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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 40. This is the beginning of the thread.
Posted by tensor on February 14, 2023, at 6:03:51
I have suffered from (TRD) depression and anxiety my whole life, I'm in my forties now and currently taking fluoxetine 40mg (upping to 60mg), clonazepam 2mg (for SA), smaller doses of mirtazapine and nortriptyline. PRN meds like melatonin, queiapine and oxazepam. In the future I'm going to have to a take a longer trip abroad by flying, I have never flown in my life because of anxiety. The idea of being away from home also gives me anxiety. I will likely try and take a shorter flight first and also talk this through with my therapist and doctor. I need some medication that can effectively suppress anxiety, benzos are not strong enough, never had any luck with atypical APs like a high dose of quetiapine. Have tried Zyprexa but only at 10mg (useless at that dose) so that could be worth trying at a higher dose. In the past I have successfully quit clonazepam over the course of 10 days with help of Lyrica/pregabalin. Lyrica is the closest med I have tried that could actually not only suppress anxiety but also lift my mood through slight euphoria (lasts a few days iirc), which is very welcome although I might react dfferently to it now, I want to enjoy this trip as much as possible. I don't drink alcohol. The trip will likely last 1-2 weeks and the destination is my wife's home country.
Things I have not tried are meds like haloperidol and trileptal, I would only take them as needed.
Any ideas greatly appreciated.
Posted by undopaminergic on February 14, 2023, at 12:03:06
In reply to Meds for severe anxiety, posted by tensor on February 14, 2023, at 6:03:51
> I need some medication that can effectively suppress anxiety, benzos are not strong enough, ...
>Have you tried opioids? Benzos are useless in my experience, but my problems with anxiety have been relatively mild. I only know that codeine wiped out all signs of anxiety (and also all signs of pain, worry, and tension; it was the only time of my life I can recall feeling completely relaxed).
-undopaminergic
Posted by Lamdage22 on February 14, 2023, at 12:34:18
In reply to Meds for severe anxiety, posted by tensor on February 14, 2023, at 6:03:51
What are you afraid of specifically?
Posted by Lamdage22 on February 14, 2023, at 12:37:20
In reply to Re: Meds for severe anxiety, posted by Lamdage22 on February 14, 2023, at 12:34:18
I dont want to give you ideas that you dont already have, but people can scared of flying for a wide range of reasons.
Posted by Lamdage22 on February 14, 2023, at 12:37:46
In reply to Re: Meds for severe anxiety, posted by Lamdage22 on February 14, 2023, at 12:37:20
What is yours?
Posted by tensor on February 14, 2023, at 12:39:56
In reply to Re: Meds for severe anxiety » tensor, posted by undopaminergic on February 14, 2023, at 12:03:06
>
> Have you tried opioids? Benzos are useless in my experience, but my problems with anxiety have been relatively mild. I only know that codeine wiped out all signs of anxiety (and also all signs of pain, worry, and tension; it was the only time of my life I can recall feeling completely relaxed).
>
> -undopaminergicHi undopaminergic!
Actually I have used a medication called Panacod quite a lot for pain, mainly headache, it's 500mg paracetamol (acetaminophen) + 30mg codeine per tablet and one dose is 2 tablets; 60 mg codeine.
I have never used illicit drugs but I can easily understand that people get hooked on opioids, and codeine is possibly the weakest of the bunch.I take fluoxetine now and at least in theory it inhibits the conversion of codeine to morphine, so I (probably) don't get the same effect anymore.
Also, there is no way I could get a doctor to prescribe me those kind of meds for anxiety. But I get your point.
I actually have an appointment with my doc tomorrow over the phone. It's probably difficult to even get pregabaline since it has gotten a bad rep, at least here in Finland, my previous doc hated it. This is why I need a backup plan. Also, I tried Lyrica today since I have a box of them in 75mg strength. They expired long ago but they still had the same effect on me - feel a little drunk/intoxicated and dizzy, took 75mg x 2 with an 1 hr interval. The effect is strong but I feel like I need something more, maybe combine it with a sedating AP like sulpiride or Risperdal.
I don't think I have realized until recently how bad my anxiety really is. I'm optimistic in my nature and often joke about my situation making my anxiety (and depression) appear milder than it really is. I have anxiety constantly and have had it since childhood for unknown reason(s).
/tensor
Posted by tensor on February 14, 2023, at 12:51:23
In reply to Re: Meds for severe anxiety, posted by Lamdage22 on February 14, 2023, at 12:34:18
> What are you afraid of specifically?
