Protracted Withdrawal or PAWS (post-acute withdrawal syndrome)

November 19, 2013

For all those who don't fit the title who are just curious let me say with all the reading I have done in the past 6 years on sites like this and not like this but related...most people are better and back to their lives completely by this point.

So if you are new and just looking around don't be bothered with this one you have much more important things to read and having this in your head will be of no service to you.

November 21, 2013

Hey, I've been off medications for 4 years now. It was a 2 month taper, after being on sertraline for 6 months. I'm not sure if that's considered slow or fast.

I still have lasting anhedonia and sexual side effects. But in the past year I have knoticed more pleasure from simple things, like music or a cool breeze or hot food. So I know things are changing.

I can function quite well these days, it took 2 years of widthdrawl symptoms after the drugs for me to leave the house. another 2 years to get where I am.

But now I catch myself thinking anxious thoughts like "I can't do this" and just do what I know I really want to, even though my stomach aches.

As for no-drug mantra I still want to stay away from medications because I see them as a short term soloution with possible dangers that outweigh the benefit.

In my opinion all my perceived problems can be solved with proper diet, exercise and state of mind. Although reciently I have considered finding a good brand of st. johns wort.

I have accepted that I may have some very long lasting or permanent sexual side effects. From one point of view I feel like giving up with sex because it is mostly pleasureless for me. But I prefer to think of myself as a genuine lover. And with the right partner I can feel pleasure knowing im giving a gift to someone else. I also have hopes for the plasticity of my brain, and with the right partner and practice I can create new neural pathways. One night stands are not in my books.

I live for each day, counting my blessings, looking for the silver lining.

November 26, 2013

Hi Btdt

If i may ask, what are your current symptoms now?

It is 7 years since I went cold turkey from 150mg of Effexor use. You can see my signature if you want more details. All this time I have been thinking I would be well by now normal even back to my life or some type of life.

I still have symptoms get drug reactions some scary and serious to me.

I have been reading sites like this for 6 years at least and most say you get well in time. Don't get me wrong I am much better than I was but not where I expected to be. Now that I have reached this 7 year mark I wonder about others who may have reach it too and what life is like for them.

So if there are any people who fit this category on here maybe even new here... come talk to me.

Things I want to talk about. Did you taper slow fast or go cold turkey.

What symptoms are you left with.. do you still have waves?

Are you functional? how functional? Can you tell somebody you will be at an event and actually go long before the event or do you have to say I will see how I feel when the time gets closer?

Can you get up everyday or even some days and go to work?

Was there a point where you had to skip the no drug mantra and take something?

What did you try... did it help.

Are you still hypersensitive to drugs... which ones have cause reactions lets say 5 years after being off antidepressants?

How do you see your life going forward?

If you did not completely recover and have accepted that this is how the rest of your life will be... how have you coped with the realization?

November 28, 2013

I'm seven years off ADs, though only three years drug free. I was going to answer your questions when I noticed you were injured by a drug given for pain.

The same thing happened to a friend of mine; given an AD for back pain, which he reacted to, which led to other drugs, more diagnoses, etc...His story is a complete nightmare, one of the worst I have heard of where the person managed to survive. All of his "mental illnesses" were caused either directly by the drugs he took or were the result of trauma from his experiences. Do you think you had serotonin toxicity from Prozac?

Your story has freaked me out as I just went back and read his and he was given pain drugs before the AD; now I am wondering if they had something to do with the adverse reaction to Prozac? I never realized he was given them before the Prozac. Were you on Codeine and Prozac at the same time?

November 28, 2013

Things I want to talk about. Did you taper slow fast or go cold turkey.

What symptoms are you left with.. do you still have waves?

Are you functional? how functional? Can you tell somebody you will be at an event and actually go long before the event or do you have to say I will see how I feel when the time gets closer?

Can you get up everyday or even some days and go to work?

Was there a point where you had to skip the no drug mantra and take something?

What did you try... did it help.

Are you still hypersensitive to drugs... which ones have cause reactions lets say 5 years after being off antidepressants?

How do you see your life going forward?

If you did not completely recover and have accepted that this is how the rest of your life will be... how have you coped with the realization?

Hi btdt,

Your story is my story, I think we have talked in the past and are basically in the same boat.

I am now slightly more than 6 years off Paxil, cold turkey from 10 mg. I had no clue abouit tapering those days, had already several failed attempts behind me but my GP kept denying every link with the Paxil, that is why I each time thought "I an now ready for it" which has turned out to be the most dangerous and harmful pitfall of my life and almost became my death.

After my last c/t, I got terrible sick, both psysically and mentally. My horrific mental symptoms, among them gruesome hallucinations about the scariest person I ever met, a sadistic bully who tormented my life when I was 19-20 years old, almost drove me insane and did make me believe that it indeed was all PTSD related. LAter I realized that I indeed had some form of PTSD but the Paxil WD excuberated the symptoms a millionfold.

Some recovery started after the 20 month mark were I had a beautiful window and also learned about WD on p*****progress. From that time I have lived in a bizarre waves and windows pattern where my cognitive abilites improved, I started again with work related study and programming projects. I did even better than before but was also hindered by nasty waves with terrible neuroparthic symptoms.

Now I work on a semi-voluntary base from home and am very eager to resume work but still cannt apply for a normal job due to the sensory overload and eletrical josts in my lleft lower chest which still drive me nuts. many times.

I never touched any illegal or legal drug since my last CT and never will. I count on further and maybe even full recovery and praise myself lucky to have had some financial buffer from the heritage of my father and also having a loving and understanding mum. Without her I would almost certainly have killed myself.

Indeed is is a trauma, but also I am gratefuil to have leanred the truth about Big PHarma and psychiatry, albeit in the hard way. I have still a life ahead of me and feel better off than the countless people still in the AD trap and still listening to their shrinks and getting drug after drug.

December 2, 2013

I'm seven years off ADs, though only three years drug free. I was going to answer your questions when I noticed you were injured by a drug given for pain.

The same thing happened to a friend of mine; given an AD for back pain, which he reacted to, which led to other drugs, more diagnoses, etc...His story is a complete nightmare, one of the worst I have heard of where the person managed to survive. All of his "mental illnesses" were caused either directly by the drugs he took or were the result of trauma from his experiences. Do you think you had serotonin toxicity from Prozac?

Your story has freaked me out as I just went back and read his and he was given pain drugs before the AD; now I am wondering if they had something to do with the adverse reaction to Prozac? I never realized he was given them before the Prozac. Were you on Codeine and Prozac at the same time?

It was 18 years ago and I would have a hard time recalling that as if feels like millions years ago indeed I feel like I have lived several lifetimes ... this may be in part due to stops and starts of my life... would explain that but it would take all night... no will try after each drug reactions and recovery which I use to be able to pull off when I was younger... I would start seemingly a new life a all I had built would be gone by the time I got back on my feet. Plus memory issues problems make it seem like a different life.

If I had to guess i would say Yes I was likely taking Tylenol #3 and prozac at the same time as to my memory I was not taken off the tylenol #3 I was taking a lot of it something I now know...I had built up tolerance to it. The doctor did not like the amount I was taking said it was too much and gave me the prozac so I could use less ...yep I was taking both...

what do you know about it?

Toxic reaction how is one to tell about that... I seen things felt things hear voices... thought I was attacked in my own shower felt a knife go thru my insides..ran out naked... . then was possessed felt a demon come out of my mouth... bat **** crazy is that toxic reaction.. the last bit I was suicidal... was going to end it all off to emerg... they did not say to quit taking it... to my recollection I just stopped taking it..more because my bf mother said she thought it was the drug... but truth be told I would take it every now and then when my leg really hurt it.. was not a psych drug it was similar to a anti inflammatory or so the doctor told me... I did not make the connection... I did not know the drug I was taking then was prozac till I joined pp in 2008.... and seen the other name of prozac... yes I still had the bottle talk about pack rat...all those years later I seen the name that started with an F and got the bottle out and looked it up.

All those years I went on thinking if i did not take the meds and go to therapy all that crazy **** would come back....till I seen that name on pp i did not know I had been on prozac I did not know I had been given a mind altering drug... i did not know I was on an antidepressant... that there could be reactions or withdrawal... i learned all that in 2008 -9 after I joined pp. If it were not for the internet I still would not know it.

what do you know?

December 2, 2013

Does the fact that I was on codeine and prozac change something? Tell me what it changes... as for the other posts I am sorry I have been away on a family health issue... bit off balance yet sorry for the delay in responding to posts.. will get to it soon now that I am back home.

January 12, 2014

It was 18 years ago and I would have a hard time recalling that as if feels like millions years ago indeed I feel like I have lived several lifetimes ... this may be in part due to stops and starts of my life... would explain that but it would take all night... no will try after each drug reactions and recovery which I use to be able to pull off when I was younger... I would start seemingly a new life a all I had built would be gone by the time I got back on my feet. Plus memory issues problems make it seem like a different life.

If I had to guess i would say Yes I was likely taking Tylenol #3 and prozac at the same time as to my memory I was not taken off the tylenol #3 I was taking a lot of it something I now know...I had built up tolerance to it. The doctor did not like the amount I was taking said it was too much and gave me the prozac so I could use less ...yep I was taking both...

what do you know about it?

