Posted by Ame Sans Vie on January 14, 2003, at 5:06:54
Well, this year started out rather oddly. It seems my former psychiatrist was knowingly involved in the diversion of amphetamines to the street. He was arrested late last month, and so that leaves me thumbing through the yellow pages desperately searching for another pdoc who accepts Medicaid. I was only able to find one that I haven't been to, 40 miles away. I guess I didn't think this would be such a big deal, but my first appointment I was immediately chastised for my relatively high dose of clonazepam ('How dare you take an adequate dose of the only medication that actually provides you any relief!!'.... what WAS I thinking?). My former pdoc has had me on 5-6mg/day for quite some time now, while at the same time trying all the more unconventional medications for avoidant personality that we could think of. My most recent meds have been 3mg clonazepam bid, 50mg Lamictal bid, and 300mg Provigil qam. The Provigil and Klonopin have always been a terrific help in relieving my symptoms of avoidancy. I have developed no tolerance to Klonopin over the past 15 months, experience no side effects from it, and have been able to abruptly discontinue it for weeks at a time without problems (other than the return of my initial symptoms, of course).
But this guy insists that I couldn't possibly need more than a total of 1mg/day (?!). In a perfect world, I would've walked out of there right then and set up an appt. with someone else... even a former psychiatrist. But unfortunately, they're all entirely unwilling to prescribe benzos at all. I suppose this is because in this area (SE Texas; SW Louisiana) benzo sales on the street are unusually rampant. A fact actually reported on our local news station just months ago. I'm sure this is a major embarrassment to the local government/police forces... maybe a lot of pdocs were scared out of their usual prescribing practices due to visits from local law enforcement?
Okay, I realize I'm rambling, and I know I wouldn't be if I were properly medicated. This is SO frustrating.
So anyway, since I guess I'm stuck with this guy for now (and he appears the most attractive option, just because he's willing to prescribe clonazepam at all), I'm just hoping someone may have a medication suggestion or two that I haven't tried yet. I know therapy is the usual treatment for personality disorders, but it's hell to an avoidant, and in my case actually exacerbated my condition. Anyway, here are the meds I've tried up to this point and the highest I've tried pushing the dose.
Paxil (80mg), Zoloft (250mg), Prozac (60mg), Celexa (60mg), Nardil (120mg), amitriptyline (250mg), imipramine (300mg), doxepin (225mg), Asendin (150mg tid), trazodone (250mg tid), Ludiomil (150mg), Effexor (100mg tid), Serzone (250mg bid), Remeron (60mg), Wellbutrin (100mg bid), Seroquel (25mg bid), thioridazine (100mg tid), Haldol (2mg bid), Zyprexa (10mg), Risperdal (1mg bid), lithium carbonate (300mg tid), Neurontin (400mg tid), Gabitril (8mg bid), Lamictal (50mg bid), Trileptal (600mg bid), Depakote (1gm tid), Adderall (30mg tid), methamphetamine HCl (5mg bid), methylphenidate (20mg qid), Provigil (300mg), phenobarbital (300mg bid), amobarbital (400mg qid), secobarbital (200mg qid), Neuramate (800mg tid), alprazolam (1mg tid + 1-2mg prn), diazepam (20mg bid), Ativan (4mg SL tid), chlordiazepoxide (10mg tid), Tranxene-SD (45mg), clonazepam (10mg bid), oxazepam (60mg qid), Centrax (60mg tid), halazepam (40mg qid), triazolam (1mg qid), BuSpar (20mg tid), propranolol (60mg tid), Vistaril (200mg tid), baclofen (20mg tid), Soma (700mg qid), propoxyphene HCl (130mg qid), Dilaudid (1mg qid), Ultram (50mg qid), Marinol (10mg bid)
Okay, that's straight from seven years' worth of prescription history printouts, just put in order in a way I thought logical. I know it's a lot, and this has been my entire adolescence; I just turned twenty earlier this month. Now a few things that are worth mentioning. First off, I'm going to assume that I probably shouldn't bother with the other two SSRI's or any other antipsychotics. The SSRI's were occasionally effective (esp. Paxil) but the side effects were just far too much to bear once we reached a dose that worked. The antipsychotics just weren't effective at all.
