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Dr. Andrew Rynne

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Hi Dr. XXXXXXX I think I am done with the

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Dr. Ashok Kumar

Psychiatrist

Practicing since :2000

Answered : 2812 Questions

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Posted on Sun, 27 Jan 2019 in General Health
Question: Hi Dr. XXXXXXX

I think I am done with the MAOIs...I've been on all of them and they are great for concentration/distraction, some borderline/PTSD symptoms like explosive anger, feeling "frantic/hysterical"; as well as some depression and anxiety.

However the feeling of detachment from friends and family is terrible, as is the compulsive behavior; I think much of the depression remains because I am indifferent to the bad behavior that I'm doing to myself. I mentally know it is destructive but I don't care if it gives me cancer or heart disease; nor to I care about professional advancement or self care; I have no interest in dating anymore and expect that I will die before retirement and that is ok.

I have tried all the SSRI's I care to try (Celexa, Zoloft, prozac) and besides the numbing feelings, they also contribute to a a feeling of franticness/distraction and busy brain that makes relationships and sex difficult. I also have drug seeking behavior to kill the numbness, and I am more prone to bouts of anger. However I am less indifferent to my own well being on the SSRIs, especailly when taken with Lamictal.

I wonder if there is a tricyclic that you would recommend. I've been studying clomimpramine. Ones with a higher noradrenaline action tend to make me hyperfocued, zoned-out, and sad.

Things that I have found most helpful in terms of emotional openness, feelings of alienation, and personal anxiety have been the anticonvulsant class of drugs like trileptal and gabapentin. They are very sedating and create a lot of cognitive impairment. The antipsychotics help with interpersonal anxiety and self agency but make me feel very dissociated and also cognitively slow.

I tried just taking Lamictal and wellbutrin but they do not help at all with severe social anxiety and trauma feeling; the lamictal also tends to increase ruminating anxiety although helps with the depression.

I have stayed on the MAOIs for nearly two years because I fear there are no other options. psychotherapy doesn't seem to help very much, although I know many of my symptoms are based in complex trauma and possible borderline and bipolar II (I have been given separate diagnosises by different doctors.

right now I feel crappy, indifferent, and tired after I take my Nardil. So then I take either small doses of modafilnil and/or ritalin to "wake up" and reduce apathy and cognitive problems. But then I get more compulsive and have anxiety which makes me need klonopin or propranolol; and then I need to take meds for sleep, which then cause various issues the next day. I am popping pills all the time and feel I'm becoming addicted to always medicating.

any advice would be welcome. thank you

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Follow up: Dr. Ashok Kumar 0 minute later
Hi Dr. XXXXXXX

I think I am done with the MAOIs...I've been on all of them and they are great for concentration/distraction, some borderline/PTSD symptoms like explosive anger, feeling "frantic/hysterical"; as well as some depression and anxiety.

However the feeling of detachment from friends and family is terrible, as is the compulsive behavior; I think much of the depression remains because I am indifferent to the bad behavior that I'm doing to myself. I mentally know it is destructive but I don't care if it gives me cancer or heart disease; nor to I care about professional advancement or self care; I have no interest in dating anymore and expect that I will die before retirement and that is ok.

I have tried all the SSRI's I care to try (Celexa, Zoloft, prozac) and besides the numbing feelings, they also contribute to a a feeling of franticness/distraction and busy brain that makes relationships and sex difficult. I also have drug seeking behavior to kill the numbness, and I am more prone to bouts of anger. However I am less indifferent to my own well being on the SSRIs, especailly when taken with Lamictal.

I wonder if there is a tricyclic that you would recommend. I've been studying clomimpramine. Ones with a higher noradrenaline action tend to make me hyperfocued, zoned-out, and sad.

Things that I have found most helpful in terms of emotional openness, feelings of alienation, and personal anxiety have been the anticonvulsant class of drugs like trileptal and gabapentin. They are very sedating and create a lot of cognitive impairment. The antipsychotics help with interpersonal anxiety and self agency but make me feel very dissociated and also cognitively slow.

I tried just taking Lamictal and wellbutrin but they do not help at all with severe social anxiety and trauma feeling; the lamictal also tends to increase ruminating anxiety although helps with the depression.