Toxic reaction how is one to tell about that... I seen things felt things hear voices... thought I was attacked in my own shower felt a knife go thru my insides..ran out naked... . then was possessed felt a demon come out of my mouth... bat **** crazy is that toxic reaction.. the last bit I was suicidal... was going to end it all off to emerg... they did not say to quit taking it... to my recollection I just stopped taking it..more because my bf mother said she thought it was the drug... but truth be told I would take it every now and then when my leg really hurt it.. was not a psych drug it was similar to a anti inflammatory or so the doctor told me... I did not make the connection... I did not know the drug I was taking then was prozac till I joined pp in 2008.... and seen the other name of prozac... yes I still had the bottle talk about pack rat...all those years later I seen the name that started with an F and got the bottle out and looked it up.

All those years I went on thinking if i did not take the meds and go to therapy all that crazy **** would come back....till I seen that name on pp i did not know I had been on prozac I did not know I had been given a mind altering drug... i did not know I was on an antidepressant... that there could be reactions or withdrawal... i learned all that in 2008 -9 after I joined pp. If it were not for the internet I still would not know it.

what do you know?

So sorry I didn't answer this sooner, btdt, memory loss made me miss it.

I am not sure if there's any relationship between a reaction to Prozac and codeine or other pain drugs. I have to wonder though, as your situation reads similar to that of my friend's. I had never considered that possibly he might have been taking pain drugs before (or with) the first AD he was given and if there was an interaction. I did a search and can't find anything really noteworthy though so maybe there isn't. If I turn up anything in future I'll post it.

Regarding serotonin toxicity, there seems to be some debate as to what does and doesn't qualify. I know you have to have taken a drug that affects serotonin, but aside from that one major criteria I'm not sure where they draw the line. I've seen it argued that they apply it mostly to people who wind up near death from drugs, which I read doesn't often happen if you only take one drug (can happen if you take two or more drugs that are contraindicated, one of which has to be a drug that affects serotonin.) It seems possible that there's a threshold beyond which you'll be told you have serotonin toxicity. If you don't have some of the most severe problems and aren't literally at death's door (suicide attempts prompted by unbearable drug-induced psych effects don't apparently count) then it seems IF they catch that the drug is to blame you'll be told you had an adverse reaction.

Trouble is, my friend had a lot of signs of serotonin toxicity and took the drug he was on for a long time--but didn't go into a coma. He had a rollercoastering body temp., which is not a sign of "depression", but IS a sign of serotonin toxicity. Also mental status changes, which is another apparent symptom. They couldn't even catch that as a reaction though, chalked it up to a depression he never had going in (since the drugs were for pain management--no history of "mental illness" with him at all.) He was fairly convinced he'd had serotonin toxicity and I tend to agree with him. To further confuse the picture, I also found a documented case of someone they claimed had it who had had it for over a year while on drugs the whole time. Again they never progressed to the point they could have been said to be at death's door...

So my guess is whether you get the diagnosis or not depends entirely on WHO you see. I could be entirely wrong though. Just how things appear from where I'm sitting.

January 14, 2014

It was 18 years ago and I would have a hard time recalling that as if feels like millions years ago indeed I feel like I have lived several lifetimes ... this may be in part due to stops and starts of my life... would explain that but it would take all night... no will try after each drug reactions and recovery which I use to be able to pull off when I was younger... I would start seemingly a new life a all I had built would be gone by the time I got back on my feet. Plus memory issues problems make it seem like a different life.

If I had to guess i would say Yes I was likely taking Tylenol #3 and prozac at the same time as to my memory I was not taken off the tylenol #3 I was taking a lot of it something I now know...I had built up tolerance to it. The doctor did not like the amount I was taking said it was too much and gave me the prozac so I could use less ...yep I was taking both...

what do you know about it?

Toxic reaction how is one to tell about that... I seen things felt things hear voices... thought I was attacked in my own shower felt a knife go thru my insides..ran out naked... . then was possessed felt a demon come out of my mouth... bat **** crazy is that toxic reaction.. the last bit I was suicidal... was going to end it all off to emerg... they did not say to quit taking it... to my recollection I just stopped taking it..more because my bf mother said she thought it was the drug... but truth be told I would take it every now and then when my leg really hurt it.. was not a psych drug it was similar to a anti inflammatory or so the doctor told me... I did not make the connection... I did not know the drug I was taking then was prozac till I joined pp in 2008.... and seen the other name of prozac... yes I still had the bottle talk about pack rat...all those years later I seen the name that started with an F and got the bottle out and looked it up.

All those years I went on thinking if i did not take the meds and go to therapy all that crazy **** would come back....till I seen that name on pp i did not know I had been on prozac I did not know I had been given a mind altering drug... i did not know I was on an antidepressant... that there could be reactions or withdrawal... i learned all that in 2008 -9 after I joined pp. If it were not for the internet I still would not know it.

what do you know?

So sorry I didn't answer this sooner, btdt, memory loss made me miss it.

I am not sure if there's any relationship between a reaction to Prozac and codeine or other pain drugs. I have to wonder though, as your situation reads similar to that of my friend's. I had never considered that possibly he might have been taking pain drugs before (or with) the first AD he was given and if there was an interaction. I did a search and can't find anything really noteworthy though so maybe there isn't. If I turn up anything in future I'll post it.

Regarding serotonin toxicity, there seems to be some debate as to what does and doesn't qualify. I know you have to have taken a drug that affects serotonin, but aside from that one major criteria I'm not sure where they draw the line. I've seen it argued that they apply it mostly to people who wind up near death from drugs, which I read doesn't often happen if you only take one drug (can happen if you take two or more drugs that are contraindicated, one of which has to be a drug that affects serotonin.) It seems possible that there's a threshold beyond which you'll be told you have serotonin toxicity. If you don't have some of the most severe problems and aren't literally at death's door (suicide attempts prompted by unbearable drug-induced psych effects don't apparently count) then it seems IF they catch that the drug is to blame you'll be told you had an adverse reaction.

Trouble is, my friend had a lot of signs of serotonin toxicity and took the drug he was on for a long time--but didn't go into a coma. He had a rollercoastering body temp., which is not a sign of "depression", but IS a sign of serotonin toxicity. Also mental status changes, which is another apparent symptom. They couldn't even catch that as a reaction though, chalked it up to a depression he never had going in (since the drugs were for pain management--no history of "mental illness" with him at all.) He was fairly convinced he'd had serotonin toxicity and I tend to agree with him. To further confuse the picture, I also found a documented case of someone they claimed had it who had had it for over a year while on drugs the whole time. Again they never progressed to the point they could have been said to be at death's door...

So my guess is whether you get the diagnosis or not depends entirely on WHO you see. I could be entirely wrong though. Just how things appear from where I'm sitting.

try this

http://qjmed.oxfordjournals.org/content/96/9/635.full

and this

http://www.uptodate.com/contents/serotonin-syndrome

both state a single drug can cause it...

last link

CLINICAL FEATURES

Overview and principles of evaluation — The diagnosis of serotonin syndrome is made solely on clinical grounds. Therefore, a detailed history and thorough physical and neurologic examinations are essential.

"Serotonin syndrome encompasses a spectrum of disease where the intensity of clinical findings is thought to reflect the degree of serotonergic activity. Mental status changes can include anxiety, agitated delirium, restlessness, and disorientation [12]. Patients may startle easily. Autonomic manifestations can include diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, and diarrhea [3]. Neuromuscular hyperactivity can manifest as tremor, muscle rigidity, myoclonus, hyperreflexia, and bilateral Babinski sign. Hyperreflexia and clonus are particularly common; these findings, as well as rigidity, are more often pronounced in the lower extremities [3].

Questions remain regarding the exact point at which serotonergic signs associated with therapeutic drug administration become the toxic reaction known as serotonin syndrome. The transition point likely depends upon an assessment of the risks and benefits of therapy. As an example, an individual treated for major depression with a serotonergic agent may develop mild tremor and hyperreflexia. Although technically meeting the diagnostic criteria for serotonin syndrome, the patient may benefit more (ie, be significantly less depressed) with continued administration of the agent, even though it produces obvious but tolerable signs of serotonergic excess. However, clinicians should be extremely careful not to add other serotonergic drugs to the regimen of such a patient, and must remain vigilant for any worsening in condition."

Physical examination — Typical vital sign abnormalities include tachycardia and hypertension, but severe cases may develop hyperthermia and dramatic swings in pulse and blood pressure. Pertinent physical examination findings may include [1]:

Hyperthermia
Agitation
Slow, continuous, horizontal eye movements (referred to as ocular clonus)
Dilated pupils
Tremor
Akathisia
Deep tendon hyperreflexia (common)
Inducible or spontaneous muscle clonus (common)
Muscle rigidity
Bilateral Babinski signs
Dry mucus membranes
Flushed skin and diaphoresis
Increased bowel sounds

Neuromuscular findings are typically more pronounced in the lower extremities.

LABORATORY EVALUATION — Serotonin syndrome is a clinical diagnosis; serum serotonin concentrations do not correlate with clinical findings, and no laboratory test confirms the diagnosis [3]. Nevertheless, some nonspecific laboratory findings may develop, including an elevated white blood cell count, elevated creatine phosphokinase, and decreased serum bicarbonate concentration.