This is a difficult one, my previous doc who knew me much better than my current doc often asked me that. But he phrased it like "what wolves are chasing you" when I told him about my severe anxiety.
There no specific thing, I lack internal "security", I don't feel safe outside my home, like I can go shopping and do errands thanks to clonazepam nuking my social phobia, but traveling with a ferry to nearby countries will stress me and produce anxiety.
When I was a kid, my family and I sometimes went to Sweden (I live in Finland) and I had anxiety every time even though my (lovely, caring) parents were next to me. I had vertigo, like the kind you get when panicking and often headache.
I can't explain it and it feels like no one understands me. It feels like the anxiety is so deeply rooted in me, that typical meds like SSRIs and benzos can't reach it./tensor
Posted by Jay2112 on February 14, 2023, at 21:19:23
In reply to Meds for severe anxiety, posted by tensor on February 14, 2023, at 6:03:51
Can you get a powerful, high potency benzo like Xanax (alprazolam) or Ativan (lorazepam) at a bit of a higher dose...even just for this trip? (2-3 mgs) These work really, really well for anxiety and panic attacks. I thought I was going to DIE of heart palpitations, and they are like a calming bullet! Much, much more striking than clonazepam (I am on that for GAD). Also, do you have nabilone (synthetic version of THC) in Finland? It works really well.
As well, it's not THAT spectacular, but Choline helps my anxiety greatly. Look it up on Reddit. I too take Lyrica, but have maxed out the dose. I used to feel really good on 600mg's...now it does little for me. Do you have addiction doctors in Finland? Tell them you are addicted to your opioids, and you can get on morphine, suboxone, or even slow-release morphine, if you are lucky ;).
Magnesium biglycinate helps my anxiety as well, and a hit-or-miss is l-taurine. I have heard many good things about the probiotic l. reuteri. It apparently helps the production of the love chemical oxytocin, making you feel relaxed and comfortable. I haven't tried it yet, but am on testosterone, vitamin e, folic acid, which are supposed to increase your body's production of oxytocin. (Not to be confused with oxycontin..LOL..but I imagine you probably knew that.)
I am always on the lookout for new GABA agonist drugs. Lyrica WAS a real awesome med for me at onetime.
Best,
Jay
Posted by Jay2112 on February 14, 2023, at 21:34:18
In reply to Re: Meds for severe anxiety » Lamdage22, posted by tensor on February 14, 2023, at 12:51:23
> > What are you afraid of specifically?
>
> This is a difficult one, my previous doc who knew me much better than my current doc often asked me that. But he phrased it like "what wolves are chasing you" when I told him about my severe anxiety.
> There no specific thing, I lack internal "security", I don't feel safe outside my home, like I can go shopping and do errands thanks to clonazepam nuking my social phobia, but traveling with a ferry to nearby countries will stress me and produce anxiety.
> When I was a kid, my family and I sometimes went to Sweden (I live in Finland) and I had anxiety every time even though my (lovely, caring) parents were next to me. I had vertigo, like the kind you get when panicking and often headache.
> I can't explain it and it feels like no one understands me. It feels like the anxiety is so deeply rooted in me, that typical meds like SSRIs and benzos can't reach it.
>
> /tensorVery similar to mine! I got dx'ed GAD and Panic Attacks, on top of Bipolar 2 and Aspergers. I am going to try back on the SRI Viibryd. It didn't make my anxiety worse, and I felt comfortable in my skin. My GAD also has agoraphobic qualities, and the more I bury myself inside, the more I don't want to go out. But, testosterone has helped that a bit. You also might want to get your testosterone levels checked, and a panel of all of your vitamins/minerals.
But, I know that fear....like you are being chased and can't enjoy life. Have you tried stimulants? ADD/ADHD often has a depressive AND anxiety component to it. Amphetamine actually REDUCED my anxiety. But, you need the benzo's to calm down a bit. Also, Tegretol (carbamazapine) seems to work well when you can't get your anxiety to stop. I like it better than Trileptil.(SP?)
Just some thoughts...hope they help. Any questions..please ask away! :)
Jay
Posted by Lamdage22 on February 14, 2023, at 23:39:38
In reply to Re: Meds for severe anxiety » tensor, posted by Jay2112 on February 14, 2023, at 21:34:18
I overcame my fear of flying recently without working on it specifically. I was literally scared of death and doom on the plane before I overcame the fear. Psychoanalysis, its not always useless.
