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RobertsBiology: Delayed onset SSRI withdrawal issues, please help

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Name: Kevin Age: 24 Sex: Male Height: 5'10" Weight: 163 lbs Race: Caucasian

I understand that the following is a large wall of text, but I beg of anyone with experience or expertise to please read my case.


For about four years I was on 20 mg/day Citalopram for mild social anxiety/mild depression. Around September/October of last year I felt that I was ready to slowly taper off of my medication (in retrospect I now know I should have done this under consultation with a physician and wish that I had done so). I decreased my dose slowly over the course of a few months, taking my last 1/8th of a dose in late/mid February.


I didn't have anything that I would have identified as immediate withdrawal symptoms, though my wife does think that I became increasingly anxious as I tapered off. My primary reasons for coming off of the medication were that I disliked the side effect making it difficult to climax, I felt emotionally flat, and did not want to remain dependent on a medication forever.


About 3 weeks later while at work, I suffered what I would most closely describe as a spontaneous panic attack with seemingly no mental provocation, feeling a flush of heat in my core, extremely rapid heart rate and extreme anxiety. A couple of times during that day I had a sensory disturbance consisting of eye floaters (raining downward through my field of vision briefly) and a very short period of ear ringing. I was essentially unable to sleep for that night and my heart rate remained very high for me (>100-110, previous to this my resting heart rate was around 60-70).


The next morning I went to my university health center and I was prescribed Clonazepam to manage my panic/heart rate/etc. My Citalopram was reinstated at 10 mg and we have slowly increased it to 30 mg since then and they want me to go up to 40 next week.


I took 0.5 mg of clonazepam three times per day for four days and then tapered my dose down to zero, having been on the clonazepam for a total of three weeks. As soon as I came off of the clonazepam I began to have strong ringing of the ears, extreme insomnia, anxiety, heart palpitations and occasionally high blood pressure.


I went to the ER for having a racing heart, palpitations, and burning/tingling sensations of the skin. They performed an EKG which was normal. They performed a head CT scan which was normal. Complete blood count, liver enzyme tests, and thyroid level tests returned normal.


After four days of what seemed like literally no sleep, my university health center put me back on the clonazepam and I'm currently taking 0.75 mg per day to manage my symptoms until we reach what they are calling a "therapeutic dose" of the citalopram.


My physician consulted with two staff psychiatrists on my case, one who recommended remaining on the clonazepam until that "therapeutic" point is reached and one who recommended putting me on risperidol.


I should clarify that I am a doctoral student in molecular biology (done with classes, but doing biomedical research at this point), but that my time as a student has been fairly easy-going and nothing much changed that I can tell in terms of my mental state to provoke these issues.


While I was on/tapering off of the clonazepam I was unable to concentrate enough to work, and I'm on leave from work for now. I do currently have more-or-less constant minor ear ringing at the moment but the benzo seems to be keeping most of my symptoms at bay for the moment. I do have difficulty concentrating. I am afraid of remaining on benzodiazepines long term as I'm aware of their long term effects.


I've read case reports in the literature of delayed onset symptoms often being permament; I'm terrified that I won't get better and I'd really appreciate any additional opinions anyone in this community could offer my case and whether the course of action my physician has decided on makes sense or any sort of referral for communication with someone who has expertise treating these issues.


I have a strong conviction that something physical is going on in my brain as a result of the SSRI discontinuation that is distinct from the typical constellation of SSRI withdrawal symptoms, and I continue to worry whether I'm on the correct course of treatment.


It has been exactly 1 month since the issues I've described began.

Thank you for your time.

Edited by Petunia
added paragraph breaks for easier reading

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Welcome to the forum RobertsBiology,


I'm sorry you've had increasing problems since coming off your medication last year, but you have come to the right place, I'm glad you found us. There is a lot of good information, experience and support here.


It would be great if you would put your drug and withdrawal history in your signature. Doing this helps people understand your context, it appears below each of your posts. Here are instructions for how to do it:


Please put your withdrawal history in your signature


Please include any other medications you are currently taking or have taken previously taken, with dates, dosages and how the drug was stopped. Details for the last 2 years are most important.