Patients with severe disease may develop severe complications, including disseminated intravascular coagulation, rhabdomyolysis, metabolic acidosis, renal failure, myoglobinuria, and acute respiratory distress syndrome [3]. (See "Clinical features, diagnosis, and treatment of disseminated intravascular coagulation in adults" and"Clinical manifestations and diagnosis of rhabdomyolysis" and "Acute respiratory distress syndrome: Epidemiology; pathophysiology; pathology; and etiology".)

In order to narrow the differential diagnosis and to monitor for potential complications, particularly in severely ill patients, the following studies may be necessary:

Complete blood count
Basic serum electrolytes
BUN and creatinine
Creatine phosphokinase
Hepatic transaminase concentrations
Coagulation studies
Blood culture
Urinalysis and urine culture
Plain chest radiograph
Cerebrospinal fluid analysis and culture
Head computed tomography (CT)

In patients whose overdose was intentional, acetaminophen and salicylate concentrations should be measured and an electrocardiogram evaluated for signs of toxicity from other agents. (See "General approach to drug poisoning in adults", section on 'Electrocardiography' and "General approach to drug poisoning in adults", section on 'Other laboratory studies'.)

DIAGNOSIS AND DIAGNOSTIC CRITERIA — Serotonin syndrome is diagnosed on the basis of clinical findings. We suggest diagnosing serotonin syndrome using the Hunter Toxicity Criteria Decision Rules [13]. To fulfill the Hunter Criteria, a patient must have taken a serotonergic agent and meet ONE of the following conditions:

Spontaneous clonus
Inducible clonus PLUS agitation or diaphoresis
Ocular clonus PLUS agitation or diaphoresis
Tremor PLUS hyperreflexia
Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus

Several sets of diagnostic criteria have been developed to define serotonin syndrome, of which the Hunter Criteria are most accurate (84 percent sensitive and 97 percent specific when compared with the gold standard of diagnosis by a medical toxicologist). In a comparison with the original Sternbach Criteria, the Hunter Criteria performed with greater accuracy and were less likely to miss early, mild, or subacute forms of serotonin syndrome.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of serotonin syndrome includes neuroleptic malignant syndrome (NMS), anticholinergic toxicity, malignant hyperthermia, intoxication from sympathomimetic agents, sedative-hypnotic withdrawal, meningitis, and encephalitis.

Serotonin syndrome is often misdiagnosed as NMS, but the two can readily be distinguished on the basis of history, examination findings, and clinical course (table 3) [9]. NMS develops over days to weeks [9], whereas serotonin syndrome develops over 24 hours [3]. Serotonin syndrome is characterized by neuromuscular hyperreactivity (tremor, hyperreflexia, myoclonus), while NMS involves sluggish neuromuscular responses (rigidity, bradyreflexia). Hyperreflexia and myoclonus are rare in NMS [9]. In addition, resolution of NMS typically requires an average of nine days, compared with less than 24 hours (usually) for resolution of serotonin syndrome [9]. Hyperthermia, altered mental status, muscle rigidity, leukocytosis, elevated creatine phosphokinase, elevated hepatic transaminases, and metabolic acidosis are seen in severe cases of both conditions, which highlight the necessity of a thorough history and physical examination. (See "Neuroleptic malignant syndrome".)

Anticholinergic toxicity classically presents with hyperthermia, agitation, altered mental status, mydriasis, dry mucous membranes, urinary retention, and decreased bowel sounds after the use of an anticholinergic agent. In contrast with serotonin syndrome, muscular tone and reflexes are normal in anticholinergic poisoning (table 4). (See"Anticholinergic poisoning".)

Malignant hyperthermia occurs in susceptible individuals exposed to halogenated volatile anesthetics and depolarizing muscle relaxants (eg, succinylcholine). It classically presents with increased concentrations of end-tidal carbon dioxide, rigor mortis-like muscle rigidity, tachycardia, hyperthermia, and acidosis [14]. (See "Malignant hyperthermia: Clinical diagnosis and management of acute crisis" and "Susceptibility to malignant hyperthermia: Evaluation and management".)

Serotonin syndrome may be distinguished from other causes of agitated delirium on the basis of neuromuscular findings. Whereas patients with serotonin syndrome show signs of neuromuscular activation (eg, tremor, hyperreflexia and clonus that are greater in the lower extremities, ocular clonus, and increased muscle tone), patients with sympathomimetic toxicity or infections of the central nervous system lack these findings.

MANAGEMENT

Key principles — A summary table to facilitate the emergent management of serotonin syndrome is provided (table 1). Five principles are central to the management of serotonin syndrome:

Discontinuation of all serotonergic agents (table 2)
Supportive care aimed at normalization of vital signs
Sedation with benzodiazepines
Administration of serotonin antagonists
Assessment of the need to resume use of causative serotonergic agents after resolution of symptoms

Application of these principles varies with the severity of illness. In mild cases, discontinuation of inciting medications, supportive care, and sedation with benzodiazepines are generally sufficient. Moderately ill patients require more aggressive treatment of autonomic instability and possibly treatment with a serotonin antagonist (see 'Antidote: Cyproheptadine' below). Hyperthermic patients (>41.1°C) are critically ill and often require neuromuscular paralysis and tracheal intubation.

Common management pitfalls include failure to recognize serotonin syndrome, misdiagnosis, and failure to understand serotonin syndrome's potentially rapid rate of progression (see 'Clinical features' above). Even if the diagnosis remains unclear, the clinician should withhold serotonergic agents and provide aggressive supportive care, anticipating the need for interventions before the patient's condition deteriorates.

Serotonin syndrome often resolves within 24 hours of discontinuing the serotonergic agent and initiating care, but drugs with long half-lives or active metabolites may cause symptoms to persist [1]. Irreversible monoamine oxidase inhibitors (MAOIs) carry the greatest risk, and symptoms can persist for several days. Selective serotonin reuptake inhibitors (SSRIs) may contribute to the development of serotonin syndrome up to several weeks after the drug has been discontinued; the half-life of fluoxetine is one week and that of its metabolite norfluoxetine is up to 2.5 weeks [15]. Although the patient may not exhibit symptoms of serotonin syndrome while taking fluoxetine, care should be taken when administering another serotonergic agent after discontinuing this or any other SSRI.

As with any toxic exposure, consultation with a medical toxicologist, clinical pharmacologist, or poison control center can provide valuable assistance with clinical decision-making. (See 'Additional resources' below.)

Supportive care and sedation — Supportive care is the mainstay of therapy and includes the administration of oxygen and intravenous fluids, continuous cardiac monitoring, and correction of vital signs. Clinicians should provide sufficient oxygen to maintain the oxygen saturation ≥ 94 percent, and give IV crystalloid to treat volume depletion, and to some extent hyperthermia.

Chemical restraint is greatly preferred to physical restraint for agitated patients; physical restraints may cause isometric muscle contractions leading to profound lactic acidosis and hyperthermia [1]. Sedation with benzodiazepines is important for controlling agitation as well as correcting mild increases in blood pressure and heart rate.Diazepam prolongs survival in a rat model of serotonin syndrome, but no specific agent has been studied in humans [16]. Regardless of the benzodiazepine selected, the clinician should give standard doses to begin therapy and titrate further treatment to effect, the goals being adequate patient sedation (not somnolence) and normal vital signs.

We treat patients with significant agitation (eg, those who do not respond immediately to verbal interventions) with intravenous (IV) benzodiazepines (eg, lorazepam 2 to 4 mg IV or diazepam 5 to 10 mg IV). These doses can be repeated every 8 to 10 minutes based upon patient response. Butyrophenones (eg, droperidol and haloperidol) should be avoided; these drugs have anticholinergic properties that inhibit sweating and dissipation of body heat.

Autonomic instability — Management of autonomic instability may be difficult since severely intoxicated patients often exhibit large and rapid changes in blood pressure and heart rate. Consequently, patients with severe hypertension and tachycardia should be treated with short-acting agents, such as esmolol or nitroprusside [1]. Dosing of these short-acting cardiovascular agents should be titrated to maintain autonomic stability; longer-acting agents, such as propranolol, should be avoided.

Hypotension from MAOIs in patients with serotonin syndrome should be treated with low doses of direct-acting sympathomimetic amines, such as phenylephrine, epinephrine, or norepinephrine [1]. Indirect agents (eg, dopamine) should be avoided because they are metabolized to epinephrine and norepinephrine; when monoamine oxidase is inhibited, epinephrine and norepinephrine production at the cellular level is not controlled, possibly leading to an exaggerated hemodynamic response [1].

Hyperthermia — Control of hyperthermia is critical and involves eliminating excessive muscle activity. Aggressive and effective control of hyperthermia can potentially minimize several severe complications of serotonin syndrome (eg, seizures, coma, disseminated intravascular coagulation, hypotension, ventricular tachycardia, and metabolic acidosis) [9]. Standard treatments for hyperthermia are discussed separately. (See "Severe nonexertional hyperthermia (classic heat stroke) in adults", section on 'Cooling measures'.)

