Waves of physical anxiety

[Windywel]

Hi all
I am 7 weeks in on citalopram and 4 and a half on 20mg. I am also on lorazepam. I have been feeling better this past week but I am experimenting with taking the lorazepam less as I’m worried it that that has caused the improvement and when I haven’t taken it I still get random waves of physical anxiety out of nowhere - ie I haven’t been thinking anxious thoughts. Is this normal? Should this have gone away by now?
Many thanks

[panic_down_under]

I am experimenting with taking the lorazepam less as I’m worried it that that has caused the improvement and when I haven’t taken it I still get random waves of physical anxiety out of nowhere - ie I haven’t been thinking anxious thoughts. Is this normal?

By "physical" do you mean fight-or-flight adrenaline surges, i.e. fast heart rate, dry mouth, sweating, upset stomach, etc? If so, it could be an AD side-effect, maybe rebound withdrawal anxiety from dropping the BZD dose, or just one of the many inexplicable things that anxiety disorders can do. Propranolol is usually very effective in blocking adrenaline surges if they are spooking you.


Should this have gone away by now?

Four and a half weeks at 20mg is at the low end of the AD 4-12 week kick-in range. Given this is the second time on citalopram it is more likely to kick-in at the high end of the range than the low end.

[Windywel]

Thanks for replying PDU - not quite so bad as that but yes hot flush, fast heart rate, sweating but it didn’t last very long. Though the rest of the morning has been a disaster. Recovered ok from the brief anxiety wave first thing but then went to yoga felt anxious all the way through and then we did breath work at the end and that set off my shortness of breath thing so I got more anxious and now having a panic attack. Sitting here crying, shaky not able to breathe properly. Have taken the lorazepam now but clearly it was masking a whole lot and now I think that the citalopram hasn’t been working at all ��

[Windywel]

Also PDU I’m interested in your view of someone on another forum who said that her psychiatrist said that any dose of citalopram was therapeutic and that she had quite a few patients on 5mg. Though I was a bit suspicious as the person in question was only on 10mg and yet had been given alprazolam to take with it for months which seemed odd to me

[Windywel]

Told my psychiatrist about the dramas this morning and he said to go up to 30 and try it for 2 weeks and if no significant improvement he would switch to something else.views? Seems pretty soon to me? Scares me because of all the implications - ie this one didn’t work, next one mightn’t etc etc

[panic_down_under]

Have taken the lorazepam now but clearly it was masking a whole lot and now I think that the citalopram hasn’t been working at all

I wouldn't have expected it to at 4 and a bit weeks.


I’m interested in your view of someone on another forum who said that her psychiatrist said that any dose of citalopram was therapeutic and that she had quite a few patients on 5mg. Though I was a bit suspicious as the person in question was only on 10mg and yet had been given alprazolam to take with it for months

Sigh! :mad: I think that wrong on many levels. The fact she also needs alprazolam pretty much proves her shrink is clueless and not worth feeding.

Unlike that fool's claims, therapeutic dose recommendations aren't pulled out of someone's posterior, but come from trial data. Making AD chemicals is a long, involved process so the pharmaceutical companies aren't going to put more of the active chemical into their pills than they need to. As it is, many people end up taking more than the minimum recommended dose to achieve optimal results.


he said to go up to 30 and try it for 2 weeks and if no significant improvement he would switch to something else.views?

I suspect you'll need more than 20mg anyway, so increasing the dose is probably a good idea. I'm less convinced about the 2 week deadline, but at least it brings you into the time frame when ADs are most likely to kick-in.


next one mightn’t etc etc

There are many ADs with many differing modes of action so there will be one that works. No point in worrying about something which probably won't happen anyway. It's not as if worrying has ever solved a problem.

[Windywel]

Thanks PDU

[Windywel]

Hi PDU I’m trying to stay focussed on your advice about why ADs take so long to work but there does seem to be a lot of research that says they do work within 4-6 weeks? I’m fact I saw one that said if no response within 2 weeks then you should increase dose or shift as it’s a marker that they won’t work! Another one said that it appeared that SSRIs worked in anxiety first and depression much later but they don’t seem to have worked on either for me after 5 weeks. I know I shouldn’t have googled but succumbed after a difficult weekend with lots of crying spells ��

[panic_down_under]

Hi PDU I’m trying to stay focussed on your advice about why ADs take so long to work but there does seem to be a lot of research that says they do work within 4-6 weeks?

If you plot AD time to response you usually get a bell curve with the peak at around 6 weeks. This is for the first exposure to ADs. It may take longer the second time around.

Some do seem to respond quickly, but this seems to owe more to the placebo effect than the med and they often, ime, end up crashing within a month, or two and become non responders. The placebo response in most drug trials is usually around 30-40%.

To quote from the findings of Star*D (https://www.nimh.nih.gov/funding/clinical-research/practical/stard/allmedicationlevels.shtml), the largest and longest AD drug trial so far undertaken:


"In addition, patience is required. While some people may experience benefits in the first six weeks of a treatment strategy, full benefits may not be realized until 10 or 12 weeks have passed. During this time, doctors should work with their patients to adjust dosages so as to find an optimal level, and avoid stopping a treatment prematurely."


