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Forum Name: Psychiatric Topics

Question: Antidepressants and emotional numbness


 ModestGoddess - Sat Sep 22, 2007 1:03 am

1.) 23
2.) female
3.) PTSD, GAD, depression, borderline "traits" (but not full-blown BPD)
4.) none
5.) family Hx of bipolar (maternal aunt, maternal grandmother), seasonal affective disorder (father, paternal uncle), depression (mother), OCD (paternal grandmother)... Extensive Hx of sexual abuse on mom's side of the family (i.e. grandfather who abused his children and grandchildren, who then did the same to younger people in the family). That's where the PTSD comes from (I also was in an abusive relationship from 15-20 and raped when I was 21.)
6.) Zoloft 150mg (now tapered down to 100mg); Klonopin 0.5-0.75 mg as needed for sleep

OK, I have been taking some sort of SSRI medication for the past year and a half. However, I have had a lot of discontinuity in my psychiatric care and have had to switch prescribers 4 times, due to graduating college and losing insurance coverage, moving, getting new insurance, etc. The problem is, every time I see someone new, each person has a new idea of what the best treatment regiment is for me. Thus, I've been on just about every SSRI/SSNRI out there, either during the past year or when I was 15-17 (but back then I never took anything for more than a month, not long enough to be effective, because I didn't want to take medications and because of side effects.) I was initially prescribed 25 mg zoloft (actually 12.5 built up to 25) in March 2006 by my university psychiatrist. Then I graduated and began seeing the PA at a primary care clinic for continued meds, due to not having insurance and that being the most affordable option. I ended up staying on 25 mg (which I later learned is a fairly ineffective dose), for about 9 months, because my new job didn't offer insurance until 6 mos of employment and, being uninsured, I was so nervous about the prospect of switching meds or upping meds because I could barely even afford ONE office visit and 'script out of pocket, let alone the additional ones often necessary to find a good fit. So basically, I was taking something that I wasn't sure worked because I was too afraid NOT to but also too afraid of the financial strain of searching for something better. I honestly couldn't tell if I felt better on or off the Zoloft. (Still can't.) One of the aspects of my PTSD is that I have been quiet detached from my emotions-- only recently like the last 10 mos or so, through therapy, I have slowly been actually able to identify and experience some emotions (and as of recently sometimes they go to the opposite extreme a little, but I am able to manage...or at least they feel extreme because for so long I felt nothing). As for therapy, I've been in therapy since I was 20 although, again, had to switch therapists a couple times for the same reasons; I was also in therapy for about a year when I was 16 following a suicide attempt and some self-injurious behaviors.

In January 2007, I finally got insurance through my work, so because I "couldn't tell" if the meds were helpful or not, I decided to let my prescriber change things up...up the dose...then switch medications, etc. I either had adverse reactions (feeling anxious, feeling detached, etc) or couldn't tell a difference. After seeing one psychiatrist that I felt really uncomfortable with, I started seeing a psychiatric APRN, whom I've been working with for the past five months. Immediately upon seeing her, she switched me to a new medication (from lexapro 10mg to cymbalta 60mg....not an immediate jump of course). After about 2 months, I still wasn't tolerating the cymbalta well, and I asked to go back to the zoloft because I felt I hadn't given it a good enough chance (i never went higher than 50 mg and then the PA wanted to put me on Lexapro), had been on such a low dose, and actually felt "best" on the low dose of zoloft compared to anything else i had taken. She was reluctant to do this, saying that I was going to have "suicidal thoughts", which of course I did not. (I admitted to her that some of the stuff coming up in therapy was making me think about cutting again, but I know I'm not going to act on it, and I told her this). She was also saying that she "just has a feeling" that the good dose for me is 150 mg (She said, "The lower the weight, the higher the dosage". I have a slender build.) So she built me up from 50mg zoloft to 150 at 25 mg per 2 weeks (she wanted to do it every week but i refused) while simultaneously tapering the cymbalta. Now, since I've told her about some of my increased emotionality (which I see as ultimately a GOOD thing considering my numbness prior), she is under the impression that I have bipolar and wants to put me on a mood stabilizer. I have never been manic or even hypomanic, and I don't really feel particularly depressed either. If anything, I feel I may have some borderline traits with regards to emotional dysregulation (either feeling numb or feeling multiple intense feelings simultaneously, not much middle ground), self devaluation, fear of abandonment, etc, but not really the impulsivity, intense anger, etc. (I am also in a DBT group in addition to my weekly therapy). Since about 2 weeks after going up to 150 mg, I have actually become to feel somewhat depressed...not miserable depressed, just like really apathetic, kind of lethargic, couldn't really think clearly, very numb. And then all of this, plus some of the side effects (like the sexual stuff) make me feel depressed on top of it-- depressed that I don't really feel like doing anything, that I don't really feel present in my life. (Everytime I've tried a new med or upped a dose I've had some sense of this, but this is the most intense.) I guess my question is, is there ever any time that medication is NOT a good idea; like if it makes me have less emotion, could it possibly be interfering with my therapy goals of being in touch with my emotions? Also, I've had a lot of major transitions over the past year and a half, and my medication status has been unstable to boot-- I kind of want to know what my "baseline" is, what is really "me" and what is just an effect or side effect of medications? My circumstances are completely different than they were in 2006 when I first decided to try medications, so I don't even know that they are necessary. I'm not suicidal, and I know what to do if I were to feel suicidal. I guess one question is, is there any validity to my concern about medication interfering with my therapy goals? And is there any harm in tapering myself off? I have slowly gone down to 100 mg, and I'm already feeling better, but I want to continue tapering.

