, I think at least partly because of this confusion (see Guardian article).

 

Helpfully, the survey confirms that the primary symptom of antidepressant discontinuation is anxiety. This would fit with my argument that antidepressant discontinuation problems are due to psychological dependence....

[Altostrata]

I am having a great deal of difficulty following Dr. Double's logic and have made a number of comments. What do you folks think?

 

[oldest comments posted first]

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Altostrata said...

 

Your current theory that antidepressant discontinuation problems are due to psychological dependence is dead wrong, Dr. Double.

 

I cannot express vehemently enough that withdrawal symptoms are mostly physiological. For the most part, they represent autonomic dysfunction, resulting in a wide range of symptomology.

 

"Brain zaps," for example, a variety of Lhermitte's sign, are seen only in psychiatric drug discontinuation and, by the way, are not benign as they indicate disrupted electrical functioning in the nervous system.

 

Anxiety is the primary symptom of withdrawal because lack of feedback by the downregulated serotonin system results in disinhibition of the alerting system (Harvey, 2003).

 

While it's true some people may become psychologically attached to the idea their drugs are a dam against a flood of distress and may be fearful of discontinuing them, hundreds of thousands of patient reports of severe withdrawal symptoms following the autonomic dysfunction model (not to mention thousands of published case reports) demonstrate difficulty in discontinuation is NOT due to psychological factors.

 

It's probably a small minority who worry themselves into "withdrawal symptoms." You may have observed patients reporting withdrawal symptoms when they accidentally forget a dose -- no anticipatory anxiety involved.

 

There is real reason to taper slowly to avoid withdrawal symptoms.

 

Antidepressants cause physical dependence. Whether or not you call this addiction is a question of semantics.

 

I am deeply appalled that you are in the camp of blaming the patient for antidepressant withdrawal symptoms. This kind of rationalization cause vast patient harm, as physicians discount their reports of withdrawal difficulties and further obscure a very definite drawback of antidepressants.

25 September 2012 18:43

 

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Duncan Double said...

 

As I've said before, Allostrata, I'm not blaming patients for antidepressant withdrawal symptoms. I think I was one of the first to recognise them in a letter to the BMJ in 1997.

 

Here's what I wrote then and I haven't changed my views since:-

 

Robert G Priest and colleagues advocate educating patients that discontinuing antidepressant treatment will not be a problem but remarkably do not cite any evidence to support their recommendation.1 They also complain that many lay people regard antidepressants as addictive. They suggest that people may be extrapolating from what they have heard about benzodiazopines. This may be, but it is also common sense to believe that discontinuing taking a drug that is thought to improve mood may be difficult. I think that the general public understands this issue better than the Royal Colleges of Psychiatrists and General Practitioners, which are responsible for the Defeat Depression Campaign.

 

Of course what Priest and colleagues mean is that there is little evidence of physical dependence caused by antidepressants, but this is not what they say. There are, however, case reports of a withdrawal syndrome.2 Clinical experience is that it can be difficult to withdraw treatment with antidepressants for various reasons. The general public might reasonably expect psychiatrists specialising in disorders of the mind to recognise psychological dependence, base their advice on clinical experience, and use their common sense.

 

Randomised controlled trials of discontinuation of antidepressant treatment have a relapse rate varying from 92%3 to 36%4 in the placebo group. Relapse rate is significantly reduced by continuing antidepressant treatment. Some patients therefore do maintain their therapeutic gains when antidepressants are withdrawn, but the relapse rate is not insubstantial and seems to support the general public's commonsense view rather than the Defeat Depression Campaign's purist scientific statement. Perhaps the public needs to be suspicious of the motives of a campaign that encourages them to seek medical treatment and also tries to help doctors recognise depression. Patronising misinformation is not constructive.

 

References

1.Priest RG,et al Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996;313:858#9. (5 October.)

2.Charney DS,et al Abrupt discontinuation of tricyclic antidepressant: evidence for noradrenergic hyperactivity. Br J Psychiatry 1982;141:377-86.

