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Protracted Withdrawal is a Real Syndrome

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Altostrata

Confirmation of what Heather Ashton, Malcolm Lader, and thousands of patients know.

 

reposted from http://www.benzo.org.uk/ecpn.htm

 

Protracted Withdrawal is a Real Syndrome
eClinical Psychiatry News
April 2002 · Volume 30 · Number 4
by Damian McNamara · Miami Bureau

AMELIA ISLAND, FLA. - Protracted withdrawal from alcohol, hypnotics, psychostimulants, and other agents is a real syndrome with real treatment implications, Dr. David Cohn reported in a presentation at the annual meeting of the American Academy of Addiction Psychiatry.

"It's a very challenging and complex field," said Dr. Cohn, director of substance abuse services at Alta Bates Summit Medical Center in Berkeley, Calif. "I got interested in protracted withdrawal because I had patients who didn't get better."

 

....You won't find protracted withdrawal syndrome in the DSM-IV because "psychiatrists are stuck on [the] nomenclature," he said.

 

Diagnosis and treatment are challenging because protracted withdrawal can mimic other psychiatric disorders.

 

The exact incidence of protracted withdrawal syndrome is unknown, but researchers say it affects a sizable minority of addicts and alcoholics. "And it has treatment implications," he said. "If you're not treating a protracted withdrawal that is there, [the patient] will relapse."

 

Protracted withdrawal syndrome can develop following chronic use of alcohol, sedative hypnotic agents, benzodiazepines, opioids, psychostimulants, and nicotine, said Dr. Cohn....

 

A particularly challenging patient is one who is withdrawing acutely from sedative-hypnotic agents. Such withdrawal is characterized by having at least two of the following symptoms: autonomic hyperactivity, hand tremor, insomnia, nausea or vomiting, transient hallucinations or illusions, psychomotor agitation, anxiety, or grand mal seizures.

 

"This is a group that will really test your diagnostic acumen," Dr. Cohn said.

 

Withdrawal from benzodiazepines features symptoms that last from days to weeks, and protracted signs may persist for months. Treatment includes a gradual dosage reduction and pharmacotherapy with antidepressants, beta-blockers, anxiolytics, and anticonvulsants. "Lingering symptoms may be mistaken for another, non–substance-induced disorder," Dr. Cohn said.

 

Protracted withdrawal from opioids is more easily diagnosed. Long lasting effects include craving or drug hunger; depression and other mood disorders; physiologic effects on respiratory, cardiac, and endocrine systems, among others; and behavioral disturbances. "Opioid-related disorder should be a separate state," Dr. Cohn said. "There is a big association with mood disorders."

 

A study cosponsored by the National Institute on Drug Abuse and University of California, Los Angeles, is underway to determine if protracted withdrawal syndrome occurs after chronic methamphetamine use. The methamphetamine study will evaluate occurrence of panic and anxiety disorders, as well as long-term neurologic effects, such as movement disorders.

 

There is some evidence that sensitization and kindling occur with psychostimulants. Someone with cocaine-induced psychosis may experience it repeatedly with subsequent drug use. Most acute withdrawal symptoms from nicotine use disappear in 4 weeks, but weight gain and craving can occur up to 2 years after cessation.

 

"The old thinking was that protracted withdrawal syndrome was a remnant of something else, but why can't it be a new disorder?" Dr. Cohn asked. There is evidence with psychostimulant medication that de novo symptoms appear that were never there before.

 

Future studies, including some evaluating basic neuroscience, are needed to effectively identify and treat protracted withdrawal, he said.

 

Protracted Withdrawal Defined
Protracted withdrawal syndrome has many names, Dr. Cohn said. These names include:

    [*]Protracted abstinence syndrome. [*]Postacute withdrawal state. [*]Extended withdrawal state. [*]Chronic withdrawal syndrome.

He defined protracted withdrawal syndrome as a set of signs and symptoms that persist, evolve, or appear beyond an expected time frame for acute withdrawal syndrome. In most cases, acute alcohol withdrawal is complete within a week to 10 days, but protracted withdrawal can last from months to years, he said. Some symptoms of acute withdrawal that overlap with the protracted state include anxiety, depression, insomnia, cognitive deficits, and autonomic symptoms, such as a feeling that one has "rubber legs."

 

Most definitions of protracted withdrawal syndrome include at least the following four features:

    [*]Structural damage. [*]Lingering drug effects. [*]Psychological components. [*]Reversal of neuro-adapted cellular, molecular, and system functions.