Posted by tensor on February 14, 2023, at 23:52:16
In reply to Re: Meds for severe anxiety, posted by Lamdage22 on February 14, 2023, at 23:39:38
> I overcame my fear of flying recently without working on it specifically. I was literally scared of death and doom on the plane before I overcame the fear. Psychoanalysis, its not always useless.
It's not the flying part that troubles me the most, I could sedate myself heavily for a few hours, but rather being far away from home makes me panicky.
Currently I'm thinking upping fluoxetine to 60mg
Use Lyrica as PRN instead of oxazepam and Seroquel.
Increase clonazepam to 3 or 4mg.
Assess after a couple of months, if not adequate, then maybe a low dose of Zyprexa or Geodon to augment.
BTW I do have a therapist./tensor
Posted by undopaminergic on February 15, 2023, at 3:04:16
In reply to Re: Meds for severe anxiety » undopaminergic, posted by tensor on February 14, 2023, at 12:39:56
>
> Hi undopaminergic!Hi!
>
> ... maybe combine it with a sedating AP like sulpiride or Risperdal.There are a lot of sedating APs, but sulpiride is not one of them. In fact, it can be a stronger stimulant than methylphenidate (Ritalin), especially at the start of treatment.
-undopaminergic
Posted by undopaminergic on February 15, 2023, at 3:36:55
In reply to Re: Meds for severe anxiety » undopaminergic, posted by tensor on February 14, 2023, at 12:39:56
>
> Actually I have used a medication called Panacod quite a lot for pain, mainly headache, it's 500mg paracetamol (acetaminophen) + 30mg codeine per tablet and one dose is 2 tablets; 60 mg codeine.
> I have never used illicit drugs but I can easily understand that people get hooked on opioids, and codeine is possibly the weakest of the bunch.
>
> I take fluoxetine now and at least in theory it inhibits the conversion of codeine to morphine, so I (probably) don't get the same effect anymore.
>
> Also, there is no way I could get a doctor to prescribe me those kind of meds for anxiety. But I get your point.
>Maybe tell the doctor that benzos are (often) harder to quit than opioids or even SSRIs.
-undopaminergic
Posted by tensor on February 15, 2023, at 3:47:19
In reply to Re: Meds for severe anxiety » tensor, posted by Jay2112 on February 14, 2023, at 21:34:18
>> Can you get a powerful, high potency benzo like Xanax (alprazolam) or Ativan (lorazepam) at a bit of a higher dose...even just for this trip? (2-3 mgs) These work really, really well for anxiety and panic attacks. I thought I was going to DIE of heart palpitations, and they are like a calming bullet! Much, much more striking than clonazepam (I am on that for GAD). Also, do you have nabilone (synthetic version of THC) in Finland? It works really well.
Yes, I have tried Xanaz 1-4mg but it's not my molecule, like I get sedated but not much anxiolytic effect, I don't like diazepam either for similar reasons.
> As well, it's not THAT spectacular, but Choline helps my anxiety greatly. Look it up on Reddit. I too take Lyrica, but have maxed out the dose. I used to feel really good on 600mg's...now it does little for me. Do you have addiction doctors in Finland? Tell them you are addicted to your opioids, and you can get on morphine, suboxone, or even slow-release morphine, if you are lucky ;).
No, this is not a path to take, I have been very careful to not abuse drugs so doctors trust me. It's hard to get pregabaline as it is without abuse history. Re Lyrica, this is why I would only take it PRN. But I still need something more to bring down my anxiety baseline on a daily basis.
> Magnesium biglycinate helps my anxiety as well, and a hit-or-miss is l-taurine. I have heard many good things about the probiotic l. reuteri. It apparently helps the production of the love chemical oxytocin, making you feel relaxed and comfortable. I haven't tried it yet, but am on testosterone, vitamin e, folic acid, which are supposed to increase your body's production of oxytocin. (Not to be confused with oxycontin..LOL..but I imagine you probably knew that.)
I take plenty of supps, esp folic acid, D3 (~110 mcg), fish oil, B-vitamins and minerals.
> I am always on the lookout for new GABA agonist drugs. Lyrica WAS a real awesome med for me at onetime.