3. Prien RF et al.Lithium prophylaxis in recurrent affective illness. Am J Psychiatry 1974;131:198-203.

4.Klerman GL et al Treatment of depression by drugs and psychotherapy. Am J Psychiatry 1974;131:186-91.

25 September 2012 19:27

 

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Altostrata said...

 

Dr. Double, are you saying the patients have psychological reactions beyond their control, in addition to neurophysiological withdrawal reactions?

 

If that is your position, it needs clarification, but we can agree.

 

One very, very common and distressing psychological reaction is that patients discover how little their doctors know about these drugs or their adverse effects. The betrayal of trust is experienced deeply and emotionally.

 

Getting back to your initial article, let us look at the use of the term "anxiety" as reported to the Royal College of Psychiatrists in its withdrawal survey.

 

Patients are often at a loss to describe withdrawal symptoms. "Anxiety" may be as close as they can come to that unprecedented, unimaginable bone-shaking inner tension that is withdrawal anxiety.

 

There is, of course, a range of severity of this reaction. At one end, you have "anxiety" that might be mistaken for normal anxiety -- except it comes in waves, out of the blue, stays for a while, and vanishes, like storm clouds blowing away, leaving blue sky.

 

At the other end, you have akathisia. Patients don't know this term, and may describe their feelings to the doctor as intense anxiety, fear, terror, inner vibrations, unbearable restlessness, etc., any of which the doctor may interpret as anxiety.

 

Beyond akathisia, there is uncontrollable extreme anger, rage, or fear, or depression. In ths state, patients may kill themselves or others.

 

(Simply having these bizarre symptoms will cause a patient to become quite understandably distressed, which might be understood as a garden-variety psychological reaction.)

 

Survey instruments simply do not have enough choices to describe withdrawal anxiety, or any withdrawal symptom that might be mistaken for an emotion.

 

Withdrawal syndrome sufferers have coined a term, "neuro-emotion," to describe those quasi-psychological symptoms magnified by neurological dysfunction, see http://tinyurl.com/8hunn2u

 

It's quite likely that the "anxiety" found by the Royal College of Psychiatrists refers to all of this and more.

 

A nervous system deranged by withdrawal produces symptoms that are far beyond any known range. You have to look into the literature on Cushing's syndrome and traumatic brain injury to grasp them.

 

This is what comes of trying to fit the round pegs of withdrawal symptoms into the square holes of standard psychiatric parlance.

25 September 2012 23:07

 

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Altostrata said...

 

The RC Psychiatry survey instrument is still visible at http://www.surveymonkey.com/s/5MVZ7SQ , and a blunt instrument it is, too.

 

Of the 30 or 40 symptoms recorded for antidepressant withdrawal, the survey chose to provide checkboxes for these six:

- Stomach upsets

- Flu-like symptoms

- Anxiety

- Dizziness

- Vivid dreams or nightmares

- Sensations in the body that feel like electric shocks

 

And a text box in which the user may specify Other.

 

This guarantees that reporting will be skewed towards the listed withdrawal effects provided with checkboxes.

 

The survey provides a duration and severity scale for each of the six listed symptoms.

 

- Mild (uncomfortable, but no big deal)

- Moderate (annoying, but did not significantly affect my daily life)

- Severe (intolerable and affected my ability to function as usual)

 

 

This is how the leaflet presents the information garnered from the symptom frequency-severity scale:

 

"Of the common symptoms reported, the one rated severe by most people was anxiety. The symptoms that were rated moderate by most people were stomach upsets, flu-like symptoms, dizziness, vivid dreams and electric shocks/brain zaps. The less common symptoms were reported as severe: returning depression, headache, suicidal thoughts, insomnia, fatigue and nausea."

 

I would have liked to know how many people reported being severely affected by each of these symptoms.

 

Note that "severe" means "intolerable," and apparently a good chunk of those reporting "anxiety" reported it as "severe" -- not your garden-variety kind of anxiety.