Protracted withdrawal is further characterized by depersonalization, derealization, gastrointestinal disorders, and CNS motor and sensory disturbances, including tinnitus.

 

 

Also at http://www.questia.com/library/1G1-85408946/protracted-withdrawal-is-a-real-syndrome-real-treatment and available for sale on Amazon.

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Narcissus

Protracted withdrawal syndrome can develop following chronic use of alcohol, sedative hypnotic agents, benzodiazepines, opioids, psychostimulants, and nicotine

 

And anti-depressants....

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Barbarannamated

If I'm reading correctly, this author states that antidepressants should be used to treat protracted withdrawal of addictive substances named.

 

"Treatment includes a gradual dosage reduction and pharmacotherapy with antidepressants, beta-blockers, anxiolytics, and anticonvulsants."

 

Please correct me if I'm wrong.

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Altostrata

Many of them seem to believe that. He might have picked it up from Ashton.

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Altostrata

Attempting to contact Dr. Cohn to get a copy of his paper.

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btdt

what a bad idea ... before the site went under the effexoractivist.org had an article about protracted withdrawal from antidepressants I had a name that escapes me just now think it may have been pane... 
Persistent Adverse Neurological Effects Following SSRI Discontinuation (PANES).
Dr Ben Green, MRCPsych, ILTM

<< Psychiatry
 
Consultant Psychiatrist, Halton Hospital, UK and Hon. Senior Lecturer, University of Liverpool, UK These prolonged reactions were first described here in Spring 2000. No other reports are known of, although this condition may well be more widespread than is presently recognised. Selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome has been described in the literature as a cluster of symptoms and signs that occur after SSRIs such as paroxetine, sertraline and fluoxetine have been discontinued Abrupt withdrawal of antidepressant therapy for 5-8 days is associated with symptoms such as dizziness, ataxia, paraesthesiae, gastrointestinal and flu-like symptoms, and other sensory and sleep disturbances. Psychiatric symptoms include anxiety, agitation, lability of mood, hypersexuality, crying spells, behaviour change and irritability. The SSRI discontinuation syndrome appears to be most marked with paroxetine and to a lesser degree sertraline, with few symptoms seen with fluoxetine (Rosenbaum et al, 1998). The frequency and severity of these symptoms appear to vary according to the half-life of the SSRI (Schatzberg et al, 1997). Schatzberg et al comment that most discontinuation symptoms rare 'short-lived', but that some effects may be longer lasting. Traditional explanations the pharmacology of SSRIs discuss the effects on the postsynaptic serotonin receptor, but the SSRIs work at a variety of locations and their effects reverberate through the nervous and endocrine systems, so that in animal models there may be altered neuroendocrine function for weeks after ceasing fluoxetine. Even 60 days after discontinuation of fluoxetine, the oxytocin response in animals was still significantly reduced by 26% compared with controls.
Transient dystonias and dyskinesias of the jaw have presviously been described with SSRIs (Fitzgerald & Healy, 1995). This report considers four patients on SSRIs who all suffered prolonged neurological symptoms for months after discontinuing their medication.
 
Mrs A. a 29 year old married lady with a moderate depressive disorder was switched to paroxetine by her general practitioner after an initial prescription of dothiepin. She had found the tricyclic dothiepin too sedating and after a week or so of this medication requested a change. After two weeks on paroxetine 20 mg daily she was reviewed by a consultant psychiatrist who increased the dose to 40 mg daily. The patient suffered a dystonic reaction to the paroxetine that required physician review and admission, but apparently responded well to procyclidine. The paroxetine was discontinued. Unfortunately the dystonic reaction persisted off all medication and required further medical admission and the re-prescription of procyclidine. The depression continued unabated and a tricyclic was started with some improvement in mood. Seven months after the paroxetine had been stopped the tardive dystonia was noted to be present and to vary with anxiety levels, body posture, alertness, and emotional state. A 35-year-old man (Mr B) was prescribed paroxetine 30 mg daily for depression. The depression resolved and the paroxetine was continued at the same dose for two years. The medication was discontinued in a staged way, with reductions to 20, then 10 mg, managed over six weeks or so. Symptoms of withdrawal occurred throughout this period and comprised vivid nightmares, lability of mood, irritability, hypersexuality, episodic lightheadedness, episodic electric-shock like sensations, glove paraesthesiae, and ataxia. These symptoms ended two weeks after the withdrawal regime was finished. Nevertheless the patient continued to describe problems of an episodic nature well after the paroxetine had been discontinued. These episodes lasting hours to days at a time and comprised paraesthesiae, dizziness, mild ataxia, and slurred speech. These episodes have occurred intermittently throughout twelve months of follow-up during which time the patient has been drug-free. There are no focal neurological signs or any features suggestive of progressive neurological disease, nor was there a family history of neurological disease.
 