Regarding the higher-than-average doses of barbiturates, benzodiazepines, and meprobamate that I was prescribed, my only explanation is an article I once read that claimed avoidants tend to be poor responders to traditional anxiolytics. I've always needed high doses, it seems, of ANY sedating type of drug. That includes antihistamines, regardless of whether they were taken for sleep, anxiety, or allergies. And I've never in my life been able to induce sleep with these types of meds. An incident when I was fourteen, suicidal, and took about 3200mg phenobarbital springs to mind. I never even felt drowsy.
As far as the amphetamines/methylphenidate, I was originally dx'd ADHD (and in retrospect I probably was throughout my childhood, but eventually grew out of it). The Ritalin really agitated my anxiety, but the amphetamines seemed pretty neutral in that area... I just didn't like the "dirty" feeling they gave me. I don't know how else to put it into words... just a general overall feeling of malaise.
The more 'atypical' antidepressants (Effexor, Asendin, trazodone, Serzone, Ludiomil, Remeron, & Wellbutrin) were completely ineffective, with the exception of Wellbutrin which I found unbearably overstimulating.
The tricyclics I'm considering looking back into, especially clomipramine which is indicated for (among other things) anxiety, agoraphobia and other phobias. I never had a problem with the ones I've tried... except amitriptyline was a little bit... umm... psychedelic? LOL That's something I'm pretty curious about actually-- has anyone else found that amitriptyline sometimes caused a somewhat disturbing alteration of consciousness soon after the dose? I know it must be pretty common, because more than one of my friends approached me during the time I was prescribed it to ask if they could buy some... What I felt specifically was for about 30-45 minutes before it would put me to sleep, I felt very strangely dissociated from my body and had what I can only describe as "waking dreams". It was slightly reminiscent of a high dose psilocybin trip. Anyway, I'll be interested to hear if anyone else has experienced this. Oh, and of course any experiences with clomipramine would be most appreciated.
One thing that I still wonder about is Nardil. I was on a pretty high dose with no effect, other than occasional orthostatic hypotension. I know there was a recall on Nardil a short time back, and that the purpose was expired and subpotent product. I believe this happened in mid-late November, and my last prescription for Nardil was in early November. That was my sixth month on the medication, and my second month at 120mg. Does anyone else think it may be likely that this 'bad batch' of Nardil COULD be the reason I responded poorly? After all, I've heard it normally works so well for SP/AvPD. It seems a bit odd that I would barely even feel a side effect from 6 months of high dose MAOI treatment... I also have considered Parnate, but maybe I should give Nardil a try once more first. Opinions/advice?
My doctor and I foolishly expected Marinol to work for me because I've always found marijuana (when ingested, definitely NOT when smoked) to be a wonderful anxiolytic. Of course the lack of most of the active cannabinoids left something to be desired, though it wasn't a complete failure. Clonazepam works better to me.
Baclofen and Soma were my own recommendations. The Soma worked unbelievably well and the baclofen just succeeded in making me dizzy. Only one former doctor was open to either of these as suggestions though, and I had to switch back to clonazepam when he relocated his practice.
Propoxyphene was the first suggestion made by my most recent pdoc when I brought up opioids, surely because it's schedule IV. Gave it a fair run of four weeks, then tried Ultram, which would have been great if keeping my food down weren't a priority. Dilaudid was good, but a little too good... the thought of opioid addiction wasn't too attractive, so I voluntarily gave it up. Upon doing so I was told that a sublingual form of buprenorphine was under review by the FDA, and now I understand it's been approved. Any word on when this is hitting the market?
Anyway, the anticonvulsants and lithium have been pretty irregular with regard to their effects, and I suppose this would be expected as their individual biological actions are so varied. Long story short, all of them caused some sort of side effects that caused me to discontinue them, Neurontin being the only exception. For some reason my pdoc wasn't willing to push the dose above 1200mg... I guess he wasn't experienced with prescribing it. I may give it another shot.
So the meds I have on my mind right now are clomipramine, Nardil (again), Parnate, buprenorphine, Neurontin (higher dose), Topamax, and trying another run with a muscle relaxant (Flexeril maybe?...it's supposed to be closely related to the tricyclics). Any opinions on these would be appreciated, as well as other suggestions. Oh, and if you actually read this far, thank you! LOL
--Michael
poster:Ame Sans Vie
thread:135789
URL: http://www.dr-bob.org/babble/20030113/msgs/135789.html