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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by Joe Schmoe on May 11, 2004, at 19:17:27
Well, I find myself in need of a medication change and I am seeing my pdoc about it this week, but I was hoping for a little input first from the gang.
I suffer from social phobia and dysthymia, and at times general anxiety. In the past I have taken Celexa, Klonopin and Wellbutrin as a combo. I still felt anxious even on 2 mg/day of Klonopin which amazed my pdoc. But I was fairly functional.
I discontinued the Celexa last fall (I think I was on 20 mg) since I didn't feel it was doing much and I was tired of having low libido. After a horrible two month withdrawal (and slow taper) I finally was over it but the libido never returned.
Looking back I can see that I became more emotionally fragile starting around December - more thin-skinned. I began to feel more and more anxious and eventually stopped the Wellbutrin and started taking Inderal as needed. This led to a deep depression this spring. I started the Wellbutrin again which got me out of the depression but the anxiety (and some social phobic episodes) has returned and become intolerable. I am also suffering testicular pain, which I have noticed in the past when taking Wellbutrin. Testicular swelling is listed as a side effect so I was not that surprised. It started to manifest around the time the depression lifted (after 3 weeks or so at 300 mg/day of Wellbutrin SR). I am taking Aleve several times a day because of it which obviously is not a good thing.
Due to a low carb diet I have lost over 30 pounds since January and am looking better (and have healthier blood chemistry) than I have in ten years.
Anyway, due to both the anxiety and the pain I do not want to continue the Wellbutrin at the therapeutic antidepressant dose (300 mg/day). I am thinking of taking another antidepressant instead and maybe taking 150 or 100 mg of Wellbutrin to supplement it for the inevitable sexual side effects. I really, really don't want to regain the weight I have lost, and for that and other reasons am not attracted to the idea of taking Nardil.
So, I am faced with two questions: first, have I become tolerant to the Klonopin, or did I just never reach the optimal dose in the first place? I suspect my pdoc will not like the idea of going above 2 mg/day of it after being on it for three years - she will probably assume I am developing tolerance, which is bad news if true, since it would mean increasing the dose is only a temporary solution.
Second, what AD should I take for my dysthymia? Celexa did not seem to do much one way or the other but then again maybe it was helping more than I realize. I have never tried Prozac, Zoloft or Effexor. Paxil I tried for three days and couldn't stand it. Serzone was pretty worthless and very sedating.
I am confused about the SSRIs because lately I have been reading about how social phobics have low dopamine, so in theory a dopamine boosting drug should help. However, drugs like Prozac and Wellbutrin, which do boost dopamine, have reputations for causing anxiety in social phobics, which makes no sense to me.
So, what do you say? As an AD to go along with Klonopin (I doubt anything could replace it, except maybe Nardil, which I don't want to take) what would you recommend? Prozac, Zoloft, Celexa, Effexor? I would be interested in your experiences. Thanks.
Posted by Kon on May 11, 2004, at 23:51:03
In reply to Social phobia meds - advice needed, posted by Joe Schmoe on May 11, 2004, at 19:17:27
According to some recent stuff I have read (Chouinard, 2004), if greater than 2 mg/day of benzo is required (or tolerance develops), some recommend the addition of small doses of gabapentin or any SSRI. Here's the exact words:
"If drug tolerance develops during treatment with high-potency benzos (maximum dose, 2mg/day), an SSRI or an anticonvulsant could be added in small doses (e.g. gabapentin at 100-600 mg/day)."
You might suggest this to your doc.
Posted by Sad Panda on May 12, 2004, at 9:51:18
In reply to Social phobia meds - advice needed, posted by Joe Schmoe on May 11, 2004, at 19:17:27
> Well, I find myself in need of a medication change and I am seeing my pdoc about it this week, but I was hoping for a little input first from the gang.
>
> I suffer from social phobia and dysthymia, and at times general anxiety. In the past I have taken Celexa, Klonopin and Wellbutrin as a combo. I still felt anxious even on 2 mg/day of Klonopin which amazed my pdoc. But I was fairly functional.
>
> I discontinued the Celexa last fall (I think I was on 20 mg) since I didn't feel it was doing much and I was tired of having low libido. After a horrible two month withdrawal (and slow taper) I finally was over it but the libido never returned.
>
> Looking back I can see that I became more emotionally fragile starting around December - more thin-skinned. I began to feel more and more anxious and eventually stopped the Wellbutrin and started taking Inderal as needed. This led to a deep depression this spring. I started the Wellbutrin again which got me out of the depression but the anxiety (and some social phobic episodes) has returned and become intolerable. I am also suffering testicular pain, which I have noticed in the past when taking Wellbutrin. Testicular swelling is listed as a side effect so I was not that surprised. It started to manifest around the time the depression lifted (after 3 weeks or so at 300 mg/day of Wellbutrin SR). I am taking Aleve several times a day because of it which obviously is not a good thing.
