# Pharmaceutical/Treatment Whizzes Needed



## apoplexy (Jan 4, 2013)

Alright.

Diagnoses:

-GAD

-OCD

-MDD

-DP

-Somatoform pain disorder

Medications used thus far:

-Paxil (SSRI)
-Lexapro (SSRI)
-Effexor (SNRI)

-Clomipramine (TCA)
-Gabapentin (anti-convulsant)

-Abilify (atypical anti-psychotic)
-Ativan (benzo)
-Klonopin (benzo)

Progress made has been 0 to none. The psychosomatic pain (perpetual burning) is the major part although naturally all of the other disorders manifest in some form as well which is very debilitating.

I'm seeing my psychiatrist on Friday and nearly completely done weening off of Effexor. A new medication and or combination is incoming. That being said, list some recommendations, what do you think I should consider? I want the medication name, the class and what your rational for the recommendation is.

I'm going to be pushing hard for ketamine infusions to see if it combats psychosomatic pain/lessens the MDD symptoms.

Also interested in lamotrigine.

I'm entering that fucked up realm of TMS, ECT, DBS, gamma knife surgery, etc -- it is not looking pretty.

Let's hear the recommendations Elliott, TDX and others. It's pharma-bro time.

Love always,

apoplexy


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## TDX (Jul 12, 2014)

> The psychosomatic pain (perpetual burning) is the major part although naturally all of the other disorders manifest in some form as well which is very debilitating.


What diagnostic were done? Where all somatic possibilities ruled out? For example did they test for a small fiber polyneuropathy? This can cause burning pain and other very annoying symptoms. In most cases the symptoms begin in the feet or hand, but in a small minority the symptoms may appear on the whole body. This is often overlooked, because only specialized clinics can make the required diagnostic tests.

I must say that I don't really trust psychsomatics. There are so many disorders that were labeled psychosomatic although they were not. Consider for example the Holy Seven: Ulcus ventriculi, Asthma bronchiale, Rheumatoide Arthritis, Neurodermitis, essential Hypertonia, Hyperthyreose and Morbus Crohn. There was never a proof for this and until the true causes were found out possibly millions of patients received useless and harmful (psychodynamic?) treatment.

I think they did not stop doing so. Examples may be Fibromyalgia, Chronic Fatigue Syndrom and Irritable Bowel Syndrome. But I must admit that my knowledge of psychosomatics is very limited. But these examples are enough for me to not trust them.



> A new medication and or combination is incoming. That being said, list some recommendations, what do you think I should consider?


Off-Label treatments for OCD, that I found with quick search in Google Scholar:

-Augmentation with Risperidone (may also improve depression and anxiety):

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=190577&fileId=S1461145703003730

http://www.sciencedirect.com/science/article/pii/S0924977X08000175

http://www.sciencedirect.com/science/article/pii/S0924977X04000847

http://archpsyc.jamanetwork.com/article.aspx?articleid=481641

http://journals.lww.com/intclinpsychopharm/abstract/2000/15050/risperidone_augmentation_in_refractory.7.aspx

http://online.liebertpub.com/doi/abs/10.1089/cap.1999.9.115

-Augmentation with Riluzole (may also improve depression, anxiety and possibly depersonalization, *very expensive*):

http://www.sciencedirect.com/science/article/pii/S0006322305005639

http://online.liebertpub.com/doi/abs/10.1089/cap.2007.0021

http://journals.lww.com/psychopharmacology/Citation/2008/06000/Riluzole_Augmentation_in_Treatment_Refractory.27.aspx

-Augmentation with Quetiapine (may also improve depression and anxiety)

http://journals.lww.com/intclinpsychopharm/Abstract/2002/05000/Quetiapine_augmentation_in_patients_with_treatment.4.aspx

http://journals.lww.com/intclinpsychopharm/Abstract/2005/07000/Adding_quetiapine_to_SRI_in_treatment_resistant.5.aspx

http://journals.lww.com/intclinpsychopharm/Abstract/2002/01000/Quetiapine_augmentation_of_serotonin_reuptake.6.aspx

https://www.psychiatrist.com/JCP/article/Pages/2005/v66n01/v66n0110.aspx

http://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-5-5

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8884703&fileId=S1092852900015029

http://journals.lww.com/psychopharmacology/Abstract/2003/10000/Lack_of_Efficacy_of_Low_Doses_of_Quetiapine.5.aspx