The problem with your first taper attempt late last year, wasn't that you didn't have physician support, but that you tapered too fast. We suggest reducing by no more than 10% of the current dose every 4 weeks, this reduces the risk of withdrawal symptoms arising. Please read through this which will explain why:


Why taper by 10% of my dosage?


and   Tips for tapering off Celexa (citalopram)


Its not uncommon for withdrawal symptoms to begin several weeks, or even several month after the last dose. It can be confusing because most people, including many doctors, assume that after the drug is out of your system, any withdrawal should be over. But psychiatric drugs don't work like that. Over time, they change the way the brain functions. The brain and nervous system make structural changes in response to a changed chemical environment. Once the drug is stopped, these changes then have to be reversed, this can take some time and during this recovery period, a variety of uncomfortable symptoms can be experienced.


I will list some links with information to help you understand more:


Why taper? Paper demonstrates importance of gradual change in plasma concentration


What is withdrawal syndrome?


Brain Remodelling (Rhi's Description of Brain Healing)


The symptoms you describe sound typical of antidepressant withdrawal, we also would have recommended reinstating, but at a lower dose than what you were given. If 20mg of Citalopram was your original maximim dose, then reinstating 10mg after being off it for a while, might have been enough.


If I were you, I would not go any higher in dose than you already are. Once the nervous system has experienced any withdrawal at all, it often becomes sensitive to drugs, and dosages which were previously tolerated.


Here is some information about reinstatement which explains more:  About reinstating and stabilizing to stop withdrawal symptoms


Using a benzo to treat antidepressant withdrawal syndrome is not a good idea. They can initially mask some of the withdrawal symptoms, but come with side effects of their own, can be very addictive and in a sensitized nervous system, can cause paradoxical reactions. If taken regularly for more than a week or two, physiological dependence can occur, and then need to be slowly tapered if you want to stop taking them. Benzo withdrawal can be as uncomfortable and as long lasting as antidepressant withdrawal, if not worse.


Here is the link to our benzo forum, please start a topic there for yourself for help with tapering off Clonazepam when you are ready.   Members-only benzo forum


If someone is taking both an antidepressant and a benzo, we generally recommend tapering off the antidepressant first. But in your case, because you have only been on Clonazepam a very short while, you might like to taper off it first.


Please see: Taking multiple psych drugs? Which drug to taper first?


Please fill in your signature with details of your drug and withdrawal history, it will help us to have a clearer picture of your situation, then we might be able to offer more specific suggestions.


How are you feeling at the moment? Are you symptoms getting better, staying about the same or getting worse?


Its a good idea to rate your symptoms daily to help you keep track of how you are doing. Withdrawal symptoms can distort our memory and make it difficult to accurately recall how we felt days and weeks ago. Here are some tips on how do do this:  


Rate symptoms daily to track patterns and progress


Dr. Joseph Glenmullen's withdrawal symptom checklist


You can use this thread as your ongoing journal to track progress, write about symptoms, ask questions and communicate with the community, add to it whenever you want. Its a good idea to bookmark it or follow it, so its easy to find again.


When we have a few more details, we may be able to suggest where to go from here, but for now, I suggest you don't make any changes to your current regime.




edit:...and one more thing, please don't worry, none of this is permanent, you will recover, but it may take some time to re-stabilize and then taper off your medications slowly and safely.

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Right now it seems that the clonazepam is more or less masking my symptoms, with the exception of a constant low-intensity ear ringing I have had since I initially tried coming off of the clonazepam. Without the clonazepam I experience very bad anxiety and panic but I of course do not want to remain on it indefinitely if I do not have to. I do feel pretty depressed, have occasional crying spells, can find it difficult to concentrate sometimes and haven't yet made any plans to go back to my work/research. I am at least able to sleep.


What do you think would be an appropriate course of action in my case? Is it possible that decreasing my citalopram dose slowly back down to 10 could help, and what evidence could I provide to my physician to support that or some other course of action? 


Thank you for your help.


Edit: I am keeping a daily/hourly log of my symptoms and activities

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Additionally, I'm having an above normal heart rate doing normal things like housework, walking, etc. These things feel abnormally taxing and it's hard for me to not just lay around.

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Still have ear ringing, but I'm feeling  slightly better in general/in demeanor, still on 30 mg Citalopram and 0.75 mg clonazepam per day for now. Have an appointment with a psychiatrist tomorrow to discuss my case. Trying to be active as I can, going on walks and whatnot. I continue to track my experiences daily.