I've already spoken with my therapist regarding this (she understands my concerns and supports whatever decision I make), and I've consulted with another psychiatrist (and he gave me a recommendation for a safe taper), but I'm afraid to tell my current prescriber (although obviously I will at my next appt) because she not only wants me to stay on the zoloft but also take lamictal on top of it. And if I have strong reservations about an SSRI, I definitely have reservations about a mood stabilizer. I mean, my impression is that if I'm already "numb" something that stabilizes my emotions would make me even more numb, would even further decrease any ups and downs. What's your perspective on this? I told her that I didn't expect that any one medication regimen would completely make me not feel anxious, angry, sad, "emotional" etc considering I'm dealing with trauma stuff that I never dealt with before. But she believes that if I was on the right combo of drugs, I wouldn't be having strong emotions. I don't' think it's possible, or even desirable, to just never feel depressed or anxious when dealing with this kind of stuff....I haven't had emotions for 23 years, so its kinda good to start feeling things.

I guess what I'm really looking for here is other professional opinions about this and support/feedback about my desire to take a med hiatus (safely, of course).
 Dr. K. Eisele - Mon Sep 24, 2007 9:01 am

User avatar Dear ModestGoddess:

Welcome back! It's good to hear from you again.

Some people do experience emotional numbing when taking SSRIs, (Zoloft is one of them, as well as Lexapro, Celexa, Paxil, and Prozac).

I'm not quite sure I understand the rationale for giving you a mood stabilizer, per se, however, your prescriber may be looking for a milder antidepressant effect. Lamictal is a mood stabilizer that is known to help prevent and treat depression, only it is normally reserved for patients with bipolar disorder. Given the emotional numbing you feel with SSRIs, Lamictal may be a reasonable choice.

Good luck!
 ModestGoddess - Sun Sep 30, 2007 10:30 pm

Hi Dr. Eisele,
Thanks for the reply. I also don't really understand the rationale for a mood stabilizer. She wants me to take the Lamictal IN ADDITION to the Zoloft, not in place of it. I don't see how adding MORE emotion-altering medications can make one LESS emotionally numb. When I think "mood stabilizer," I kind of think of something that will complete iron out my emotional state, i.e. completely "stabilize" it, so that I experience neither highs nor lows. I actually want the highs and the lows...rather than just feeling so numb and empty. I want to feel true grief, sadness, anger, etc (as well as happiness, joy, calmness, etc)-- all the feelings I didn't feel as a child and teenager when these thing were happening to me. I have had these problems with emotional numbness long before I took any medications-- I just don't think the medications particularly help with it. I don't know for sure that I even have "depression"-- I am almost positive it is more PTSD than anythign else. But my main question is, is it ever contraindicated for people with PTSD to take psychiatric medications (like SSRIs or mood stabilizers). I mean, especially for those with more of the numbing symptoms, can it actually keep you from processing/experiencing your feelings about the traumas? Thanks!

Oh, by the way, I have been tapering off Zoloft and am almost done with it. Over the past few days, I have had a lot of intrusive memories/flashbacks (well, not full blown flashbacks per se, but can't stop thinking about the past). It wasn't generally this bad before I started medication treatment, so I'm not sure if this is my PTSD coming out full force (and will stay like this long past the medication being completely out of my body) or if it's more of a withdrawal symptom. I mean, I know flashbacks aren't a withdrawal symptom per se, but anxiety certainly is. However, I did have a really really triggering experience a few days ago, so who knows if I may have felt this way even if I was still on my full dose of medication. What are your thoughts on this?
Anyway, I'm going to see my prescriber tomorrow, but I would really like a 2nd opinion (well, already got a second opinion in person but another professional perspective). I just feel that my prescriber is kind of biased because she's only seen me when I was already on medication (and was experiencing the negative effects of that medication), has not seen me in my "natural" state. Thanks for your time and help.