I have stayed on the MAOIs for nearly two years because I fear there are no other options. psychotherapy doesn't seem to help very much, although I know many of my symptoms are based in complex trauma and possible borderline and bipolar II (I have been given separate diagnosises by different doctors.

right now I feel crappy, indifferent, and tired after I take my Nardil. So then I take either small doses of modafilnil and/or ritalin to "wake up" and reduce apathy and cognitive problems. But then I get more compulsive and have anxiety which makes me need klonopin or propranolol; and then I need to take meds for sleep, which then cause various issues the next day. I am popping pills all the time and feel I'm becoming addicted to always medicating.

any advice would be welcome. thank you

doctor
Answered by Dr. Ashok Kumar 32 hours later
Brief Answer:
Consultation

Detailed Answer:
Hello,
Thanks for writing to me for a piece of advice.

First of all I acknowledge that almost all antidepressants cause some form of detachment from self and surroundings and to some extent it helps in depression but too much of it takes the pleasure away from life.

I also agree with your most feedbacks about different medications but I like to inform you that Clomipramine is TCA which is similar to SSRI and have very little noradrenaline action. So definitely this is out of option at this time for you. However I feel Dothiepin (Prothiden) can be a better choice among the TCAs as the side effects of TCAs are much less in compare to other TCAs (atleast in my clinical experience) and causes much less detachment due to relatively more action at noradrenaline. In addition I found that Dothiepin is an medication which shows effect over the smallest dose so trying low dose can tell us whether it is going to work for you.

The second option in this regard is SNRI which are closer to TCA but with less side effects. I do not remember whether you used any of the options but in case we need to give a try Desvenlafaxine (Pristiq) could be good choice.

I hope this helps you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
doctor
Answered by Dr. Ashok Kumar 0 minute later
Brief Answer:
Consultation

Detailed Answer:
Hello,
Thanks for writing to me for a piece of advice.

First of all I acknowledge that almost all antidepressants cause some form of detachment from self and surroundings and to some extent it helps in depression but too much of it takes the pleasure away from life.

I also agree with your most feedbacks about different medications but I like to inform you that Clomipramine is TCA which is similar to SSRI and have very little noradrenaline action. So definitely this is out of option at this time for you. However I feel Dothiepin (Prothiden) can be a better choice among the TCAs as the side effects of TCAs are much less in compare to other TCAs (atleast in my clinical experience) and causes much less detachment due to relatively more action at noradrenaline. In addition I found that Dothiepin is an medication which shows effect over the smallest dose so trying low dose can tell us whether it is going to work for you.

The second option in this regard is SNRI which are closer to TCA but with less side effects. I do not remember whether you used any of the options but in case we need to give a try Desvenlafaxine (Pristiq) could be good choice.

I hope this helps you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Ashok Kumar 40 hours later
thanks for your follow up:

you may have missed where I wrote "I wonder if there is a tricyclic that you would recommend. I've been studying clomimpramine. Ones with a higher noradrenaline action tend to make me hyperfocued, zoned-out, and sad."

so for some reason, higher noredrenaline actions traditionally create a zoned-out, sad, dissociated, hyperfocused state. Not sure why this is so, but that was my experience on wellbutrin, effexor, nortryptline, desipramine, and the MOAIs...parnate seemed the worse. my interpretation might be wrong.

Alpha and beta blockers frequently help with some of this and interpersonal reactivity.

Would this change your recommendation?
thanks

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Follow up: Dr. Ashok Kumar 0 minute later
thanks for your follow up:

you may have missed where I wrote "I wonder if there is a tricyclic that you would recommend. I've been studying clomimpramine. Ones with a higher noradrenaline action tend to make me hyperfocued, zoned-out, and sad."

so for some reason, higher noredrenaline actions traditionally create a zoned-out, sad, dissociated, hyperfocused state. Not sure why this is so, but that was my experience on wellbutrin, effexor, nortryptline, desipramine, and the MOAIs...parnate seemed the worse. my interpretation might be wrong.

Alpha and beta blockers frequently help with some of this and interpersonal reactivity.

Would this change your recommendation?
thanks

doctor
Answered by Dr. Ashok Kumar 16 hours later
Brief Answer:
Follow up

Detailed Answer:
Hello,
Thanks for follow up.

Yes I missed that part and read it in continuation of clomipramine statement.