Mrs C., a 29-year-old mother of one, became ill with depression when her son was aged eight months. She was suicidal and required hospital admission where she was started on fluoxetine 20 mg daily. The antidepressant worked well and her mood was restored within four weeks of admission. She was discharged home, but commented that her sleep was occasionally disturbed by bad dreams and she was aware of twitching in the bed. She was kept on the fluoxetine for a further twelve months and at outpatient reviews mentioned that her sleep was still occasionally disturbed by nocturnal twitching. She said that her husband had started to sleep separately, because he was 'tired of being kicked' in the middle of the night. The fluoxetine was discontinued eighteen months after the admission. Mrs C described no worsening of her mood and was euthymic and outpatient review. However, she was distressed to report that her nocturnal twitching, which took the form of sudden myoclonic jerks of her limbs, had actually worsened off fluoxetine. During the day these abnormal involuntary movements were less marked and more easily disguised, but nonetheless problematic for the patient. At follow-up eight months after discontinuation the untoward myoclonic jerks were continuing. There are no focal neurological signs or any features suggestive of progressive neurological disease, nor was there a family history of neurological disease.
 
Mrs D., a 49 year old health professional was prescribed 20 mg paroxetine daily in April 2000 for a depressive disorder. This relieved the depression, but aftr three months the patient started to develop paresthesiae in the right hand, and some weeks later experienced her fingers being 'fumbly'. She visited her GP and complained that although her mood was satisfactory there were unpleasant side effects. He asked her to reduce the dose to 10 mg daily. Mrs D began to experience painful, restless legs at night and vivid dreams. The tingling in her hand spread into her body and head. After a week of the 10 mg dose the patient discontinued the paroxetine altogether in the belief that the paroxetine would be out of her system in a few days and her symptoms would subside. The symptoms however persisted. She took a week off work, but the following symptoms persisted for the next three months:

  • paraesthesiae in hands and feet spreading up arms and legs intermittently
  •  
  • stiffness in calf muscles
  •  
  • unsteadiness on her feet with wide gait
  •  
  • clumsy fingers
  •  
  • loose bowels
  •  
  • disinhibited mood
  •  

These symptoms appeared worst at the end of the day, following heavy physical work,and with even small amounts of alcohol. By December, four months after discontinuing the paroxetine most of the symptoms had reduced in severity to near normal.
 
Mrs E., a 48 year old woman was prescribed citalopram by her GP for eleven months. The indication for the prescription was chronic anxiety. For fifteen months folowing the discontinuation of this therapy she suffered headaches and dizziness. She also complained of a fluttering sensation across her scalp. To date there has been little improvement.
Discussion These five patients all demonstrated neurological side effects or withdrawal effects that occurred either during SSRI therapy or in the discontinuation phase associated with an SSRI. However, these neurological effects persisted for months after discontinuation and in most cases persist up until the time of writing. Whether the association with treatment or discontinuation is causal could be debated, but the chronological association seems good and three of the five patients (Mr B, Mrs C and Mrs D) were psychotropic drug-naïve at the start of the SSRI therapy and wholly drug free following this. The three SSRIs prescribed and mentioned above (fluoxetine, paroxetine and citalopram) differ in terms of structural and pharmacokinetic properties, but share a relatively selective ability to affect serotonin re-uptake. Paroxetine and citalopram have a relatively short half-life and it may be that they are more prone to association withe discontinuation effects and PANES. It may be that this common ability of the SSRIs (to affect serotonin re-uptake), or an indirect consequence of this ability is responsible for these persistent adverse neurological effects. These effects appear to have been first described in this report. There is something of a similarity to the effects seen after benzodiazepine discontinuation (Ashton, 1987). In benzodiazpine witrhdrawal the symptoms occur 1-2 weeks after withdrawal and may persist to some degree. Th mechanism is thought to be related to GABA-ergic systems. Further case reports and surveillance data are needed to establish the significance or otherwise of what we propose to be persistent adverse neurological effects of SSRIs (PANES). Contact The Author Dr Ben Green, MRCPsych, ILTM, Consultant Psychiatrist, Halton Hospital, UK and Hon. Senior Lecturer, University of Liverpool, UK References
Ashton, H (1987)Brain systems, disorders and psychotropic drugs. Oxford, OUP.
Fitzgerald K, Healy, D. (1995) Dystonias and dyskinesias of the jaw associated with the use of SSRIs. Human Psychopharmacology, 10, 215-219.
Raap DK; Garcia F; Muma Na et al. (1999) Sustained desensitization of hypothalamic 5-Hydroxytryptamine1A receptors after discontinuation of fluoxetine: inhibited neuroendocrine responses to 8-hydroxy-2-(Dipropylamino)Tetralin in the absence of changes in Gi/o/z proteins. J Pharmacol Exp Ther, Feb, 288:2, 561-7.
Rosenbaum JF; Fava M; Hoog SL; Ascroft RC; Krebs WB (1998) Selective serotonin reuptake inhibitor discontinuation syndrome: a randomized clinical trial [see comments] Biol Psychiatry, 1998 Jul, 44:2, 77-87.
Schatzberg AF; Haddad P; Kaplan EM et al. (1997) Serotonin reuptake inhibitor discontinuation syndrome: a hypothetical definition. Discontinuation Consensus panel. J Clin Psychiatry, 1997, 58 Suppl 7:, 5-10
 