 

One significant finding noted by the leaflet: "People in our survey report that the symptoms generally lasted for up to 6 weeks. A small percentage of symptoms lasted longer than this. A quarter of our group reported anxiety lasting more than 12 weeks."

 

To me, this indicates the received wisdom that withdrawal syndrome lasts only a few weeks is absolutely wrong. And, in fact, prolonged withdrawal syndrome of months or even years is much, much more common than medicine has so far confessed. (Ask Peter Haddad about this.)

 

As for the "relapse" reported in the leaflet after quitting ("63% of people in our survey said they had experienced withdrawal or a return of depression."), I suggest that this survey, as well as almost every paper written about antidepressant discontinuation, is contaminated with misdiagnosis of attenuated withdrawal symptoms as garden-variety "depression" or "relapse." Very few studies include protocols to distinguish between withdrawal-induced depression ("neuro-depression") and normal depression, utilizing survey instruments almost as dumb as this one.

26 September 2012 17:36

 

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Duncan Double said...

 

I think where we're agreed, Altostratus, is that antidepressant discontinuation problems are real and can be prolonged.

26 September 2012 19:46

 

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Altostrata said...

 

Dr. Double, perhaps I've misunderstood your statement in your recent blog post: "antidepressant discontinuation problems are due to psychological dependence" [rather than physical dependence]. Could you please explain it?

 

There is plenty of evidence that antidepressants cause physical dependence. The reason they are not considered "addictive" is that in the 1987 DSM-III revision, the American Psychiatric Association deliberately redefined "substance dependence" so that it did not apply to antidepressants.

 

The exemption of antidepressants from addictiveness is carefully described in NICE guidelines CG90 Depression in adults: full guidance 28 October 2009 http://guidance.nice.org.uk/CG90/Guidance/pdf/English

 

This semantic distinction has been enshrined in every reference to antidepressant withdrawal symptoms, and it is to this I believe the RCP leaflet refers.

 

However, see Nielsen, 2011 What is the difference between dependence and withdrawal reactions? for a counter-argument.

27 September 2012 03:30

 

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Duncan Double said...

 

Perhaps we need to debate what the evidence is for physical withdrawal - you don't say what it is.

27 September 2012 09:35

 

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Altostrata said...

 

Are you looking for visual evidence of nerve damage? Is it your contention that all symptoms have a psychological rather than neurological origin?

 

How do you account for the fact of downregulation? Do you think the receptors immediately bounce back?

 

See Harvey, 2003 rodent studies.

 

There are thousands of papers on psychiatric drug withdrawal syndromes. In PubMed:

 

http://www.ncbi.nlm.nih.gov/pubmed?term=ssri%20withdrawal%20syndrome

http://www.ncbi.nlm.nih.gov/pubmed?term=ssri%20discontinuation%20syndrome

http://www.ncbi.nlm.nih.gov/pubmed?term=antidepressant%20discontinuation%20syndrome

http://www.ncbi.nlm.nih.gov/pubmed?term=antidepressant%20withdrawal%20syndrome

 

and so forth, also search for "paroxetine withdrawal syndrome," "venlafaxine discontinuation syndrome," "quetiapine withdrawal syndrome," etc.

 

I've got a collection of papers here http://survivingantidepressants.org/index.php?/forum/16-from-journals-and-scientific-sources/ , with highlights here: http://survivingantidepressants.org/index.php?/topic/317-important-topics-in-journals-and-scientific-sources/

 

Here's a clinical guide to Adverse Syndromes and Psychiatric Drugs by Peter Haddad, a major psychiatric researcher in withdrawal syndrome: http://books.google.com/books/about/Adverse_Syndromes_and_Psychiatric_Drugs.html?id=uV1rE_hOvJ8C

27 September 2012 19:45

 

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Altostrata said...

 

Here are 365 case histories http://tinyurl.com/3o4k3j5

 

Many of these people went off cold turkey or too fast, with no particular apprehension other than they wanted to exit medication as quickly as possible.

 

They would have vastly preferred not to have withdrawal symptoms, but they did, quite severely.