Patients whose temperature is above 41.1ºC require immediate sedation, paralysis, and tracheal intubation [1]. Standard rapid sequence intubation (RSI) using an induction and paralytic agent should be performed. Etomidate (0.3 mg/kg IV) and succinylcholine (1.5 to 2 mg/kg IV) can generally be used; succinylcholine should be avoided in patients with possible hyperkalemia (as may occur in patients with acute renal failure or rhabdomyolysis). After intubation, paralysis can be maintained with a longer-acting nondepolarizing agent, such as vecuronium. Clinicians must provide adequate sedation, typically with a benzodiazepine, while the patient is paralyzed. (See "Rapid sequence intubation in adults" and "Sedative-analgesic medications in critically ill patients: Selection, initiation, maintenance, and withdrawal".)

In hyperthermia associated with serotonin syndrome, there is no role for antipyretic agents, such as acetaminophen; the increase in body temperature is not due to an alteration in the hypothalamic temperature set point, but rather an increase in muscular activity [1].

Antidote: Cyproheptadine — If benzodiazepines and supportive care fail to improve agitation and correct vital signs, we suggest antidotal therapy with cyproheptadine[17]. Cyproheptadine is a histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-HT2A antagonistic properties [17]. It also has weak anticholinergic activity.

Cyproheptadine is available in 4 mg tablets or 2 mg/5 mL syrup [9]. When administered as an antidote for serotonin syndrome, an initial dose of 12 mg is recommended, followed by 2 mg every two hours until clinical response is seen. Cyproheptadine is only available in an oral form, but it may be crushed and given through a nasogastric or orogastric tube.

Cyproheptadine may lead to sedation, but this effect is consistent with the goals of management [1]. Furthermore, as a nonspecific serotonin antagonist, cyproheptadine may produce transient hypotension due to the reversal of serotonin-mediated increases in vascular tone. Such hypotension usually responds to intravenous fluids. Cyproheptadine is rated category B for safety in pregnancy by the US Food and Drug administration (FDA) (table 5) [9].

Definitive evidence of cyproheptadine's effectiveness is lacking. A small study used PET scan to assess 5-HT2 blockade in two volunteers after taking cyproheptadine (12 mg and 18 mg per day for six days). At 12 mg/day, there was 85 percent blockade and at 18 mg/day there was over 95 percent blockade of 5-HT2 receptors in the prefrontal cortex [18]. In addition, many reports describe the successful use of cyproheptadine to treat serotonin syndrome [17,19-24]. The majority of these patients received cyproheptadine at an initial dose of 8 mg, while fewer patients responded to as little as 4 mg and some had no response to as much as 16 mg.

Other antidotes — Antipsychotic agents with 5-HT2A antagonist activity, such as olanzapine and chlorpromazine, have been considered for antidotal treatment, but their efficacy is unproven and we do NOT recommend their use [1]. Chlorpromazine can cause orthostatic hypotension, although this is generally not an issue with serotonin syndrome, in which hypertension is common. Chlorpromazine can also increase hyperthermia.

Treatment with propranolol, bromocriptine, or dantrolene is not recommended. Propranolol has a long duration of action, may cause prolonged hypotension, and can mask tachycardia that can be used to monitor the effectiveness of treatment. Bromocriptine, a serotonin agonist, may exacerbate serotonin syndrome [1]. Dantrolene has no effect on survival in animal models.

DISPOSITION AND PROGNOSIS — Patients with severe serotonin syndrome (eg, hyperthermia, autonomic instability, agitated delirium) require care in an intensive care unit. Those with moderate symptoms should be admitted for observation and placed on a cardiac monitor until symptoms resolve. Symptoms usually resolve within 24 hours of discontinuing the serotonergic agent and initiating care, but drugs with long durations of action or active metabolites may cause prolonged symptoms [1]. Mild cases may be observed for four to six hours. If during that period the patient's mental status and vital signs remain normal, there is no increase in clonus or deep tendon reflexes, and close follow-up is assured, the patient may be discharged home.

It merits reiteration that serotonin syndrome manifests a broad spectrum of clinical severity. Particularly in mild cases, clinicians must weigh benefits and risks when determining treatment and whether to continue the causative agent. (See 'Clinical features' above.)

Prognosis is generally favorable, as long as the entity is recognized and complications are treated appropriately.

PEDIATRIC CONSIDERATIONS — Serotonin syndrome in the pediatric population parallels that in the adult population, with similar pathophysiology and manifestations. Any drug or drug combination that increases serotonergic neurotransmission can produce the syndrome (table 2). The same diagnostic criteria, characterized by increased neuromuscular activity, are used in the pediatric population. Hyperreflexia, clonus, and hyperthermia remain important findings. (See 'Diagnosis and diagnostic criteria'above.)

Although multiple case reports have been published, several obstacles make the diagnosis of serotonin syndrome more difficult in pediatric patients [25-28]. Children may not be able to communicate vague symptoms; clinicians may not consider the syndrome a pediatric problem; and adolescents may be reluctant to disclose recreational drug use, which may include serotonergic agents, such as methylenedioxymethamphetamine (MDMA; "ecstasy") or dextromethorphan [12]. (See "MDMA (ecstasy) intoxication" and "Dextromethorphan poisoning: Epidemiology, pharmacology and clinical features".)

The fundamental principles of serotonin syndrome management remain unchanged in pediatrics. Any serotonergic agent is discontinued. Supportive care is provided, the goals being adequate patient sedation and normal vital signs. Standard interventions include oxygen, intravenous fluids, and continuous cardiac monitoring. Autonomic instability and hyperthermia require aggressive treatment. Sedation with weight-based doses of benzodiazepines is recommended for the treatment of agitation. (See'Management' above.)

In pediatric patients with severe symptoms, serotonergic antagonists can be given; cyproheptadine may be used in pediatric patients with a dose of 0.25 mg/kg/day divided every six hours. Doses should be titrated to maintain adequate sedation. General dosing is as follows:

Children younger than two years can be given approximately 0.06 mg/kg per dose every six hours, if needed (not to exceed 0.25 mg/kg/day).
Children two to six years can be given 2 mg every six hours, if needed (not to exceed 12 mg/day).
Children 7 to 14 years can be given 4 mg every six hours, if needed (not to exceed 16 mg/day).

Pediatric patients with severe serotonin syndrome require management in an intensive care unit. Pediatric patients with mild to moderate symptoms should be placed on a cardiac monitor and admitted for observation. If serotonin syndrome is recognized and complications are treated appropriately, the prognosis is generally favorable.

In addition to cases in the general pediatric population, there are rare reports of neonates with symptoms resembling serotonin syndrome. One small study showed that infants exposed to SSRIs late in pregnancy were at increased risk for adverse central nervous system (CNS) effects [29]. The most prominent findings were restlessness, tremor, and rigidity; myoclonus and hyperreflexia occurred less often. Symptoms appeared to subside quickly without any specific treatment [29].

PREVENTION — Serotonin syndrome can be avoided by applying pharmacologic principles, educating clinicians, and modifying prescription practices [1]. Multi-drug regimens should be avoided, if possible.

ADDITIONAL RESOURCES — Once serotonin syndrome occurs, a medical toxicologist, clinical pharmacologist, or poison control center should be consulted for assistance. Regional poison control centers in the United States (1-800-222-1222) are available at all times for consultation on patients who are critically ill, require admission, or have clinical pictures that are unclear. The World Health Organization provides a listing of international poison centers at its website:www.who.int/gho/phe/chemical_safety/poisons_centres/en/index.html

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topic (see "Patient information: Serotonin syndrome (The Basics)")

SUMMARY AND RECOMMENDATIONS

Diagnosis

Serotonin syndrome is a potentially life-threatening condition associated with increased serotonergic activity in the central nervous system (CNS). It is seen with therapeutic medication use, inadvertent interactions between drugs, and intentional self-poisoning. A summary table to facilitate the emergent management of serotonin syndrome is provided (table 1).
The majority of cases of serotonin syndrome present within 24 hours, and most within six hours, of a change or initiation of a drug (table 2). The patient's history should include a detailed description of prescription drugs, over-the-counter medications, illicit substances, and dietary supplements used, as well as any change in dosing and schedule. Clinicians should ask about both the dose, the formulation (eg, sustained release), and any recent changes in all medications. (See 'History'above.)
Typical vital sign abnormalities include tachycardia and hypertension, but severe cases may develop hyperthermia and rapid, dramatic swings in pulse and blood pressure. Pertinent physical examination findings include: hyperthermia, agitation, ocular clonus, tremor, akathisia, deep tendon hyperreflexia, inducible or spontaneous clonus, muscle rigidity, dilated pupils, dry mucus membranes, increased bowel sounds, flushed skin, and diaphoresis. Neuromuscular findings are typically more pronounced in the lower extremities. (See 'Physical examination' above.)
The diagnosis of serotonin syndrome is made solely on clinical grounds using the Hunter Criteria; a detailed history and thorough physical and neurologic examination are essential. To fulfill the Hunter Criteria, a patient must have taken a serotonergic agent and meet ONE of the following conditions (see 'Physical examination' above):

Spontaneous clonus
Inducible clonus PLUS agitation or diaphoresis
Ocular clonus PLUS agitation or diaphoresis
Tremor PLUS hyperreflexia
Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus

Serotonin syndrome is a clinical diagnosis; serotonin concentrations do not correlate with clinical findings, and no laboratory test confirms the diagnosis. To narrow the differential diagnosis and to monitor potential complications, particularly in severely ill patients, additional diagnostic studies may be necessary. (See 'Laboratory evaluation' above.)