-Augmentation with Olanzapine:

http://www.psychiatrist.com/JCP/article/Pages/2000/v61n07/v61n0709.aspx

http://www.sciencedirect.com/science/article/pii/S0924977X08000175

http://europepmc.org/abstract/med/11387793

http://jop.sagepub.com/content/19/4/392.short

http://www.sciencedirect.com/science/article/pii/S0278584603000502

-Augmentation with Pindolol (probably not effective):

http://www.sciencedirect.com/science/article/pii/S0924977X00000651

-Morphine (may also be beneficial for the pain and maybe for depersonalization. Ask for it because of your pain if you want it):

http://www.psychiatrist.com/jcp/article/Pages/2005/v66n03/v66n0312.aspx

-Augmentation with Memantine:

http://journals.lww.com/psychopharmacology/Abstract/2009/02000/Memantine_Augmentation_in_Treatment_Resistant.11.aspx

http://journals.lww.com/psychopharmacology/Abstract/2010/02000/A_Single_Blinded_Case_Control_Study_of_Memantine.6.aspx

http://www.sciencedirect.com/science/article/pii/S0278584606001758

https://www.researchgate.net/profile/Jamie_Feusner/publication/23995074_Differential_efficacy_of_memantine_for_obsessive-compulsive_disorder_vs._generalized_anxiety_disorder_an_open-label_trial/links/0deec5335da40a09f1000000.pdf

http://www.sciencedirect.com/science/article/pii/S0022395612002956

-Augmentation with Topiramte (may also help depersonalization):

http://onlinelibrary.wiley.com/doi/10.1002/da.20118/full

https://www.psychiatrist.com/JCP/article/Pages/2011/v72n05/v72n0520.aspx

http://journals.lww.com/intclinpsychopharm/Abstract/2006/05000/Topiramate_plus_paroxetine_in_treatment_resistant.9.aspx

-Augmentation with Amisulpride:

http://onlinelibrary.wiley.com/doi/10.1002/hup.512/abstract

-Clomipramine+Citalopram:

http://www.sciencedirect.com/science/article/pii/S0924933899807251

-Augmentation with Sumatriptan (I ask myself if this could help against depersonalization):

http://www.sciencedirect.com/science/article/pii/S0924977X97000928

-Augmentation with Acetylcystein (maybe this helps against depersonalization):

http://link.springer.com/article/10.1007/s00213-005-0246-6

http://journals.lww.com/psychopharmacology/Abstract/2012/12000/N_Acetylcysteine_Add_On_Treatment_in_Refractory.10.aspx

-Augmentation with Ondansetron:

http://link.springer.com/article/10.2165/11530240-000000000-00000

-Augmentation with Lamotrigine (may also work against depersonalization):

https://ijnp.oxfordjournals.org/content/16/3/557.full

http://jop.sagepub.com/content/26/11/1456.short

http://www.tandfonline.com/doi/abs/10.1080/j.1440-1614.2000.0751c.x?journalCode=ianp20

-Augmentation with Caffeine or Amphetamine:

http://www.psychiatrist.com/JCP/article/Pages/2009/v70n11/v70n1107.aspx

-Lithium and tryptophan:

http://www.ncbi.nlm.nih.gov/pubmed/6435460

http://journals.lww.com/psychopharmacology/Abstract/1991/06000/A_Controlled_Trial_of_Lithium_Augmentation_in.5.aspx

-Trazadone:

http://journals.lww.com/clinicalneuropharm/abstract/1990/08000/trazodone_treatment_in_clomipramine_resistant.7.aspx

Fluoxetin+Buspiron:

http://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.150.5.819?journalCode=ajp

http://search.proquest.com/openview/a5949780e7e01e51478e6cb50971e6a8/1.pdf?pq-origsite=gscholar&cbl=40661

Clomipramine+Buspiron:

http://journals.lww.com/psychopharmacology/abstract/1992/02000/a_double_blind_study_of_adjuvant_buspirone.3.aspx

High-dose-Escitalopram:

http://journals.lww.com/intclinpsychopharm/Abstract/2008/01000/High_dose_escitalopram_for_the_treatment_of.7.aspx