http://www.priory.com/psych/panes.htm
 
The effexoractivist.org site goes up and down ... I am told they put it up and "they" take it down.. it is an ongoing thing if you ever find it up copy and paste some of the articles wish I had as I can't seem to find them other places.  
 
Seems like this may be somewhat the same. 
Is this a hijack?  sorry if it is.
See also Venlafaxine - long-term adverse effects (2002)
 
Version 1.0

Edited by Altostrata
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Altostrata

Yes, I've corresponded with Ben Green, too.

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mammaP

Why is all this information not finding it's way down to the psychiatrists and GPs who prescribe 

all this poison?  Do none of them do ANY research once they leave uni? What about the people

who teach the teachers? It's incredulous that all these studies are out there, yet they all remain clueless.

I can understand GPs to a point, my gp was always directed by my psychiatrist and never added any psych

drugs that weren't ordered by psych. (They do prescribe, just not in my case) . They have to stay on top

of ALL  areas of medicine and don't have the time to research everything. That is no excuse for not listening

to patients though, they should be putting 2 and 2 together by now! 

 

The psychs are another league, they specialise and SHOULD KNOW! 

 

*Climbs off soap box*

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Jemima

It's all about money.  I expect even the universities are beholden to Big Pharma for funding so the dangers of antidepressants are suppressed.  As for GPs, here in the States we're lucky to get fifteen minutes of a doctor's time for a medical problem, so I doubt the doctors have any time to spare for research, which, by the way, they are not taught to interpret in medical school.  Doctors here are required to take so many units of continuing education per year, but much of that is also sponsored by Big Pharma, often in some exotic vacation resort so that the cost of a vacation can be written off income taxes.

 

As for psychiatrists, their entire livelihood is all about prescribing drugs so they aren't about to let on that what they're doing is harmful at best and hocus-pocus at the very least.

 

Drugs are a money-maker for all concerned except the patient. It's so much more profitable to take five minutes and write a prescription than to spend whatever time is necessary to find the cause of a problem.

 

Sickening, yes.

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Barbarannamated

The universities ESPECIALLY are influenced (aka. Bought) by the pharmaceutical industry. Many, if not most, of the clinical trials are done at universities and funded by pharma.

 

Just one article about the pharma - med school connection:

http://www.propublica.org/article/medical-schools-policies-on-faculty-and-drug-company-speaking-circuit

 

There were a few new antidepressants approved by the FDA just recently, some SSRIs, I believe.

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btdt

Yes, I've corresponded with Ben Green, too.

Has he been involved in any further research that was a long time ago. 

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westcoast

I just came across a little Q&A on SSRI WD.

 

I was surprised that the doctor said about 20% of discontinuers hd symptoms like the ones the question was worried about. They usually say "quite rare," or the like. But then he said symptoms were usually mild and lasted a couple of weeks. Then he did something stranger, namely mention serotonin.

 

In the case of medications like Paxil that affect serotonin, we believe most of the withdrawal symptoms are related to a sudden increase in serotonin activity for which body and brain are not prepared.

 

 

 

http://www.cnn.com/2010/HEALTH/expert.q.a/09/21/antidepressants.withdrawl.symptoms.raison/index.html?iref=mpstoryview

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Lilu

I have a new psychiatrist and it's back to square one. He doesn't know anything about protracted withdrawal and attributes all my symptoms to personality disorders like bipolar and borderline.  I cannot find a single professional paper to give to him to prove to him that this is a real syndrome with all the crazy side effects that I've had and not me. 