Treatment

An overview of the management of serotonin syndrome is provided (table 1). Application of the following principles is central to management of acute serotonin syndrome:

Discontinuation of all serotonergic agents
Supportive care aimed at normalization of vital signs
Sedation with benzodiazepines
Administration of serotonin antagonists

Application of these principles varies with the severity of illness. In mild cases, discontinuation of inciting medications, supportive care, and sedation with benzodiazepines is generally sufficient. Moderately ill patients require more aggressive treatment of autonomic instability and possibly treatment with a serotonin antagonist. Hyperthermic patients are critically ill and often require paralysis and endotracheal intubation. (See 'Management' above.)

Supportive care is the mainstay of therapy. For all patients who fulfill the Hunter Criteria, we suggest the following standard treatments (Grade 2C):

Oxygen to maintain SpO2 ≥94 percent
Intravenous fluids for volume depletion
Continuous cardiac monitoring
Correction of vital signs

We suggest sedation with benzodiazepines for controlling agitation as well as correcting mild increases in blood pressure and heart rate (Grade 2C). (See'Management' above.)
Management of autonomic instability may be difficult; severely intoxicated patients often exhibit rapid, dramatic changes in vital signs. For patients with severe hypertension and tachycardia, we suggest treatment with short-acting agents, such as esmolol and nitroprusside (Grade 2C). For hypotension from monoamine oxidase inhibitors (MAOIs), we suggest treatment with low doses of direct-acting sympathomimetic amines such as phenylephrine, epinephrine, or norepinephrine (Grade 2C). We recommend that indirect agents (eg, dopamine) NOT be used (Grade 1C). (See 'Management' above.)
Control of hyperthermia is critical and involves eliminating excessive muscle activity. For patients whose temperature is above 41.1ºC, we recommend treatment with immediate sedation, paralysis, and tracheal intubation (Grade 1C). In hyperthermia associated with serotonin syndrome, antipyretic agents (eg, acetaminophen) are ineffective and should NOT be used. (See 'Management' above.) Standard treatments for hyperthermia should be implemented and are discussed separately. (See"Severe nonexertional hyperthermia (classic heat stroke) in adults", section on 'Cooling measures'.)
If benzodiazepines and supportive care fail to improve agitation and correct vital signs, we suggest treatment with cyproheptadine, a histamine-1 receptor antagonist (Grade 2C). When administered as an antidote for serotonin syndrome, an initial dose of 12 mg is given, followed by 2 mg every two hours until clinical response is seen. Cyproheptadine is only available in an oral form, but it may be crushed and given through a nasogastric tube. Cyproheptadine may lead to sedation and transient hypotension that is responsive to intravenous fluids. (See 'Antidote: Cyproheptadine' above.) Detailed pediatric dosing is provided above. (See 'Pediatric considerations' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

January 14, 2014

Oh, I know a single drug can cause it...What I read though was that it was unlikely you'd die if you developed serotonin toxicity (should be called that instead of serotonin syndrome, as the latter wrongly implies it's idiosyncratic--Dr. Ken Gillman? I think wrote that it ISN'T idiosyncratic, it's a kind of poisoning that can happen to anyone so long as they take one or more of the relevant drugs that cause it. So, basically, too much of a serotonergic drug is bad for anyone--but how much is "too much" varies from person to person) if you only took one drug. If you take two or more drugs too there's a greater chance you won't process them as well, depending on what they are and what kind of shape you are in.

Of course, the "one drug not leading to fatalities" line could be very far from the truth, given how wrong doctors can be about so many other things. And I don't believe he factored in suicides either...

I didn't realize that akathisia was technically a part of ST. Nice. Good that the doctors I saw never bothered to tell me that.

You wonder if everyone had the capability to sue, and if the justice system was remotely fair, how many minutes longer they'd be in business.

January 14, 2014

"Particularly in mild cases, clinicians must weigh benefits and risks when determining treatment and whether to continue the causative agent."

Very disturbing.

January 15, 2014

"Particularly in mild cases, clinicians must weigh benefits and risks when determining treatment and whether to continue the causative agent."

Very disturbing.

agree

January 19, 2014

My face is red I just figured out due to another post on here started by Iggy that I am not 7 years off I am SIX and yes it is embarassing but more important that I tell the truth than to save face as this process is an exercise in truth for me. So whatever else comes I need it to be truthful at least. Sorry if I bummed a lot of people out who were hoping to be done this by 7 years as that was my next great hope which I thought I had missed... wow this is a brain trip... it will take some time to get my head around this.

I am having some problems thinking not sure why... but they are there. It is not new either it has been with me throughout this process comes and goes like all other things.

If it were not for a post made by another person who quit one month ahead of me who said she was at 6 years off I would not have caught on... then again I made 4 mistakes this morning trying to make muffins I use to make almost with my eyes closed and I was following a recipe. Not sure what it all means just know it is a drag to figure this out now... after making a thread with this title maybe we can change the title to 6 years or maybe we should just leave it so other who make the same mistake will see they are not alone.. if anyone should I am not suggesting this is common.

January 21, 2014

I think you can be forgiven bdtd, this process makes us not able to think clearly. I've had periods where I have forgotten how long I've been off drugs for, so it's not unheard of. Though I think the longer withdrawal scenarios are unusual (hoping anyway.) Sorry to hear things are hard for you at the moment regardless.

January 23, 2014

Yes I think my problematic year has not helped any and the addition of more drugs for pain after accident broken foot and surgery... I will blame that for a time .. a bit all the while knowing I do ok for a time then fall on my face for not other apparent reason. Someday it may all be behind me till then this is how it goes. I hope this year at least puts me back to where I was before that car accident last year. Life goes on and does not take it easy on us cause we are in withdrawal. We wish.

I have had to overcome large embarrassments for sure... one thing that is good about all this getting embarrassed gets to be old hat,,, the skin thickens.

January 23, 2014

hey bt, just wondering since you're from Canada, are you quebecoise?

January 24, 2014

hey bt, just wondering since you're from Canada, are you quebecoise?

Why do you ask?

January 26, 2014

Yes I think my problematic year has not helped any and the addition of more drugs for pain after accident broken foot and surgery... I will blame that for a time .. a bit all the while knowing I do ok for a time then fall on my face for not other apparent reason. Someday it may all be behind me till then this is how it goes. I hope this year at least puts me back to where I was before that car accident last year. Life goes on and does not take it easy on us cause we are in withdrawal. We wish.

I have had to overcome large embarrassments for sure... one thing that is good about all this getting embarrassed gets to be old hat,,, the skin thickens.

I just looked for your thread but couldn't find it...Didn't realize you were in an accident last year. Argh. How is your foot? I would guess the pain meds would cause a setback if you've had one, it's so frustrating how sensitive we become to drugs thanks to ADs. I hope you see some improvements soon.

January 28, 2014

Yes I think my problematic year has not helped any and the addition of more drugs for pain after accident broken foot and surgery... I will blame that for a time .. a bit all the while knowing I do ok for a time then fall on my face for not other apparent reason. Someday it may all be behind me till then this is how it goes. I hope this year at least puts me back to where I was before that car accident last year. Life goes on and does not take it easy on us cause we are in withdrawal. We wish.

I have had to overcome large embarrassments for sure... one thing that is good about all this getting embarrassed gets to be old hat,,, the skin thickens.

I just looked for your thread but couldn't find it...Didn't realize you were in an accident last year. Argh. How is your foot? I would guess the pain meds would cause a setback if you've had one, it's so frustrating how sensitive we become to drugs thanks to ADs. I hope you see some improvements soon.

Yes pain meds accident broken foot surgery now in physio which is helping... yes pain meds antibiotics from infections for pneumonia I broke a rib in the accident and have had trouble with pneumonia since ... then more antibiotics and pain meds with surgery ... a long time on antibiotics with that one in June... still on pain meds but rarely mostly need them to sleep and choose not to sleep rather than take a pill ... add a few migraines in there for good measure yes a set back not two ways around it... On my personal calendar 2013 will have setback on the year.

However not all is lost I am making a plan but I can only go as quickly as my body will allow it is not healing like it use to but it is healing and that is encouraging just more time I guess and so far I have that

peace to you thanks for noticing.

January 28, 2014

There are many reasons for a set back and some maybe drug related and some may well be a combination of withdrawal and all the other things I can't rule it out as I have not had a long clear time yet not enough to call myself done and still don't have stamina guess if withdrawal lasts into old age that would be expected too.

January 31, 2014

Yes pain meds accident broken foot surgery now in physio which is helping... yes pain meds antibiotics from infections for pneumonia I broke a rib in the accident and have had trouble with pneumonia since ... then more antibiotics and pain meds with surgery ... a long time on antibiotics with that one in June... still on pain meds but rarely mostly need them to sleep and choose not to sleep rather than take a pill ... add a few migraines in there for good measure yes a set back not two ways around it... On my personal calendar 2013 will have setback on the year.

However not all is lost I am making a plan but I can only go as quickly as my body will allow it is not healing like it use to but it is healing and that is encouraging just more time I guess and so far I have that

peace to you thanks for noticing.

No problem, bdtd, hope you feel better soon. Pneumonia too, geez you deserve a break.

