Shall I restart Cymbalta for my extreme depersonalization feel?

Question

Hi doctor,

I am a 32 year old man. I have been experiencing panic disorder, OCD symptoms and excessive levels of anxiety. In the last few months, major changes in my life have happened. For instance; quitting my job and moving to another city triggered my anxiety symptoms. I usually feel drowned in fears, health anxiety, fear of losing my mind or becoming delusional, losing my beloved ones, etc. I cannot get rid of those running thoughts. I learn that I have mild Hashimoto's and a kind of mild rheumatologic problems. Also, in the last few days, I feel extreme depersonalization. I strongly feel that I am going to lose my mind and this unreal feeling with dizziness accompany with my anxiety. Three months ago, I visited a neurologist and he prescribed Cymbalta for my neuropathic pain like symptoms and high levels of anxiety. One week later, I visited a psychiatrist to confirm if the medicine is right for me. And, according to my history, the psychiatrist decided to stop Cymbalta and we started Risperdal. I think he had been thinking I have something like borderline disorder. Then, we gradually changed the treatment. I think the psychiatrist thought the responsibility of my anxiety is Duloxetine, however, he could not understand I was more anxious before it. One month, when I took both Cymbalta (30 mg) and Risperdal (0.5 mg to 1 mg) was one of the most peaceful periods of my life. But, the following month I stopped using Cymbalta and my horrible thoughts came back, they are much stronger than before. Nowadays, I am on 1.25 mg Risperdal. Also, I have been on Fluvoxamine for two years for my panic attacks around 15 years ago. Please help.

Answer 1

Hi,

Welcome to our platform.

Thank you for describing your query in detail.

To start with, you might be absolutely right in saying that the current increase in your anxiety and associated feelings could be secondary to the change of place. Change of residence and workplace is always an anxiety-provoking event.

Most people are able to handle the anxiety related to uncertainty without getting too disturbed. You too can reach that stage where such triggers stop affecting your emotional health. It will take a few modifications.

I would like to know a few things about your current situation. Why was Duloxetine stopped, when it gave you relief while you were taking it? Was there any adverse effect?

You mentioned the horrible thoughts have come back. Can you describe what do you mean by the horrible thoughts? Can you describe some of those thoughts?

Do you feel relief with Risperdal (Risperidone)? How is it when compared to the effect of Duloxetine?

Fluvoxamine was most probably prescribed for your OCD. Can you describe the content of your OCD? In other words, can you write some details about how your OCD looked like?

Hashimoto’s thyroiditis leads to a low functioning thyroid, which is usually treated with supplements of L-thyroxine. Levothyroxine is known to cause anxiety as a side effect. I would like to know if you are or were taking any treatment for Hashimoto’s thyroiditis.

Please write back with these details so that we can have a better picture. Meanwhile, I have these thoughts about what you have described in the query.

Depersonalization is a common feature of anxiety disorders. If you are experiencing panic attacks, even now, you may experience depersonalization more often. You also seem to be anxious about what might happen in the future in this new place you have shifted to you, including anxiety about family and loved ones.

First of all, it is important for you to acknowledge the current situation as a part of your life. Our instincts prompt us to search for security and certainty. When life throws some challenges, such as change of place, the security and certainty are not in obvious sight. This is in conflict with our inner demand for certainty.

You also seem to have anxiety about anxiety. Questions such as why am I feeling so anxious might be circulating in your mind. There may be an inner demand that says I must never be feeling this way. Please try to check if this is the case.

Tolerance is a very important skill. While you are seeking medical help, you may not be having an effective self talk about tolerance. What will help is saying I want my anxieties to go away, but if they do not go away soon, I can still tolerate that situation.

Let me also suggest you maintain a thought diary or journal daily. The things to note in the journal are the daily triggers that lead to anxiety. Please note that I have not said cause anxiety. This is because; triggers are activating events that activate thoughts.

Thought eventually leads to disturbed emotions. Hence, it is easy to understand that the key to reducing anxiety and disturbance is changing or modifying the thoughts. So, note down thoughts about the future and uncertainty, if it is there.

Lastly, I suggest you seek psychotherapy, preferably cognitive behavior therapy, which is very helpful in dealing with emotional disturbances.

Some of the thoughts I shared with you above are in accordance with the psychotherapy principles. You may search for trained psychotherapists in your area and try a few sessions. You can also try online sessions through this platform.

Risperdal is known to help with OCD, which does not respond to usual treatment such as Fluvoxamine or Fluoxetine. However, it is usually used as an add-on to the primary drug for OCD.

Answer 2

Hi,

Welcome back to icliniq.com.

Thank you for writing back with more details. Let me comment on some of the things you have written.

It seems that the anxiety about health has been a major issue for a long time. It can be, in a way, considered obsessive in nature and leading to the compulsive action of visiting doctors to check if everything is fine.

I have noticed is that in most of your descriptions here, a major anxiety theme is what if something bad happens or what if my condition worsens or what if I lose control of my own mind. We have to work on this health anxiety as a priority.