Sam
 Dr. K. Eisele - Mon Oct 01, 2007 10:23 pm

User avatar Dear Sam:

About your current symptoms, it is practically impossible to know with any certainty if it was the trigger that caused it or the withdrawal from Zoloft. Psychotropic medications are not contraindicated for PTSD, but sometimes it is difficult to find an effective medication. Some prescribers will turn to antipsychotic medications for patients with severe cases of PTSD when other more conventional treatments have not been successful. Quetiapine (Seroquel) is an antipsychotic that has been used for this purpose, in low doses. At low doses, the side effects consist mostly of sedation/headache, but this usually goes away within a week of starting the medication. It can cause weight gain, however.

For people with symptoms of numbness as their primary complaint, I usually suggest venlafaxine (Effexor XR) or bupropion (Wellbutrin). While it is true that venlafaxine can have a truly wicked withdrawal syndrome, there are ways to deal with it medically. For my patients, simply knowing that they will feel some withdrawal symptoms helps them work through it. The only problem with bupropion for you, though, is your anxiety; bupropion is a very mildly activating medication which helps people with numbness, but it can make the anxiety worse. Some prescribers would prefer to use a low dose of prn (as needed) alprazolam (Xanax) or clonazepam (Klonopin).

Mood stabilizers have various effects depending on which agent is chosen. Divalproex (Depakote) tends to bring people down, and could very well exacerbate your feelings of numbness. Lithium will stabilize the mood (along with dampen the impulsivity which you don't need), but it is useful for patients who tend to be depressed. Lamictal is similar, but not as potent, as lithium.

The take-home message is that different mood stabilizers stabilize the mood at different levels, with lithium and lamotrigine stabilizing the mood at a higher (or better mood) level than Depakote.
 ModestGoddess - Tue Oct 02, 2007 8:12 pm

Hi Dr. E,
Thanks for the feedback/advice. I did take Seroquel for one day, the lowest possible dose (25mg), and I felt worse I have ever felt on any psychotropic med. I felt dizzy, disoriented, kind of depersonalized-- it was actually prescribed for sleep/anxiety, and although it made me dead tired initially (the doc said I should take it 1-2 hrs before bed, but after 5 min I could barely walk up the stairs to bed I was so groggy), I woke up in the middle of the night and couldn't get back to sleep but also was too tired to move or really do anything throughout the day. Wellbutrin was okay, I took that for about a month and a half prior to trying Zoloft. I felt pretty decent on it for a week but then had tremendous anxiety following that, so much that I was visibly anxious to other people, even got into a small fender-bender because I was driving too "cautiously." But mood-wise, it was great. Is there anything aside from a benzo I could take along with it for anxiety? (I can't see myself taking a benzo only "as needed" because it would be needed daily as I have anxiety daily and sleep problems nightly,probably due to being abused at night).
I guess another thing I am having trouble with is the idea of taking medication in general. The thought of "needing" something daily to function is depressing to me. The side effects (sexual dysfunction, exhaustion, numbness, apathy) are depressing to me. The thought of gaining any weight is unbearable to me. (I am not overweight by any means but have tendency toward weight obsession, will restrict if I find myself remotely gaining weight). It was hard enough for me to take Zoloft at first because of the slight possibility of weight gain. The idea of not knowing if I feel a certain way because that's how I really feel or if it's because of an effect of a medication, is depressing to me-- I will almost always assume it's the medication. I know you are a psychiatrist and the primary role of psychiatrists in this society is to prescribe medication. But do you ever NOT recommend patients to take medications, or ever advocate a medication break (especially if the patient doesn't even remember why she was taking medication in the first place.)? I'm not saying that I don't think medication could be useful for me. But I obviously have tremendous mental blocks to taking meds. How does one overcome these feelings in order to allow medications to be effective? And how do you know if the medications are working, if you've never really been aware of your emotions and moods in the first place?
Sorry for all of these quasi-philosophical questions. I don't mean to be difficult. I'm just really struggling with the idea of being controlled by a substance (possibly also related to past abuse...i.e. control issues.) Anyway, thanks for all your help/advice.

Sam
 Dr. K. Eisele - Sat Oct 06, 2007 7:04 pm

User avatar Dear Sam:

Fortunately, I am not a psychiatrist who sees her primary role as prescribing medicines. I also do a lot of therapy. Let me outline my treatment philosophy so you'll know my perspective a bit better.

Medications for psychiatric problems are no different, in principle, from medications used to treat "somatic" illnesses, such as hypertension, diabetes, etc. Depression is to the brain what somatic illnesses are to the body. If you were told that you had high blood pressure, you would expect to be told that you need to try some lifestyle modifications, depending on the severity of your hypertension, and if that didn't control the condition, you would then be prescribed some medication. The same thing applies to psychiatric problems. The lifestyle modifications you would be asked to try are analogous to therapy for depression. If therapy doesn't work, then medications are considered. That doesn't mean you get to stop the lifestyle modifications (or therapy in depression), because to be truly healthy you need both--non-medical and medical therapies.