January 31, 2014

Yes pain meds accident broken foot surgery now in physio which is helping... yes pain meds antibiotics from infections for pneumonia I broke a rib in the accident and have had trouble with pneumonia since ... then more antibiotics and pain meds with surgery ... a long time on antibiotics with that one in June... still on pain meds but rarely mostly need them to sleep and choose not to sleep rather than take a pill ... add a few migraines in there for good measure yes a set back not two ways around it... On my personal calendar 2013 will have setback on the year.

However not all is lost I am making a plan but I can only go as quickly as my body will allow it is not healing like it use to but it is healing and that is encouraging just more time I guess and so far I have that

peace to you thanks for noticing.

No problem, bdtd, hope you feel better soon. Pneumonia too, geez you deserve a break.

Blood work from last wk brings the pancreas back into the picture not sure what is up with that but a urgent ultra sound and more blood work this wk seems it has settled some doc warned I may have to go the hosp but I got out of it. Now I am thinking maybe this rib and back pain that will not leave this year is my pancreas. I had pancreas issues while on Effexor in the form of a vomiting a lot of blood. I have been have gastro issues again but thought I might have the flu. While I am glad to not have to go to the hosp I would appreciate some diagnostics which seem to be none existent since this accident.

Finding out my rib was broken too 3 wks and 3 days so 24 days and many trips to the hosp and clinic was told so many things none of them right. So many trips to the doctor hosp and clinic to find out what is actually going on and still I think maybe they are missing something. Not much I can do about but keep going. I think doctors are in a big hurry to be done with a person here and get them out of the clinic and out of the emergency room the hurry leads to things getting missed several repeat visits I don't know but I think this actually costs more in the long run. Maybe a lot more suffering for the patients too I know I have not gone when maybe I should have as it is not worth the bother and the endless wait to leave not better then you went in. The word impotent comes to mind we use to have such wonderful health care wonder where it went wrong.

January 31, 2014

I went to the doc cause the last migraine I had was a zinger and seemed to be started by swelling up I have abdominal swelling and my bp was very high even after it was higher than it should be. I had this fluctuating bp before and they tried to treat it but when it goes down it really goes down.. so that scares me. it is still doing this fluctuating thing up a few days really high then normal then some times under normal. I went in to talk about this and asked her to please check my liver and my pancreas she did it but was not thinking she would find anything I can tell the thinks I am a whiner... then I waited 10 days for my next apt to see the results of the blood work when I get there she is like be prepared to go the hosp ... makes me wonder why I did not have a call in the mean time surely she seen these results before some time during those 10 days ... but it worked out well I guess as I did not have to go to hosp but maybe if I had I would have found out what this pain in my back and side is thinking it may be a chronic pancreas pain now as it has not left this year and prevents me from lifting things or walking much.

February 3, 2014

bdtd, you have been through way too much. I hope you get it sorted out. Your Effexor story is utterly horrifying. How long were you kept on the drug after that started happening? Honestly that sounds like lawsuit material, not that you'd be likely to get anywhere.

And just so I am understanding this, you have a broken rib from the accident, and the current pancreatic issue started before that?

And I hear you about the state of health care here. I could tell many horror stories. It does not surprise me at all that you waited that long to get a result. I really very much hope they get with the program as it sounds like you could use some quality help.

February 5, 2014

bdtd, you have been through way too much. I hope you get it sorted out. Your Effexor story is utterly horrifying. How long were you kept on the drug after that started happening? Honestly that sounds like lawsuit material, not that you'd be likely to get anywhere.

And just so I am understanding this, you have a broken rib from the accident, and the current pancreatic issue started before that?

And I hear you about the state of health care here. I could tell many horror stories. It does not surprise me at all that you waited that long to get a result. I really very much hope they get with the program as it sounds like you could use some quality help.

After what started happening I don't know what you mean ...lol lawsuit believe me I called a lot of lawyer nobody will touch the effexor stuff not interested... hear the same from all the others who have tried. I had a broken rib it should be long ago healed it was in dec 2012 but still have pain maybe something else but I am told rib pain can go on for a year... I don't know this is my first broken rib apparently the stuff between the rib can be injured... and that takes time I have been way patient I feel...

I had pancreatitis long ago

2003 bleeding lots of it woman kind ... they took out a cystic ovary in 2004... as we thought it was the cause... still bled... he gave me a drug Iooked up when I joined pp after months off E and found it to be a hemophiliac drug or maybe Scott told don't recall. but I did not know it was that just trusted him...

a month later I vomited a lot of blood a LOT ... went to emerg.. was told I had pancreatitis... he gave me papers said see your gp but where I lived then I could not get a gp and had not had one in years I only had a gynoclogist and a shrink... so when I was sick next time I went to emerg as I could not get into the one clinic the city had ...

They sent the papers from the first emerg to a specialist and I got an apt the next year ...when I got there he did not have the papers from the first emerg they had been lost in transit... that was 2006 guess it was actually more than a year almost two years later...

I was constantly sick with infections in 2005 and 2006 I took very little of the stop bleeding drug... maybe two or three as they reacted badly on me

After the ovary was taken and the vomiting blood I was on E two more years before the neurologist said get off was having head drops and foot dragging by then along with the heavy period.. still.

It is hard to think back to all that I think my brain does not want to go there it was such a confusing painful time I was losing everything I worked for and my mind and health... but I am still here.

I had no treatment for the pancreatis had some blood work was told what it was it was 2 years before I seen a specialist when I did he looked down my neck and said I had gerd and gave me ppi drugs that put me back in emerg... they said it was not a drug reaction but not to take the ppi for a few days and then take it... I did NOT take it again.. went back to the specialist was given another ppi when I got to the drug store talked to the druggist he said it was the same sore of drug he called the doc ... they chatted I got a different one pariet... took it for a long time gradually went off it..

As for why I had pancreatitis again I don't know I have been swollen up since the accident... but thought I had an accident broken foot and surgery this year.. I have gained weight make sense right

But the right after the accident and for a lot of the time after I can't wear a bra... or my normal clothes.. I am swolllen and things around my body cause pain so I no longer wear a bra or any of my old clothes I am into other people's track pants and track suits and in the summer dresses save my life... home if i lived along I would only wear a night gown as most cloths hurt to wear ...

I don't know what the answers are. I really don't know.

I know E can cause pancreatitis and ovarian cysts and extended period and vomiting blood ... but I do not know why I had pancreatis again now ... I do not know how long I had it ... I have been in pain for over a year was part of it this I don'[t know but think they would have checked my pancreas in blood work before surgery but I don't know that they did...

I asked her to check it just to be sure it was ok... cause of the pain in that area before the migraine instinct told me it had something to do with my stomach but it could have been the storm or a combination... I am only guessing as usual I don't know anything..

I really don't know....

February 5, 2014

On the pancreas I had an issue in summer of 2004 I had my next issue with it this month... as far as proof that is all I can prove. I am not too sure if I answered your question but I gave it a shot.

That is 10 years between incidents that is a long time. I have no idea if why. I was told having it once makes it easier to have again.

February 17, 2014

Sorry for responding so late bdtd, I've been having some problems lately that kept me from replying.

Wow, it sounds like you've really been put through a lot. Two years to see someone for pancreatitis is a complete outrage. I am not surprised though, as health care here now hardly merits that name...My friend had issues with pancreatitis as well, and was run around by doctors also. But two years is just horrible. His situation was bad, and yours somehow has trumped his. Unbelievable.

That you were kept on Effexor while vomiting blood also leaves me deeply distrustful of medical professionals. Not that I wasn't already.

Do you have anyone you take to appointments to advocate on your behalf, re the current issues? I know sometimes it's beneficial to have someone else there . Your story re the pancreatitis and the wait is very alarming to me, I'd hate to think they'd let you sit through something else like that again. I hope you have someone there with you who can get tough with them if need be. Are you feeling any better lately?

February 17, 2014

Not sure it was two years it was one year I think from the time I had it till I seen a specialist. I just had it again and it cleared up by itself I guess that is not too uncommon I really don't know much about it. When I asked why I got it this time I was told the things that cause it are drugs and maybe a virus. I asked for the blood work on liver pancreas and sugar as I had pain a long time was told it was from a broken rib or muscle injury from a car accident last year had physio for a few months ... it got worse I had pain on breathing sometimes and felt like something was pushing on my one lung. So asked for those tests as I was expecting the same story if I gave the same story of pain. Tests showed I had pancreatitis again.

I told her I had it before she said after you have had it once chances are higher you will have it twice. I had been taking tylenol 3 for pain down to aprox on pill a day that last three months I cut them up and only use them when I really need them mostly to sleep as I can't sleep in pain and get messed in the head when I can't sleep. Many nights I would be up taking a quarter mostly a half as a quarter stopped working but I would always try to sleep without it.. but around 3-4 am I would cave and take one.

By the time the blood work came back and I got in to see her it had been 10 days and new blood work showed I no longer had it. Tho my liver was still high. The only thing I did that may have helped was stop eating I did not feel well and did not eat ... had a salt bath that is all I can think of.

So if the one pill of tylenol 3 caused this and I am very doubtful it did... I need to stop taking it .. so trying even harder to not take it.

I was on a lot of pain pills and some antibiotics this year... had a car accident broke my foot and had surgery after which was hampered by infections about 6 wks. so was on higher doses of pain killers earlier in the year and whatever they gave me in surgery who knows... know it was an ongoing problem this pain.

I am going to lay low try not to take any T3 and see if that keeps it away.