 

What do I give my psychiatrist to make him believe?

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Lilu

Have you seen this paper? It describes protracted antidepressant and psychotropic drug withdrawal which they call persistent withdrawal. As well as criteria for distinguishing rebound symptoms form relapse.

 

http://www.karger.com/Article/FullText/371865

 

http://www.karger.com/Article/Pdf/371865

 

I also found Dr. Healy's draft papers

 

http://davidhealy.org/wp-content/uploads/2012/06/DBM-Paper-Medicine-Induced-Stress-Syndromes.pdf

 

http://davidhealy.org/wp-content/uploads/2012/06/DBM-Paper-Dependence-and-Withdrawal.pdf

 

http://davidhealy.org/wp-content/uploads/2012/06/DBM-Paper-Halting-Antidepressants.pdf

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cymbaltawithdrawal5600

Lilu,

 

Forgive me for being a bit dense here, but is this not a moot point as you just want to go back on the meds? Is he not happy just giving you the meds you want? Why would you want to convince him of wd syndrome?

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compsports

Hi Lilu,

 

It is a losing battle convincing a psychiatrist of WD syndrome unless he/she believes in it already.   When I tapered off of meds, my only goal was to get my psychiatrist to write the prescriptions that I needed to safely taper and I would do the rest.   I shared as little detail as possible regarding my situation because I knew doing anything else would be an exercise in extreme frustration.

 

Why did you start with a new psychiatrist?   What are your goals regarding meds?

 

CS

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Lilu

Lilu,

 

Forgive me for being a bit dense here, but is this not a moot point as you just want to go back on the meds? Is he not happy just giving you the meds you want? Why would you want to convince him of wd syndrome?

 

Because he has diagnosed me with Bipolar II and Borderline Personality Disorder and it pisses me off!!!  I am trying to convince him that my anxiety,anxiety attacks, insomnia, racing heartbeat, and hyperarousal is due to withdrawal not a personality disorder that I never had to begin with.

Also because I am an advocate at heart and I am hell bent on educated everyone I come across. Everyone. I'm so effing pissed off at the ignorance, the horror stories, all the suffering that we are all enduring at the hands of these meds.  I feel it's my responsibility to spread the truth.  I guess I am trying to put meaning into my suffering by sharing the reality of these drugs and the existence of protracted withdrawal. I'm driven by anger at what these drugs did to my mind and my body and I want everyone to know!  

But Oh boy did I get into a heated debate with my new shrink today. Thank God he's a kind patient elderly man and not some egomaniac. He stuck to his guns about the Bipolar thing, but said that he would read the literature that I provided.

But yes, it is exhausting trying to convince someone who does not see you as an equal and doesn't believe what you are telling him.  When you think about it, it is almost comical at how a doctor who is technically a scientist and should abide by scientific inquiry, would not pause to consider that if a patient has suddenly developed symptoms of bipolar disorder upon discontinuing a psychotropic drug, that in all likelihood it's the withdrawal from the drug and not a personality disorder.

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Lilu

Hi Lilu,

 

It is a losing battle convincing a psychiatrist of WD syndrome unless he/she believes in it already.   When I tapered off of meds, my only goal was to get my psychiatrist to write the prescriptions that I needed to safely taper and I would do the rest.   I shared as little detail as possible regarding my situation because I knew doing anything else would be an exercise in extreme frustration.

 

Why did you start with a new psychiatrist?   What are your goals regarding meds?

 

CS

I got a new psychiatrist because I was transferred to a partial hospitalization program as opposed to outpatient through a University here. Having medicaid this is the only way I can get to a psychiatrist and mental health care. 

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Faithbarelysurviving

I have a new psychiatrist and it's back to square one. He doesn't know anything about protracted withdrawal and attributes all my symptoms to personality disorders like bipolar and borderline.  I cannot find a single professional paper to give to him to prove to him that this is a real syndrome with all the crazy side effects that I've had and not me. 

 

What do I give my psychiatrist to make him believe?

Lilu, same thing is happening with me. He is diagnosing me with conversion disorder, borderline and something else maybe.....

I understand you. And he will not change his mind. I don t know what the answer is

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Mort81

All ive needed was a note to keep my job for me when I'm physically healthy enough. Its like pulling teeth. Ive thrown in thr the towel. Im better off on my own , less stress.

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artSet3561

Ya ive given up on doctors. 100 percent given up.

Ditto, I gave up a long time ago, I was fed up of being treated like a child despite the fact I know more about my symptoms etc.. than they do...I am living them FGS and I'm not stupid...I have a degree too and I am able to read

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