 

Among these 365 case histories of withdrawal syndrome are only a few who express any fear at all about saying goodbye to their drugs. Almost all wanted to be rid of them and the merry-go-round of psychiatric treatment.

 

There is plenty of psychological trauma in withdrawal, mainly because of the realization of betrayal of trust, but not much of what you would call psychological dependency on the drugs.

 

If there is no psychological dependency or expectation of withdrawal symptoms, the complaints must represent authentic neuropsychiatric symptoms -- unless you want to contend there is an epidemic of factitious illness among people who coincidentally also have discontinued psychiatric medications.

27 September 2012 19:54

[Barbarannamated]

I am not familiar with his past statements, but this is appalling!! I'm trying to follow his reasoning and it sounds exactly as you have said: psychological issues that circle back to patient issues.

 

You're doing great. I'm speechless.

[compsports]

Great job Alto.

 

I am absolutely stunned at what this guy has said but I guess I shouldn't be shocked.

 

CS

[Barbarannamated]

This upset me badly last night.

 

Even though I'm not very familiar with this person, I knew of Alto's respect for his work and I know that respect is not easily won.

 

I feel betrayal that is even harder to deal with because it's by someone I thought *knew* the truth. To say that withdrawal symptoms are "psychological" is the same (to me) as saying "it's all in your head". Also, the fact that I never had a positive response to SS/NRIs, even temporarily, puts a different spin on this. I didn't have a response or improved mood to want to return to. For me, the anxiety/akathisia was uncomfortable, but energizing. I was far more functional in acute withdrawal than now in protracted withdrawal.

 

I plan to comment on the blog. I will include my comparison between opiate withdrawal and Pristiq withdrawal (the latter being far worse).

 

Thank you, Alto. I read your responses in awe. I am humbled and amazed at your knowledge and tireless work that has helped and will help many people in the future.

 

EDIT: To what "randomized, controlled trials of discontinuation" is he referring? The last I knew, they we're extremely limited and included subjects on relatively short term treatment and followed for only a few weeks.

[Altostrata]

I have respect for him in that he's been critical of psychiatry. That is fast being eroded.

[Altostrata]

Oh, please do post your personal experience.

 

David Healy says he doesn't understand Duncan Double's worldview.

[Altostrata]

Altostrata said...

 

See Advances in Psychiatric Treatment (2007) 13: 447-457

Recognising and managing antidepressant discontinuation symptoms

Peter M. Haddad and Ian M. Anderson

 

"....The syndrome was initially reported in case reports and adverse drug reaction reports (Haddad, 1998) but its features have been confirmed in several double-blind studies in which SSRI treatment is briefly interrupted with placebo (Rosenbaum et al, 1998; Michelson et al, 2000; Judge et al, 2002)....

 

Fava et al (1997) reported that during the 3 days following stoppage of venlafaxine and placebo under double-blind conditions, seven (78%) of nine participants treated with venlafaxine and two (22%) of nine placebo-treated individuals reported the emergence of adverse events, a statistically significant difference...."

 

Now, why would blinded patients react psychologically or psychosomatically to a discontinuation of which they are unaware?

 

"....Among the SSRIs several prospective studies have show that paroxetine is associated with the highest incidence of discontinuation symptoms and fluoxetine the lowest (Rosenbaum et al, 1998; Michelson et al, 2000; Bogetto et al, 2002; Judge et al, 2002; Tint et al, 2007)...."

 

Why would there be variation in psychological or psychosomatic withdrawal symptoms among antidepressants?

 

How does your theory of withdrawal syndrome being a purely psychological (or psychosomatic) reaction explain the following symptoms as reported by Haddad and confirmed by many, many other sources (as you can see from my post above, too numerous to list):

- Electric–shock-like sensations ("brain zaps") (associated only with drug withdrawal; very unlikely patients have prior experience with this)

- Akathisia (exists only iatrogenically)

- Parkinsonism

- Cardiac arrhythmias

- Extrapyramidal symptoms

- Irregularities in blood pressure

- Generalised seizures

- Neonatal withdrawal symptoms

 

In addition -- not covered in Haddad, 2007 -- how does your psychological (or psychosomatic) theory explain that people who intentionally quit abruptly develop withdrawal symptoms?