>
> Due to a low carb diet I have lost over 30 pounds since January and am looking better (and have healthier blood chemistry) than I have in ten years.
>
> Anyway, due to both the anxiety and the pain I do not want to continue the Wellbutrin at the therapeutic antidepressant dose (300 mg/day). I am thinking of taking another antidepressant instead and maybe taking 150 or 100 mg of Wellbutrin to supplement it for the inevitable sexual side effects. I really, really don't want to regain the weight I have lost, and for that and other reasons am not attracted to the idea of taking Nardil.
>
> So, I am faced with two questions: first, have I become tolerant to the Klonopin, or did I just never reach the optimal dose in the first place? I suspect my pdoc will not like the idea of going above 2 mg/day of it after being on it for three years - she will probably assume I am developing tolerance, which is bad news if true, since it would mean increasing the dose is only a temporary solution.
>
> Second, what AD should I take for my dysthymia? Celexa did not seem to do much one way or the other but then again maybe it was helping more than I realize. I have never tried Prozac, Zoloft or Effexor. Paxil I tried for three days and couldn't stand it. Serzone was pretty worthless and very sedating.
>
> I am confused about the SSRIs because lately I have been reading about how social phobics have low dopamine, so in theory a dopamine boosting drug should help. However, drugs like Prozac and Wellbutrin, which do boost dopamine, have reputations for causing anxiety in social phobics, which makes no sense to me.
>
> So, what do you say? As an AD to go along with Klonopin (I doubt anything could replace it, except maybe Nardil, which I don't want to take) what would you recommend? Prozac, Zoloft, Celexa, Effexor? I would be interested in your experiences. Thanks.
>
>Hi Joe,
If SSRI's aren't helping then it's time to try either Nardil or Clomipramine depending on which side effects you prefer.
Cheers,
Panda.
Posted by ramsea on May 12, 2004, at 13:53:47
In reply to Re: Social phobia meds - advice needed » Joe Schmoe, posted by Kon on May 11, 2004, at 23:51:03
Congrats on the weight loss, I know just how hard and discouraging med weight gain can be. I don't feel qualified to address your problem even from experience as I have bipolar to deal with, plus social phobia (very severe unfortunately). The lithium and Seroquel I take help even out moods and help me sleep, but do nothing for my social anxiety difficulty.
In the past I have taken Prozac--it can cause massive weight gain and mania in the form of increased agitation/irritability/etc. as well as euphoria. I think the fact it made me go hypomanic and eventually manic and in hospital is why I had the following happen. At first I was only on Prozac and lowdose valium to deal with Prozac's agitating/stimulating effects in the first few weeks. This was after a period of virtually no meds at all of some 8 years. The first two months or so were great--I had a happy euphoric reaction (hypomania) which caused me to be very socially at ease, in fact it swung too much that way. So yeah, Prozac over-rode my social anxiety. But I am bipolar, so this may have no insight to offer you.
I was on Prozac for about a year when I ended up in terrible shape. I'd gained weight on the stuff too. Also, Prozac often kills libido. But some people manage with Prozac very well and I can see how it would be worth a try for a pretty much definite non-bipolar, who has no bipolar genetic heritage. Good luck.
Posted by jlbl2l on May 12, 2004, at 14:09:31
In reply to Re: Social phobia meds - advice needed » Joe Schmoe, posted by Kon on May 11, 2004, at 23:51:03
i can vouche for the effects of klonopin & gabapentin combined as helping with social phobia, after tolerance to both klonopin & gabapentin developed...
when combined, tolerance to both meds lessoned and social interaction was superior to that of 1 or the other.
jlbl2l
Posted by Impermanence on May 12, 2004, at 17:25:58
In reply to Re: Social phobia meds - advice needed, posted by jlbl2l on May 12, 2004, at 14:09:31
I suffer from social phobia and I found Mirtazapine (Zispin in U.K., Remeron in U.S.) excellent for anxiety but not very good for lifting my mood, minimal side effects.
Posted by Keith Talent on May 13, 2004, at 8:13:07
In reply to Social phobia meds - advice needed, posted by Joe Schmoe on May 11, 2004, at 19:17:27
Why does it matter one way or the other whether you became tolerant to Klonopin or never reached a therapeutic dose? The psychiatrist sounds very patronising if she stops prescribing something that obviously helped you because tolerance developed. People post here all the time about taking more than 2 mg per day (one person was on 16 mg per day). You've got to be able to function in life.
Posted by bobbiedobbs on May 15, 2004, at 12:38:33
In reply to Re: Social phobia meds - advice needed, posted by Keith Talent on May 13, 2004, at 8:13:07
If you have social phobia and given the prior drug trials you owe it to yourself to try nardil or parnate. Of all the stuff I've taken, Nardil was the ONLY medication that really made a difference in this area. What's the resistance about? The food precautions are way overstated.There should be plenty on that elsewhere.
Phil
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