> Very similar to mine! I got dx'ed GAD and Panic Attacks, on top of Bipolar 2 and Aspergers. I am going to try back on the SRI Viibryd. It didn't make my anxiety worse, and I felt comfortable in my skin. My GAD also has agoraphobic qualities, and the more I bury myself inside, the more I don't want to go out. But, testosterone has helped that a bit. You also might want to get your testosterone levels checked, and a panel of all of your vitamins/minerals.I asked my doc once about a testosterone test but he didn't seem to think it was needed.
> But, I know that fear....like you are being chased and can't enjoy life. Have you tried stimulants? ADD/ADHD often has a depressive AND anxiety component to it. Amphetamine actually REDUCED my anxiety. But, you need the benzo's to calm down a bit. Also, Tegretol (carbamazapine) seems to work well when you can't get your anxiety to stop. I like it better than Trileptil.(SP?)
I have taken modafinil for a year and it was extremely powerful in terms of energy, it single-handedly allowed me to work for one extra year. Did help with SP and became more outgoing, but not so much for GAD/PD, actually made me nervous. Also tried Concerta but only got a bit elevated pulse. Amphetamines would probably only be possible to get if you had severe ADHD and nothing else worked. Tegretol's s/e profile scares me tbh. You get any relief from Trileptal?
> Just some thoughts...hope they help. Any questions..please ask away! :)
Thanks :)
Posted by tensor on February 15, 2023, at 3:59:45
In reply to Re: Meds for severe anxiety » tensor, posted by undopaminergic on February 15, 2023, at 3:36:55
Just had a call with my doc, I managed to get my point through, that my anxiety is not under control and that we need to look at other options. As a side note, I'm chronically depressed and am on disability pension. Though finding relief for anxiety is more important now, it doesn't hurt if the treatment can lift my energy a bit.
As I had anticipated, her immediate reaction to pregabaline was no, like a knee jerk reaction. But I emphasized my anxiety is severe and that I would only take it as needed. She paused for a while (probably reading my journal) and asked if I was interested in trying Ketamine. But said she needed to consult with previous doc about what to do since he knows me better.
What do think about Ketamine?/tensor
Posted by tensor on February 15, 2023, at 4:03:05
In reply to Re: Meds for severe anxiety » tensor, posted by undopaminergic on February 15, 2023, at 3:36:55
> Maybe tell the doctor that benzos are (often) harder to quit than opioids or even SSRIs.
>
> -undopaminergic
>My doc won't get schooled by me :) Also, opioids build tolerance over time so that's a hard pass.
/tensor
Posted by tensor on February 15, 2023, at 4:06:09
In reply to Re: Meds for severe anxiety » tensor, posted by undopaminergic on February 15, 2023, at 3:04:16
> There are a lot of sedating APs, but sulpiride is not one of them. In fact, it can be a stronger stimulant than methylphenidate (Ritalin), especially at the start of treatment.
>
> -undopaminergic
>Low dose sulpiride is a med I have been using on and off in the past, it does have a calming effect at a low dose for me, like 50 mg.
/tensor
Posted by undopaminergic on February 15, 2023, at 11:52:43
In reply to Re: Meds for severe anxiety » undopaminergic, posted by tensor on February 15, 2023, at 4:06:09
> > There are a lot of sedating APs, but sulpiride is not one of them. In fact, it can be a stronger stimulant than methylphenidate (Ritalin), especially at the start of treatment.
> >
> > -undopaminergic
> >
>
> Low dose sulpiride is a med I have been using on and off in the past, it does have a calming effect at a low dose for me, like 50 mg.
>
> /tensorIt is very selective for dopamine D2 and D3 receptors, but apparently does something with GHB receptors as well. I assume you haven't tried Xyrem?
-undopaminergic
Posted by tensor on February 15, 2023, at 12:02:43
In reply to Re: Meds for severe anxiety » tensor, posted by undopaminergic on February 15, 2023, at 11:52:43
> It is very selective for dopamine D2 and D3 receptors, but apparently does something with GHB receptors as well. I assume you haven't tried Xyrem?
>
> -undopaminergic
>I haven't tried any illicit drugs or something that wasn't prescribed to me. I'm too scared of s/e, one of my 150 phobias.
You have any experience with Ketamine?
/tensor
Posted by undopaminergic on February 15, 2023, at 12:16:14
In reply to Re: Meds for severe anxiety » undopaminergic, posted by tensor on February 15, 2023, at 12:02:43
> > It is very selective for dopamine D2 and D3 receptors, but apparently does something with GHB receptors as well. I assume you haven't tried Xyrem?