There is talk of further testing to check on what is really going on but no apt yet. Lately one doc says he will order tests and they never happen so I will not hold my breath.

Since the pancreas fiaso the pain is better I don't trust it yet but just now it is easier to live in my body and I am grateful for that.

If you don't have a doctor it is hard to get anything done when you do have a doc it is in and out so fast it is difficult to make a point in the time you have find I am generally brushed off with muscle pain fibro some crap like that and out the door.

I think she was surprised to find my pancreas blood work so high she seemed a bit scared by it all actually you would think I would be the one scared not her. She did a fast and furious few things to find out what was going on and while I still was not feeling well she said my numbers were better ultra sound good and I did not have to got to the hosp.

Waiting for the other shoe to drop as usual. Time will tell if this is an upward swing in healing or just a blip that will pass and it will all come back one day hard to say just now.

February 20, 2014

I'm nearly 5 1/2 years into my recovery and am still having a lot of really bad problems. You can read more about me and my situation in my introduction topic. I just posted an update.

February 20, 2014

It is a hard road protracted withdrawal is no way to live but there are few choices once your in it. I get all you have said did six wks in a homeless shelter too do you have family that can help you? There are many of us that have had our lives and ourselves completely changed by medication way too many of us. Sad to say we have a lot in common. I will look at your thread later today. Peace to you.

February 27, 2014

What keeps you fighting.... prevents you from ending your lives? I'm not nearly as far out as you (3 years) and I don't have any plans in place to end things, but I do think about it constantly.

February 28, 2014

The people I would hurt if I did the knowing I have been bad off before and if I had taken a drastic measure I would have missed some of the greatest moments of my life and I would not have been there when my loved ones needed me. I have been thru this before without the knowledge it was drug induced. I got better with drugs then after a very long time suffering... I see others every day who have healed on these forums maybe they are not perfect but they are at least enjoying some aspects of their lives. Things may change things may be learned that could help us.. we may find it ourselves that is the hope I have. Time heals a lot of things our bodies go thru things while healing different states that would surely be medicated if we were open to it... I have this idea take the drugs away and let the body reset I may be wrong ... but I think of where I have been and all the things I have been thru already... how far I have come I have healed a LOT! I have head set backs but my body wants to live and it wants to live well... it keeps going if I stop I cheat my body out of the success it may get yet.

I am stubborn as hell... I was put here to have a life it is mine always has been mine ... it has been taken over by drugs I was put on for stupid reasons. That pisses me off to the extent I want to win this... I don't start things to lose I never have. I know this has been a losing battle so far ...except when I look back to the years on drugs and the first few years of healing... I see a huge difference a huge improvement so I know it is possible. No I am not the glowing 20 something who was going to take life by the horns and milk it for all it was worth when I was put on these drugs ... but I am not done yet... I will never be that again. I get that. I know there are others just like me ...who are having their withdrawal symptoms dx as some other illness physical or psychological... I know it... I want to be part of what puts an end to that. Even a tiny little part of giving validation to one or two people when they are at their worst that is so important... it was for me when somebody else took the time to help me in my early days. When they get well and they tell two people and they tell two more... even if only one in ten believe it... they will still be further ahead than I was all those years I was drugged. They will have a better chance.

I can decide at any time I want out... I can do it... if I chose to I have spent years ... actually I want to say wasted years thinking about this but it was not a waste sometimes we think about death to figure out we own our lives... we really do they belong to us. Any of us can stop this trip at any time just takes a psychotic break or an impulsive moment and it is all over. I have watched others who have done it watched what happened to their families... felt it myself some were people I loved and love. It is a huge mess so much pain and it begets more pain... so much more pain. I am not doing that to my family to my loved ones.

I have talked about suicide openly a lot during the past years when I had an open non judgmental audience( and no they were not paid to hear me they were =s) that made a big difference to me. It was an ongoing issue for me for years many years... some of those years had I done it then I would have left a child without a mother ... those years were often a dog fight...that took everything I had to win... but I did win. I did not go thru all that to give up now.

At some point when I was relatively stable but still had an exit plan... I started to read books about suicide. I posted a link to the best book I ever read on the subject... this is it.

http://www.amazon.com/Suicide-Decision-Paul-G-Quinnett/dp/0824513525/ref=sr_1_7?s=books&ie=UTF8&qid=1392397811&sr=1-7&keywords=suicide

That helped me and after I read it I thought what the hell is this about all the time why do I keep going thru this... at the time I did not understand the effects of drugs on the brain... I trusted the doctors and the drugs and thought this suicide crap was just part of the mental illness I had since I took that drug for leg pain.. never even had that big put together in my head at that point... thought I went mad put that together later... I always thought the drugs were helping me and if I were not on them I would be way worse having ...hallucinations and **** like I did when I took prozac but did not know I was having an adverse reaction.

I suffered so many years... so many years that should have been years for me in MY life were taken over by drugs... I may not be top form now but I am so much better I know who I am and what I believe ... I do not see things... I am not stuck in absolute negativity like I was on drugs... I am not far away from myself so far I can't think... I am not as bad as when I was on drugs... I am getting better.

Even tho I am getting old I have missed so much life so many good things I could have had... and yes I am left in a bad situation due to the life I have lived that may make for a challenging future... I don't care it is finally MY FUTURE

I want to see what happens... tho I b**** and whine on here and other places too... I want to live... when it comes right down to it I want to live.

There have been times I didn't want to live because life was so dreadful... struggle all the time internally externally struggle battles on all sides and there were not any rewards I could not feel them even if there were... I held on for others then people I loved kept me here and they had and have no idea.. to this day they don't know.

I must want to live very badly given all the **** I will put up with to stay here... really I do.

Some things I have learned during this ...

What you think is forever isn't ... tho it may feel like it.

A drug reaction can cause suicidal impulses and this needs to be taken seriously and seen for what it is.. I know the difference now... a reaction ...suicidal thoughts come out of left field pop in your head this is a drug reaction... sometimes to stomach drugs like proton pump inhibitors and the like ... if this happens and you have started a drug in the last six months look it up and talk to your doctor if you can live without it don't take it... there are so many drugs that cause this you would be surprised. I did a study on it and was very surprised.

Even the suicidal thoughts that were long drawn out plans I know think were all related to drugs or withdrawal... I just did not know it then.

I never had a suicidal thought before I took drugs! A very good clue. Plus I have learned the after affects of these drugs can be at least as debilitating as the effects while taking them. It takes a long time for our bodies to regulate themselves to something stable after the cart of apples is dumped... the body has to put the apples back in the right place and I think some of the apples are damaged and can't be repaired very well. It takes a long time.

There were drugs I was given when effexor pooped out on me to treat the symptoms of withdrawal that were not recognized as withdrawal. Blood pressure meds ... parkinsons meds type meds ... downers... which cause depression btw...

When I quit Effexor I quit them all and yes that was likely bad... but these drugs affect a lot of things in our bodies not just our minds yet I am counting on my body to heal it self... still. Could this be a mistake maybe but this is my body and my life and the mistakes are now mine to make.

I think after all these years and all these set backs that I am going to heal to a point that makes it all worth it and I will win this battle.

I think I used suicide all those years as a pressure release valve some of the time I made a plan and instantly had a release of pressure all the suffering would end all the pain would stop all the pressure would ease... it was a rest I needed and since there was no rest any other way it helped me stay... and fight another day.

I think sometimes we get caught up in suffering too long and lose hope... and it is easy when depleted to think poorly and think this is an answer. Really I can't go so far as to say it is not an answer cause I know if things are bad enough for long enough it surely is an answer... I can't lie and say it isn't when we all know it is... it is just a bad answer or not the best answer.

When I looked at how I was using suicide why it had become such a big part of my life plan I notices it was often a break... and I thought why do I have to go to such extremes to have a break... why can't I take a bath... do mediation ... or do whatever I think I want to sooth myself before it gets to this level. I started to notice the things that were leading up to me feeling desperate... the signs... not having any fun... at all ever... in any way... not doing anything that brought me satisfaction... so I tried to change that.

I looked for things that brought the slightest amount of feeling content... or satisfied... I found some simple things can make me feel these things... a book I read... a song ... colouring a picture.. making something a person I love likes to eat... doing my nails... talking to a girl friend who loves me... reading a book or coloring at the beach laying in a hammock... visiting a pet store and touching the kittens watching them play... so many small things. I thought of who I was when I was a kid what did I love... I loved kittens then .. and I still do I loved the beach and still do in the right mood and the right beach...

I spent days sitting in my car at the beach watching the water writing in my journal or reading a meditation book or book on other forms of healing ... did they help... they did not hurt me.. that is what is important...

Keep in mind do not harm... drugs can harm you.

If this is withdrawal then your body like all our bodies it is not giving up on you it is healing as fast as it can and it IS healing even if you can't see it today... there are long spells in withdrawal where it looks like nothing is changing but truth me things are changing underneath your healing... if your not putting more drugs in there to mess it up it is doing the best it can to heal it just takes a long time... those long periods where it looks like nothing is changing are hard to get thru but not impossible.

Think of what you liked as a kid.. what brought you joy try them... even if they do not make you joyful they may spike something just enough that a glimmer gets thru... it is a start. Sometimes coloring seems ridiculous to me and pissed me off other times it was just what the doctor ordered I would feel the slightest bit of satisfaction... and a slight bit is where we have to start here. Find something that you can engage in that is a kid thing.. your kid thing. It is a start and try not to judge you now self none of us are who or what we were and beating ourselves up about it just makes our situation worse.