Considering the fact that SSRI caused same form of detachment there is possibility that Clomipramine may cause some detachment. However since alpha and beta blockers helped you to some extent, I feel giving a trial to clomipramine is well placed decision.


The second option in this regard could be tianeptine. I am not sure whether it is available in your country but in case it is available this could be something which causes least detachment.

I hope this helps you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
doctor
Answered by Dr. Ashok Kumar 0 minute later
Brief Answer:
Follow up

Detailed Answer:
Hello,
Thanks for follow up.

Yes I missed that part and read it in continuation of clomipramine statement.

Considering the fact that SSRI caused same form of detachment there is possibility that Clomipramine may cause some detachment. However since alpha and beta blockers helped you to some extent, I feel giving a trial to clomipramine is well placed decision.


The second option in this regard could be tianeptine. I am not sure whether it is available in your country but in case it is available this could be something which causes least detachment.

I hope this helps you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Ashok Kumar 26 hours later
I am very interested in tianeptine, although it is not available in the US...I would need to order it as a "supplement"...have you had success with it?
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Follow up: Dr. Ashok Kumar 0 minute later
I am very interested in tianeptine, although it is not available in the US...I would need to order it as a "supplement"...have you had success with it?
doctor
Answered by Dr. Ashok Kumar 12 hours later
Brief Answer:
Yes

Detailed Answer:
Hello,
Thanks for follow up.

I am not the very supporter of tianeptine because of certain side effects but I have used in almost 40-50 patients till now and do not feel there is any lack of efficacy as claimed by some individuals. In other words I found it quite good in some individuals without any detachment from surroundings environment.

I hope this answers you.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Ashok Kumar 0 minute later
Brief Answer:
Yes

Detailed Answer:
Hello,
Thanks for follow up.

I am not the very supporter of tianeptine because of certain side effects but I have used in almost 40-50 patients till now and do not feel there is any lack of efficacy as claimed by some individuals. In other words I found it quite good in some individuals without any detachment from surroundings environment.

I hope this answers you.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 10 hours later
I am reading more and see that one of tianeptine's modes of action is modulation of the glutamate/nmda system. I am currently taking lamotrigine (Lamictal) which also acts on the same system. Would they interfere with one another?

Lamictal has done wonders for my mood and self agency/motivation, but can increase cognitive problems and obsessive ruminations.

Should I post a separate question to you specifically regarding tianeptine?

Thank you!
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Follow up: Dr. Ashok Kumar 0 minute later
I am reading more and see that one of tianeptine's modes of action is modulation of the glutamate/nmda system. I am currently taking lamotrigine (Lamictal) which also acts on the same system. Would they interfere with one another?

Lamictal has done wonders for my mood and self agency/motivation, but can increase cognitive problems and obsessive ruminations.

Should I post a separate question to you specifically regarding tianeptine?

Thank you!
doctor
Answered by Dr. Ashok Kumar 45 hours later
Brief Answer:
Fortunately no significant interactions

Detailed Answer:
Hello,
Thanks for reverting back to me and sorry for delay as it is year end.

Regarding your question fortunately there are no significant interactions between tianeptine and lamictal. I also like to clear that involvement of glutamate was most proposed mechanism of action of tianeptine but there are many more modes of action. Over the last three years involvement of mu receptors of opioid system is considered more important in compare to past and the coming years may see more clarity in this regard.

Cognitive impairment is very minimal if any, and thats why medication is used three times a day.

In case it is available in suitable manner (where purity is guaranteed) I do not see any serious side effects.

I hope this clarifies.
Thanks and regards.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Ashok Kumar 0 minute later
Brief Answer:
Fortunately no significant interactions

Detailed Answer:
Hello,
Thanks for reverting back to me and sorry for delay as it is year end.

Regarding your question fortunately there are no significant interactions between tianeptine and lamictal. I also like to clear that involvement of glutamate was most proposed mechanism of action of tianeptine but there are many more modes of action. Over the last three years involvement of mu receptors of opioid system is considered more important in compare to past and the coming years may see more clarity in this regard.

Cognitive impairment is very minimal if any, and thats why medication is used three times a day.

In case it is available in suitable manner (where purity is guaranteed) I do not see any serious side effects.

I hope this clarifies.
Thanks and regards.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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