I’m fact I saw one that said if no response within 2 weeks then you should increase dose or shift as it’s a marker that they won’t work!

And what mechanism do they propose to account for this, given it takes, in the case of citalopram, 7 days just for plasma levels to stabilize and about 7 weeks (http://cshperspectives.cshlp.org/content/7/9/a018812.full) for hippocampal cells to bud, grow and mature?:


"Adult neurogenesis can be divided into four phases: a precursor cell phase, an early survival phase, a postmitotic maturation phase, and a late survival phase."


"The precursor cell phase serves the expansion of the pool of cells that might differentiate into neurons. The early survival phase marks the exit from the cell cycle. Most newborn cells are eliminated within days after they are born. The postmitotic maturation phase is associated with the establishment of functional connections, the growth of axon and dendrites, and synaptogenesis. The late survival phase represents a period of fine-tuning. It has been estimated that the entire period of adult neurogenesis takes ~ 7 wk.


Another one said that it appeared that SSRIs worked in anxiety first and depression much later

Undoubtedly true, SSRIs seem to be more effective anti anxiety meds than they are anti depressives.


but they don’t seem to have worked on either for me after 5 weeks.

I'm not surprised, even if the authors of what you've been reading might be.


I know I shouldn’t have googled

Sage advice, imho.


but succumbed after a difficult weekend with lots of crying spells

Are you still taking lorazepam daily? Has any consideration been given to trying alternatives such as mirtazapine, or propranolol instead as I've suggested?

[Sober2000june]

Hi Windy,

I cant totally identify with how you feel. I'm 5weeks on duloxetine, 1st half on 30mg and last 18 dys on 30 evenng and 30 morning. I also take lorazopam daily and all the worries that go with it. mornings are atrocious with shakes, nausea. try to avoid my head all day but its so hard when i feel so low. been trying to keep busy. but the constant thought of when will i get out of this twilight zone and be me again. I have a new consultant i see privately who is really nice, but says i need to persevere a few more weeks and is talking of 90mg. I wish you well and hopefully we can keep each other going.

[Sober2000june]

I hope you're feeling a little better this morning windywel. I'm guessing its early morning down under?

Kind regards

[Windywel]

Hi Sober2000 yes absolutely we should support each other. It will get better we just need to be patient x

[Windywel]

Hi yes it’s 9.30am - feeling a little better this morning but I still have this awful shortness of breath thing that just gets me anxious and down. Trying to just take one lorazepam today so waiting for a while. How are you feeling?

[Windywel]

Thanks so much PDU - that does help a lot. I have tried propranolol but it didn’t really do much for me. I asked the psychiatrist about mirtazapine but he said we would keep it in reserve. He said better to keep things simple at this stage with just the citalopram and lorazepam as I was already on it. I am reducing back down to 0.5mg of that a day. I am still worried about increasing the dose though - I know he’s going to recommend going up to 30. But lots of people on the forums have said not to as you get the side effects all over again and not many people seem to have had good experiences increasing (mind you I guess the ones who did aren’t on here). They reckon staying on 20 for at least 12 weeks.

[panic_down_under]

But lots of people on the forums have said not to as you get the side effects all over again

Side-effects may indeed increase for a while after ramping up the dose, but they are usually less severe than at the beginning simply because the rate of change is less.

Forums can give a greatly distorted picture simply because the majority that have few issues don't join them. You're looking at a small subset of patients. Even if 99.99999% claim a particular issue this doesn't mean you will also be affected. Only you have your DNA.

Dr Google is not your friend. Stop 'listening' to it and looking for reasons to not do something, please. Go for a walk every time you're tempted instead. It will do you far more good.

[Windywel]

Will do - I have been much better at not googling - just had a brief relapse yesterday. I am feeling better than I was just have times when I feel terrible again and fall back into bad habits. I know I need to help myself to get better and not just rely on the meds. I do appreciate your support

[Sober2000june]

You're up late Windywel. Its early afternoon and evening cannot come quick enough. Was down visiting my mum, who's recovering from knee replacement. Killed a bit of time but the 50 min drive there and back with my head is not fun was looking at the pics of my kids she has on wall and i just wept. I just so miss being able to feel them emotionally. This insidious darkness, splinter in my obsessive mind, just rides me all day. but ive held on for 1yr today so gotta keep going one day at a a time. Keep going my friend.:bighug1:

[Windywel]

Hi how come it’s a year? Have you been trying lots of different meds? Do you have both anxiety and depression?

[Sober2000june]

Yes this i my 4th since January. Yes i have both. since i have upped my dose of duloxotine my depression is getting worse. trying to hold onto its only 19 days on 60mg. it is just that it is making me more apathetic so that make it so hard to do things to distract myself from my obsessive head.

[Sober2000june]

hope you are feeling better windywel.
take care:hugs:

[Sober2000june]

I see you're up early windywel. hope you are well.

[Windywel]

Thanks - been up and down the last few days. Hope you’re feeling a bit better.

[Sober2000june]

tbh still really struggling, my depression is getting deeper on the 60 mg but consultant told me to please try and persevere, roll on 8is in evening when my head gives me a bit of a break.
hope you're improving.