Sometimes, the blood pressure is so high that medications need to be prescribed first, in order to make it safe for the person to try the lifestyle modifications. We call this a hypertensive crisis. In psychiatry, sometimes the situation also calls for stabilization with medications first, to make it safe for the person to engage in therapy. We call this a psychiatric emergency, e.g., suicidal thoughts, suicide attempt, or even homicidality. It is a situation in which the patient cannot function without immediate intervention. Some people, on the other hand, prefer to be simply medicated.

It sounds to me like you are able to function, and so it is possible that you don’t need to be treated with medications, but don’t reject medications on the grounds that they are “optional” in severe psychiatric illness, or that psychiatric illness is not real illness.

Seroquel often does make people feel really awful for the first few days they take it. I’ve never had a patient in whom those side effects lasted longer. Benzodiazepines do not necessarily have to be taken as needed. They can be taken on a scheduled basis for people who are responsible—and I do recom-mend frequent medication “vacations” for those taking the benzodiazepines, which help them avoid tolerance. Like other medications, sometimes side effects last only a few days, after which they simply disappear. Your body simply learns to accommodate them better. The same is true for non-psychotropic medicines, but the side effects are simply less noticeable because they aren’t “psychoac-tive,” meaning they have little or no effect on the brain itself, if they can even get past the blood-brain barrier.

Hope this answers your questions.
 jbackey - Sun Apr 13, 2008 4:45 am

Modest Goddess,
I have not had the trauma you have had but I do have PTSD. I found a wonderful therapist who specializes in EMDR and it has changed my life. EMDR mimics rapid eye movement (REM sleep) and helps you release and resolve all of the trauma over the years. I have been doing EMDR for 5 yrs with my therapist. I still have the impulse to cut and suicidal impulses occasionally and we have yet to cover that with EMDR, but I did resolve my childhood traumas and it helped so much that I decreased my antidepressant twice because I could tell I was more sedated than I needed to be. I was on Celexa and Zoloft and felt completely in a haze with them. I was on Effexor for 5 yrs and it has helped me stay stable while working through all my trauma. Now I've been off Effexor for a month an a half and am having serious withdrawal symptoms. I gained a lot of weight (100 lbs) in the years of taking meds and I was alway tired. I think you should feel things as you go through them and maybe since you were so detached to survive all those years you should feel things while healing in therapy. Always believe that you know what is best for you and hang in there.
 Dr. E. Seigle - Mon Apr 14, 2008 5:57 pm

Hi modestgoddess,

You have provided a clear picture of your background, history, and treatment. You have made a number of valid points, as follows:

1. Zoloft, and all of the SSRIs can sometimes cause a side effect of feeling numb or "zombie"-like.

2. It is possible, given the facts that you feel that your therapy is productive, that you are growing, that you are not depressed, and that your life and maturity are different now than in the past, that it may be an opportune time to have a trial period off of medication. Sometimes, people have been on medication for so long that, as you said, they want to know what they feel like without medication, and want to see if they even need medication. Often, abuse victims like yourself, can safely go off of medication after healing/growth through psychotherapy.

3. The issue of bipolar disorder can be knotty. Sometimes, people who have PTSD and/or borderline traits or personality disorder are incorrectly diagnosed as bipolar, and sometimes people diagnosed as borderline personality disorder have a real, undiagnosed bipolar disorder. You probably know some of the common symptoms of hypomania or mania include periods of decreased need for sleep, great amounts of energy, feeling elated or markedly irritable, or "on top of the world", markedly increased productivity, impulsive decisions to do reckless, pleasureable activities such as sex, spending, racing thoughts, disorganized thoughts, increased rate and amount of talking, talking in a pressured, rapid manner, distractibility, and trouble concentrating. Hypomanic episodes can be subtle tough to diagnose with reliability. Your family history of bipolar disorder elevates your risk for having the disorder, but doesn't mean you have it.

So, you may want to ask your provider what "target symptoms" she was seeing or hearing from you that made her think that you have a bipolar disorder. If you are not persuaded, you may decide not to be treated with the Zoloft or the Lamictal. You may want to see this as a pragmatic experiment and if you feel worse, with manic or depressed symptoms, you can always return to medication. You may just want to have your "team" of supports- close friends and therapist, perhaps family, to notice any changes over the weeks and months following discontinuation of the Zoloft and discuss them with you. And, of course, you will observe as well.

To reiterate, it's often okay to have a trial off of medication. We can tend to over-emphasize the use of psychiatric medication sometimes, in my opinion. I can't say that this is right for you, not being your doctor, but yes, it can be wisely done. Be sure it's a good time to do this "test", that there's not a lot of stress imminent. Good luck!

Eliot Seigle MD

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