> >
> > -undopaminergic
> >
>
> I haven't tried any illicit drugs or something that wasn't prescribed to me. I'm too scared of s/e, one of my 150 phobias.
>Xyrem is a prescription drug that contains the sodium salt of GHB:
https://en.wikipedia.org/wiki/Sodium_oxybate> You have any experience with Ketamine?
>No. Memantine and methoxetamine are as close as I got to it so far. Memantine gave euphoria and methoxetamine gave dysphoria...
-undopaminergic
Posted by Jay2112 on February 15, 2023, at 16:11:14
In reply to Re: Meds for severe anxiety » Jay2112, posted by tensor on February 15, 2023, at 3:47:19
Just throwing out a few other meds (I am going to re-try these actually).
1. Nabilone (generic name) It's the synthetic equivalent of THC. It has a gentle anti-anxiety effect.
2. Propranolol (beta-blocker used extensively in anxiety/depression treatment) and/or a calcium channel blocker.
3. Risperdal (generic name risperidone) Atypical antipsychotic. Greatly reduces agitated depression/anxiety.
4. Methoprazine (brand name Nozinan here in Canada) Hit/or/miss, but works when nothing else does.
5. Have to mention choline again. It's been found to be very low in people with GAD/Panic Attacks.
I'd really take a shot at ketamine. It's not perfect, but is a very unique treatment.
Jay
Posted by atypical on February 15, 2023, at 23:19:15
In reply to Meds for severe anxiety, posted by tensor on February 14, 2023, at 6:03:51
Have you tried a MAOI?
Posted by tensor on February 16, 2023, at 2:55:30
In reply to Re: Meds for severe anxiety, posted by atypical on February 15, 2023, at 23:19:15
> Have you tried a MAOI?
Yes I have tried Parnate but not Nardil. Quite good for panic, but is loses efficacy after a while and I eventually hit max dose. Also the afternoon crash was a big drawback.
Posted by tensor on February 16, 2023, at 3:21:50
In reply to Re: Meds for severe anxiety » tensor, posted by Jay2112 on February 15, 2023, at 16:11:14
Hi Jay!
> 1. Nabilone (generic name) It's the synthetic equivalent of THC. It has a gentle anti-anxiety effect.I have to research this one.
> 2. Propranolol (beta-blocker used extensively in anxiety/depression treatment) and/or a calcium channel blocker.
I use propranolol periodically and it's a med worth having in my arsenal especially for situational anxiety.
> 3. Risperdal (generic name risperidone) Atypical antipsychotic. Greatly reduces agitated depression/anxiety.
Does it work PRN? I have tried several AAP but not risperdal. The only one I remember gave me a calming effect was Geodon, which I gave up on too early, I slept a lot for a week but that was also due to depression. Some dose tweking had been a better idea.
Which makes me interested in Latuda, structurally close to Geodon and also Risperdal, but with even more favorable s/e profile, little to no prolactin (esp < 120mg) and no metabolic problems, with once a day dosing. I'm thinking of adding e g Latuda to my meds and take Lyrica as needed (if I can get it prescribed).> 4. Methoprazine (brand name Nozinan here in Canada) Hit/or/miss, but works when nothing else does.> 5. Have to mention choline again. It's been found to be very low in people with GAD/Panic Attacks.
I need to read up on these.
> I'd really take a shot at ketamine. It's not perfect, but is a very unique treatment.
Yeah, let's see what my doc says when she calls me. It's either that or Latuda I guess.
Side effects always scare with new medications, and Ketamine has some unique s/e for a couple of hours at least. I could do without the whole "tripping" experience./tensor
Posted by tensor on February 16, 2023, at 8:47:54
In reply to Re: Meds for severe anxiety » tensor, posted by Jay2112 on February 15, 2023, at 16:11:14
Had a call with my doc today so here's an update. Maybe it can be useful to someone in the future.
There is a consensus on my psychiatric hospital that pregabalin is not prescribed because of too many bad experiences. We started talking about alternatives like anti-psychotics, I suggested Latuda to take regularly but we agreed it's better to take an anti-psychotic as needed, since the severity of my anxiety increases in certain situations/circumstances. She said Latuda is too week, and she suggested Chlorprothixene which is an FGA. I already picked it up from the pharmacy and took a low dose of 15mg 30 minutes ago. I can already feel a nice calming effect but it's too early to tell how it will work for me, but it feels promising.
If you are in a similar situation, consider a medication like this./tensor
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