Your symptom history does not suggest there was or there is a mood disorder, such as bipolar disorder. It started with anxiety related to health, which was added on by feelings of depersonalization and panic attacks.

In such situations, if any medication can help, it is usually an SSRI (selective serotonin reuptake inhibitor). SSRIs are antidepressants, also known to be very effective for anxiety and panic.

Of course, different SSRIs have different uses. If you are taking an SSRI or even an SNRI (Cymbalta - serotonin-norepinephrine reuptake inhibitor), you have more chances of feeling relief from anxiety.

Risperidone, on the other hand, is an anti-psychotic. It is also used in some cases where there extreme mood changes in bipolar disorder. In your situation, there are no hints of either psychosis or bipolar disorder. Therefore, Risperidone is not a very appropriate treatment for your symptoms. The relief you felt during that one month was most probably because of Cymbalta.

Risperidone can be stopped safely, over a couple of weeks by reducing the dose to half every 5 days or so. Your concern is that you might develop psychosis if you stop Risperidone. But, let me remind you that you never had symptoms of psychosis.

Also, Risperidone was not started for psychosis, but it was started probably for obsessive symptoms. Hence, your fear about going crazy is based just on an assumption and I can assure you that your current or past symptoms do not suggest psychosis or bipolar disorder.

You will also have to take help of either an SSRI or Cymbalta for a few months until you settle down in the new place. So, you can consult your psychiatrist, discuss with him or her and start the medicine with consent.

Now talking about the health anxiety and the general anxiety about the future, I would suggest a few things:

You have to let go of the need for certainty about the future. Uncertainty is not necessarily a bad thing. But, being constantly scared of future uncertainties will affect your health.

The fear of going crazy is based on assumptions. One of the assumptions is I will go crazy if I stop Risperdal, because I might be having psychosis or bipolar disorder already. You have to examine if there is any evidence for it. From all of your description, there is no evidence of psychosis or bipolar disorder.

If someone tells you that you do not have psychosis or you will not go crazy, it still may not solve the problem. This is because you cannot trust anyone’s assurance.

So, let us imagine for just a minute that you do develop psychosis, what will happen next? Will that be the worst thing that can happen to anyone in life? Will you be totally helpless? Will you harm yourself or your loved ones? How can you be sure that you will lose control of yourself?

All these are assumptions you are probably carrying in your mind for a long time. And there may be an inner belief that says that I must always be in control of my situation, otherwise I will lose my mind, and that will be horrible. This is something you can start changing today.

An alternate way to think is I want to be in control of my situation, but I am aware of the fact that I cannot have control over all the things in life all the time. The future is not guaranteed and I cannot have a certainty about everything. And if something goes wrong, it is not necessary that I will lose my mind. I can still find a way out.

And in fact, you are finding a way out, by sharing your problem with a doctor. Please note that I am suggesting a cognitive therapy. That includes cognitive behavior therapy (CBT) and rational emotive behavior therapy (REBT). These are the two most effective psychotherapies currently.

Find a cognitive therapist in your area or online and try a few sessions. Each session is usually 45 minutes long. It involves identifying external and internal triggers, irrational beliefs, replacing irrational with rational and helpful beliefs and coming up with an action plan to make a habit of healthier thinking process. After all, our own thoughts are responsible for how we perceive a situation.

Do not allow yourself to go into the victim mode for a long time. Come out, tell yourself that you can overcome this, as you have done in the past and focus on the more important projects that you might be handling currently.

Please maintain your thought diary as I mentioned in my previous reply. Please take out 5 minutes each day, to write your thoughts about different events and situations. Writing and reading your own thoughts every day will bring about a positive change.

Whenever you can, check the thyroid function and adjust Levothyroxine dose accordingly. You do not have to take more than needed.

Answer 3

Hi,

Welcome back to icliniq.com.

Cymbalta is known to cause initial side effects, however, those usually passes off and reduce over the next week or two. If you can manage to tolerate the side effects for the next few days, you should continue Cymbalta and give it a fair chance to show the desired effect.

Also, I think you can add any other benzodiazepine other than Midazolam, for taking care of the anxiety. Midazolam has a higher potential for addiction. You can consider Clonazepam 0.5 mg per day with Cymbalta, only with a prescription.

If your anxiety does not reduce over the next week or so, then you might have to shift to an SSRI.

Overall, it does appear that your current anxiety is brought on by starting Cymbalta and added by the reduction in Risperdal dose. Medication changes are best tolerated when done gradually. You can consult your treating psychiatrist about a more gradual reduction of Risperdal and also may be starting Cymbalta with an anxiolytic.

We are considering Cymbalta only because you have a positive experience with it earlier. This time, though, if Cymbalta does not help, it is time to shift to a different family of medicines as I mentioned earlier.

The most important factor here will be your own tolerance. The more you increase it, the better it is for medication to show benefits.

For further information consult a psychiatrist online.