We have side to be on here our own healing side or our drugged negative side we have to pick sides and it is not always easy to pick. Sometimes we have to fight to win.. sometimes letting it go is the only thing we can do till we get a bit stronger. There are all types of ups and downs ... surviving that is what this is about just like the title of this site says some days it takes more to survive then others... some survival plans take more work than others ... all our plans are different as we are all different and what sooths us will be different.

I am afraid this has become too long and may not be precise enough... I am sorry if I have overwhelmed you with my answer. I am trying to help. It is a very open question and I could likely talk about the varies issues within this topic for a couple of hours. If I missed "it" the "it" you seeking try to narrow it down and I will try again as this is a very important issue and I don't want to do it wrong... and that is important too.. however you survive there is nothing wrong with it if it keeps you here it is not wrong.. I don't care what it is as long as it is not hurting another it is ok.. do it find what sooths you satisfies you and have it for yourself... have all you need for as long as you want.

Peace Barb.

February 28, 2014

Some times Barb you just have to get thru this second it will turn into a minute or hour...sometimes distraction is what works till it passes and sometimes I have turned getting thru these spells into a new talent... like working in clay... or a special relationship with a dog or God... try everything... just don't quit. I am sure I have kept a few anonymous crisis lines in business thru the years too when I needed to talk I like the fact they were anonymous. I found them helpful. I wish you peace.

February 28, 2014

Not sure it was two years it was one year I think from the time I had it till I seen a specialist. I just had it again and it cleared up by itself I guess that is not too uncommon I really don't know much about it. When I asked why I got it this time I was told the things that cause it are drugs and maybe a virus. I asked for the blood work on liver pancreas and sugar as I had pain a long time was told it was from a broken rib or muscle injury from a car accident last year had physio for a few months ... it got worse I had pain on breathing sometimes and felt like something was pushing on my one lung. So asked for those tests as I was expecting the same story if I gave the same story of pain. Tests showed I had pancreatitis again.

I told her I had it before she said after you have had it once chances are higher you will have it twice. I had been taking tylenol 3 for pain down to aprox on pill a day that last three months I cut them up and only use them when I really need them mostly to sleep as I can't sleep in pain and get messed in the head when I can't sleep. Many nights I would be up taking a quarter mostly a half as a quarter stopped working but I would always try to sleep without it.. but around 3-4 am I would cave and take one.

By the time the blood work came back and I got in to see her it had been 10 days and new blood work showed I no longer had it. Tho my liver was still high. The only thing I did that may have helped was stop eating I did not feel well and did not eat ... had a salt bath that is all I can think of.

So if the one pill of tylenol 3 caused this and I am very doubtful it did... I need to stop taking it .. so trying even harder to not take it.

I was on a lot of pain pills and some antibiotics this year... had a car accident broke my foot and had surgery after which was hampered by infections about 6 wks. so was on higher doses of pain killers earlier in the year and whatever they gave me in surgery who knows... know it was an ongoing problem this pain.

I am going to lay low try not to take any T3 and see if that keeps it away.

There is talk of further testing to check on what is really going on but no apt yet. Lately one doc says he will order tests and they never happen so I will not hold my breath.

Since the pancreas fiaso the pain is better I don't trust it yet but just now it is easier to live in my body and I am grateful for that.

If you don't have a doctor it is hard to get anything done when you do have a doc it is in and out so fast it is difficult to make a point in the time you have find I am generally brushed off with muscle pain fibro some crap like that and out the door.

I think she was surprised to find my pancreas blood work so high she seemed a bit scared by it all actually you would think I would be the one scared not her. She did a fast and furious few things to find out what was going on and while I still was not feeling well she said my numbers were better ultra sound good and I did not have to got to the hosp.

Waiting for the other shoe to drop as usual. Time will tell if this is an upward swing in healing or just a blip that will pass and it will all come back one day hard to say just now.

I'm surprised they actually told you drugs can cause pancreatitis. They wouldn't admit that to my friend whom had it from drugs. Glad to hear things are improving a bit though, and hoping that the healing with take root and be of a more permanent variety this time.

February 28, 2014

Thank you, Btdt. Your answer is very thorough and thoughtful.

My situation is a bit unusual as I am truly fighting for myself and have had disabling health problems for 20 years. I have no children and my husband has expressed that his life would be easier without me. I made the mistake of staying in a bad marriage for many years and am now financially dependent. We lost a house and most of our finances in the housing crash in 2008, so our financial situation is not good. I have friends, but none nearby, all on the other coast. I really have noplace else to go other than live with my husband at this point. He works at home, so we are together 24/7. His work is an MD and medical management of prescription drugs, so I hear him discussing these meds all day. I try to get out of our 2 room house, but am not well enough most of the time. It's a constant reminder. He's also very drugged.

I'm not saying I'm giving up or at the point of quitting, but going thru a very difficult period with no escape from my situation in sight. I've talked about this ad nauseum in the Toxic Family thread.

You've been through so much... more than me... and I appreciate your input. So many people have come on forum and moved on in the 2+ years ive been here. I realize not everyone has moved on or back to drug free lives, but I find myself assuming that at times. I had a very unhappy situation for years and then a few good years after which I "tapered" off of Pristiq and really screwed myself up (before I found this forum). Truthfully, if I could put my house of cards back together, I would, but I can't because I react paradoxically to those now.

Prior to withdrawal, I spent 10 years doing anything I could to stay occupied: volunteer work, church groups, my horses and pets, partial hospitalization programs, etc. I feel like ive "tried it all" and feel incredibly defeated, especially being so isolated and my primary "support" being quite the opposite. I had already lost 10 years of my life to disability prior to withdrawal. In early wd when I was fueled by anxiety, I did escape my situation and drove across the country. I came back home to place my horses and crashed in exhaustion, never able to leave again. Leaving my animals was very difficult.

Thank you again, Btdt.

February 28, 2014

Not sure it was two years it was one year I think from the time I had it till I seen a specialist. I just had it again and it cleared up by itself I guess that is not too uncommon I really don't know much about it. When I asked why I got it this time I was told the things that cause it are drugs and maybe a virus. I asked for the blood work on liver pancreas and sugar as I had pain a long time was told it was from a broken rib or muscle injury from a car accident last year had physio for a few months ... it got worse I had pain on breathing sometimes and felt like something was pushing on my one lung. So asked for those tests as I was expecting the same story if I gave the same story of pain. Tests showed I had pancreatitis again.

I told her I had it before she said after you have had it once chances are higher you will have it twice. I had been taking tylenol 3 for pain down to aprox on pill a day that last three months I cut them up and only use them when I really need them mostly to sleep as I can't sleep in pain and get messed in the head when I can't sleep. Many nights I would be up taking a quarter mostly a half as a quarter stopped working but I would always try to sleep without it.. but around 3-4 am I would cave and take one.

By the time the blood work came back and I got in to see her it had been 10 days and new blood work showed I no longer had it. Tho my liver was still high. The only thing I did that may have helped was stop eating I did not feel well and did not eat ... had a salt bath that is all I can think of.

So if the one pill of tylenol 3 caused this and I am very doubtful it did... I need to stop taking it .. so trying even harder to not take it.

I was on a lot of pain pills and some antibiotics this year... had a car accident broke my foot and had surgery after which was hampered by infections about 6 wks. so was on higher doses of pain killers earlier in the year and whatever they gave me in surgery who knows... know it was an ongoing problem this pain.

I am going to lay low try not to take any T3 and see if that keeps it away.

There is talk of further testing to check on what is really going on but no apt yet. Lately one doc says he will order tests and they never happen so I will not hold my breath.

Since the pancreas fiaso the pain is better I don't trust it yet but just now it is easier to live in my body and I am grateful for that.

If you don't have a doctor it is hard to get anything done when you do have a doc it is in and out so fast it is difficult to make a point in the time you have find I am generally brushed off with muscle pain fibro some crap like that and out the door.

I think she was surprised to find my pancreas blood work so high she seemed a bit scared by it all actually you would think I would be the one scared not her. She did a fast and furious few things to find out what was going on and while I still was not feeling well she said my numbers were better ultra sound good and I did not have to got to the hosp.

Waiting for the other shoe to drop as usual. Time will tell if this is an upward swing in healing or just a blip that will pass and it will all come back one day hard to say just now.

I'm surprised they actually told you drugs can cause pancreatitis. They wouldn't admit that to my friend whom had it from drugs. Glad to hear things are improving a bit though, and hoping that the healing with take root and be of a more permanent variety this time.

It was my family doctor who told me this during this bout but the other doctors previously did not say it could be caused by drugs that was at an emergency room they did not say any cause.

Protracted Withdrawal or PAWS (post-acute withdrawal syndrome)

Recommended Posts

btdt

Link to comment

Share on other sites

Top Posters In This Topic

Top Posters In This Topic

Popular Posts

squirrel

Altostrata

Altostrata

CharlieBrown

Link to comment

Share on other sites

NoMeaning25

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites

Claudius

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

Rhiannon

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

btdt

Link to comment

Share on other sites

UnfoldingSky

Link to comment

Share on other sites