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Met with the psychiatrist yesterday, who is having me taper off of the reinstated Citalopram and going onto Prozac/Fluoxetine. The protocol she has set up is the following:


dropping down from 30 mg citalopram per day to 20 mg citalopram per day for 6 days, taking 10 mg prozac per day as well during these 6 days, then discontinuing the citalopram and moving the prozac up to 20 mg per day. I started this process yesterday, taking both at bedtime along with my klonopin as directed. Was worried about the possibility of serotonin syndrome since I'm taking two SSRIs at once but was reassured that it is unlikely at this dosage.


Did have some trouble sleeping but I've been functioning relatively okay today. Over the past 2-3 days I've been able to do some more activities with less anxiety. Yesterday (before starting the new regime) I walked 3 miles which is the most I've been able to since my issues started. Walked about 1.5 miles today. Been able to start dealing with work emails a bit again and play games and whatnot.


I know that prozac can be somewhat stimulating, so I may start taking that in the mornings to as per a communication I had with my primary care doctor. A bit worried that the prozac may cause more sleep disturbances. About to take all three of the medications for tonight and will report whether I have sleep issues again.


The psychiatrist states that she intends to get me off of the klonopin when ready, but seems to want to see if changing the SSRI variable helps first. She has stated that she may be interested in putting me on Risperdal (odd to me as I'm not sure how anxiolytic Risperdal is.) after I do come off of the klonopin. My primary care doctor mentioned lamictal as a possibility as well but the psychiatrist did not bring up lamictal yet. Still taking 0.75 mg Klonopin per day, been taking 0.25 mg in the late morning and 0.5 near bedtime. I meet with the psychiatrist again in a little under two weeks but am also in constant communication with my primary care doctor.


My psychiatrist didn't really address the potential presence/concept of a delayed onset/protracted SSRI withdrawal syndrome (if that is indeed what occurred/is occuring to me); I'm a bit familiar with some of the literature and will be bringing some to my next appointment and she has indicated  a willingness to read what I bring (unfortunately the medical literature is quite narrow on this area and seems practically nonexistent when it comes to advising a course of treatment, but I could be missing some important journal articles).


I am trying my best not to obsess over the matter though as I know that obsessing over course of treatment and whatnot can be anxiety inducing itself. Perhaps that I'm a molecular biologist and have studied these issues makes me obsessive to a degree, but I am trying my best to trust my physicians for now. 


I do continue to have lowish intensity ear ringing, but it's sort of off and on and hasn't been as emotionally taxing on me lately as it has been. It's nighttime/bedtime soon here and started feeling a bit of anxiety earlier but nothing bad yet.


Thanks to you all for reading my walls of text and your support. Will continue reporting my condition as this process continues. I'm somewhat optimistic that my being young may be advantageous for my recovery.

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Hi RB,

I'm sorry to hear about your psychiatrist's plan for you. Unfortunately, it sounds like she intends more drugs, rather than less, in an experimental fashion, rather than actually knowing what she's doing. If you are happy to have your brain and nervous system experimented on like this, its your life and your decision, but from my own experience, putting my trust in psychiatrists has made my life worse, not better.


It sounds like she is willing to learn about withdrawal though, which is great, but quite shocking really, considering that she prescribes these drugs to people every day and yet doesn't understand how they work.


We don't recommend adding drugs as a method for coming off drugs. Tapering off the original drug is best, unless this is impossible for various reasons. Switching to Prozac or other drugs for tapering has risks, often doesn't work, can cause sleep problems and can worsen symptoms.


The main purpose of this site is to help people safely taper off their medication, so if you are happy to trust your doctor's plan for you, which seems to be more drugs, not less. I don't see how we can help you.



I am trying my best not to obsess over the matter though as I know that obsessing over course of treatment and whatnot can be anxiety inducing itself. Perhaps that I'm a molecular biologist and have studied these issues makes me obsessive to a degree, but I am trying my best to trust my physicians for now. 



If your physician happens to be a psychiatrist, then I think you are very wise to be obsessing about your health and safety. This is one situation where blind faith might be a mistake. Do your own research, find out the truth for yourself and make your own decisions about what is best for your health and life.


Please be careful, you only have one brain. These drugs are powerful, brain changing substances and can have long lasting negative effects on your  life. They don't cure anything, but work by creating a chemical imbalance in the brain, which alters natural brain function. I'd highly recommend reading Anatomy of an Epidemic by Robert Whitaker..... before you agree to any new drugs.


Other resources you may find useful:

From journals and scientific sources

Council for Evidence Based Psychiatry

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