 

How about those who never felt any benefit from the drug?

 

How about those who loathe their medication and its side effects?

 

All of these groups get withdrawal symptoms (in a range of frequency and severity), yet have no psychological attachment to the medication.

 

How about those who inadvertently forget to take their medication? They aren't even aware they've quit. This happens quite frequently. It's the way most people become aware they're physically dependent on the drug.

 

28 September 2012 21:59

[Altostrata]

Barb, was that your most excellent comment?

[compsports]

Just posted this. Needless, to say, I am not happy.

 

Dr. Doubleday,

 

I am confused in reading this blog entry. You seem to be inferring that the primary antidepressant withdrawal symptoms are due to psychological dependence. Yet in your book, "Why were doctors so slow to recognise antidepressant discontinuation problems", there is this exert:

 

Many of the reported symptoms associated with SSRI withdrawal are physical rather than psychological. Schatzberg, et al (1997) divided the somatic symptoms into five clusters: (1) disequilibrium (eg. dizziness, vertigo, ataxia) (2) gastrointestinal symptoms (eg. nausea, vomiting) (3) flu-like symptoms (eg. fatigue, lethargy, myalgia, chills) (4)　sensory disturbances (eg. paraesthesias, sensations of electric shock), and (5) sleep disturbances (eg. insomnia, vivid dreams). "

 

Can you please clarify this discrepancy?

 

Also, you seemed to be inferring that since anxiety was the number one symptom of AD withdrawal as 71% people reported this, that AD withdrawal had to psychologically and physically addictive.

 

However, dizziness (61%)

vivid dreams (51%)

electric shocks / head zaps (48%) were also reported and these are physical in nature. Therefore, I am perplexed as to how you can reach the conclusion that you did.

 

Thanks!

[Barbarannamated]

His last post suggests that it is "an amplified nocebo response"..??

 

Wow!

[Altostrata]

Psychosomatic -- thinking causing bodily reactions.

 

What he really needs to hear are personal testimonies contesting his theory from patients.

[compsports]

Psychosomatic -- thinking causing bodily reactions.

 

Hi Alto,

 

I am not following you.

 

CS

[Altostrata]

There are psychosomatic conditions in which people unconsciously cause physical symptoms.

 

That's why I gave him a list of conditions that could not be caused by unconscious beliefs, such as withdrawal symptoms in newborns.

[compsports]

There are psychosomatic conditions in which people unconsciously cause physical symptoms.

 

That's why I gave him a list of conditions that could not be caused by unconscious beliefs, such as withdrawal symptoms in newborns.

 

He mentions in his book that physical symptoms of withdrawal have been established. And if you mention personal stories, he will call that anecdotal evidence.

 

It sounds like his mind is made up in spite of the facts and his facts.

 

CS

[Altostrata]

Yes, there seems to be an unusual psychological dynamic at play in Dr. Double.

[Barbarannamated]

I'm baffled and insulted by his complete change of opinion. He seems to have a very simplistic view of dependence and withdrawal. I separate "dependence" from "tolerance". Is he thinking that because tolerance/dose escalation doesn't generally happen, there can be no physical addiction or withdrawal? He obviously has been sold the term "discontinuation" that was fabricated by the committee to avoid withdrawal and addiction being associated with SS/NRIs.

[Altostrata]

No, he thinks the symptoms are psychosomatic -- patients are psychologically dependent on the drugs, they get scared going off them, and create their own withdrawal symptoms.

 

This supports his contention the drugs are addictive, they have a psychological dependency component.

 

What he wants to do is prove antidepressants are addictive. His logic is convoluted and it broke along the way.

[Barbarannamated]

Sure did break.

 

This is what I was referring to, as spoken by Ashton, just FYI:

 

http://survivingantidepressants.org/index.php?/topic/1516-ashton-on-ssri-discontinuation-and-drug-development-2007/page__fromsearch__1

 

" In a scramble to prove that SSRIs were not addictive, psychiatrists actually changed the definition of drug dependence. Criteria for substance dependence were altered in the 1994 DSM IV by the American Psychiatric Association. In this edition, withdrawal effects alone were not enough. A patient now also had to have evidence of tolerance, dose escalation, continued use despite efforts to stop and other characteristics to qualify for dependence. And the withdrawal syndrome was replaced by the patronising euphemism "discontinuation reaction". As if a patient would think there was some subtle difference between 'discontinuation' and 'withdrawal'."

 

EDIT: I didn't see if you mentioned withdrawal in babies exposed to SS/NRIs in utero or how that might support the argument.

[alexjuice]

Yes, there seems to be an unusual psychological dynamic at play in Dr. Double.

 

It seems he's of two minds on the issue. At least appropriate apropos the Bond-villian sounding surname.

[Altostrata]

LOL, alex!

 

It occurred to me Dr. Double may not publish my last comment (and I do mean last) on his blog (apologies for the length):

 

Dr. Double, caring psychotherapeutic treatment can do a lot of good, but when the doctor denies the patient's reality, it does a lot of harm.

 

When patients are suffering withdrawal syndrome, what they need is partial reinstatement of the drug (if very recently quit) and subsequent slower tapering, not to be told they are somehow psychologically generating their symptoms.

 

It's a primary pitfall of psychotherapy that the mental health expert reinterprets the patient's reality. The doctor, rather than the patient, holds the correct interpretation of what the patient is feeling.

 

This can undermine the patient's confidence and mental health. When it comes to withdrawal syndrome, it can undermine physical health as well.

 

You posit your theory against massive scientific evidence; concordance among medicine, pharma (however reluctant), patient advocates, and withdrawal experts (Breggin, Healy, Glenmullen, Haddad, Fava, etc.); and testimony from the patients themselves.

 

All but the last might be understandable, as experts may be wrong and, in psychiatry, universal agreement is not entirely trustworthy.

 

But to deny what patients are telling you about their experience is a very, very grave error.

 

Patients experiencing withdrawal symptoms run into all kinds of denial from doctors. Sometimes the doctor doesn't "believe in" withdrawal symptoms at all -- apparently the doctor thinks the patient is fabricating or, maybe, picking up some nonsense from the Web.

 

Sometimes the doctor believes the lie that withdrawal symptoms are invariably mild and last only a couple of weeks, and dismiss further complaints.

 

Sometimes the doctor tells the patient "it's all in your mind."

 

Sometimes the doctor tells the patient outright that he or she is deluded.

 

Patients hear this, compare what they know of their reality versus the doctor's intepretation of it, and lose respect for the doctor.

 

There is a limit to the mystique of a medical degree.

 

The hundreds of thousands of postings by patients all over the Web complaining of severe withdrawal symptoms and the 365 case histories on my site are there DESPITE the patients having heard such rationalizations from their doctors.

 

The patients INSIST they understand their own reality better -- and they're right.

 

They often say things like "my doctor said it's psychological but I feel there's something physical about it" or "I'm feeling it in my body, not my head."

 

They find that CBT or other techniques don't eliminate the symptoms. They go through long periods of guilt and frustration thinking they haven't done therapy right.

 

In fact, it takes time -- months or years -- for the neurological dysregulation of withdrawal syndrome to resolve. Not much can be done to hurry this, which is why gradual individualized tapering, withdrawal symptom recognition, and reinstatement are essential medical knowledge for doctors.

 

As in any chronic condition, psychological techniques can help the patient cope with symptoms, but they do not eliminate the symptoms.

[Barbarannamated]

It's interesting that the opposite of tolerance becomes evident with SS/NRIs in withdrawal: greater sensitivity necessitating less drug. Are there other known classes that cause that? I wonder how often people reinstate under advice of doctors who are unaware of the sensitivity and then have extreme reaction.

 

I was shocked when I took a small piece of Pristiq months after stopping. Extreme agitation, anxiety.