Ketamine:

http://www.nature.com/npp/journal/v38/n12/abs/npp2013150a.html

http://www.psychiatrist.com/jcp/article/Pages/2011/v72n04/v72n0420.aspx

http://www.sciencedirect.com/science/article/pii/S0006322312005069

Gylcine:

http://www.sciencedirect.com/science/article/pii/S0022395608002379

Augmentation with Pregabaline:

http://journals.lww.com/intclinpsychopharm/Abstract/2011/07000/Pregabalin_augmentation_in_treatment_resistant.6.aspx

http://journals.lww.com/psychopharmacology/Citation/2011/10000/Pregabalin_Augmentation_in_Treatment_Resistant.29.aspx

Meditation:

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8879487&fileId=S1092852900006805

ECT:

http://journals.lww.com/ectjournal/Abstract/1988/04040/Electroconvulsive_Therapy_in_Obsessive_Compulsive.7.aspx

http://journals.lww.com/ectjournal/Citation/2003/03000/Remission_of_Major_Depression_and.11.aspx

See also:

http://journals.lww.com/psychopharmacology/Abstract/2009/02000/Memantine_Augmentation_in_Treatment_Resistant.11.aspx

http://europepmc.org/abstract/med/8732312

http://www.sciencedirect.com/science/article/pii/S0924977X06001313

http://europepmc.org/abstract/med/12032425

http://www.sciencedirect.com/science/article/pii/S1545534305000076

http://www.psychiatrist.com/JCP/article/Pages/2009/v70n06/v70n0610.aspx

https://ijnp.oxfordjournals.org/content/16/3/557.full

http://link.springer.com/article/10.2165/11587860-000000000-00000

http://search.proquest.com/openview/c7f7bf356267b62c2e2d9416c3c48e61/1?pq-origsite=gscholar

http://www.psychiatrist.com/jcp/article/Pages/2004/v65s14/v65s1402.aspx

http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2004.00502.x/abstract?userIsAuthenticated=false&deniedAccessCustomisedMessage=

http://www.tandfonline.com/doi/abs/10.1080/j.1440-1614.2005.01591.x



> I want the medication name, the class and what your rational for the recommendation is.


I have not read most of the studies (you must do this). Most of them are probably positive, but you should check them out. Reading the abstract is often sufficient.

There seems to be a pattern of different strategies for treatment-resistant OCD:

-Augmentation with other antipsychotics.

-Messing with the glutamatergic system with Lamotrigine, Acetylcystein, Riluzol, Topiramate and Memantine.

-Using Ketamine.

-DBS

As there might be some anecdotal evidence for Lamotrigine, it might be not a bad idea to use it. Pregabaline is often used for neuropathic pain, so it might also be good idea. As you never have used opioids for your pain, it might also be a good idea to ask for Morphine. If he refuses to give it to you, mabye Tramadol is an option, which is also an SNRI. For depersonalization Buprenorphine-Naltrexone might be worth a try. It could also be useful against the depression, although the fail of ALKS-5461 make speak against this. Unfortunetly there is a 99% chance you won't get this.

As an *absolute last resort* you could try *Cannabis* for the pain. There seems to be some evidence that it can alleviate pain that cannot be treated by other means. But be aware that you might be in a high-risk population for it's depersonalizing effect, which could make you *incredibly* and *permanently* worse. Only use it if you're about to kill yourself and the bad effect don't matter anyway.



> I'm going to be pushing hard for ketamine infusions to see if it combats psychosomatic pain/lessens the MDD symptoms.


If don't know how Ketamine-infusions are used to treat depression and pain, if they do it subanaesthetic you'll have to expect at least temporary worsening of your depersonalization symptoms, as it can induce them even for healthy people. But there seems to be some anecdotal evidence that it can also work for OCD for up to one week after the infusion. If it can also work against pain it might be worth a try, but don't forget that in a few years Rapastinel might come, which might have the same effect, but without the downsides of Ketamine.



> I'm entering that fucked up realm of TMS, ECT, DBS, gamma knife surgery, etc -- it is not looking pretty.


ECT might help your depression and the depersonalization, if the depersonalization is secondary to depression. If the depersonalization is not secondary it will be unchanged or worsed. There is some anecdotal evidence of OCD-improvement in ECT, but the lack of further studies could indicate that this is rare or non-existent.

TMS might be approved for depression, but it's often regarded as disappointing.

DBS might be more useful. If you can get it, you should do it.


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## apoplexy (Jan 4, 2013)

Always a pleasure TDX.

Need to wait 2 weeks to discuss ketamine with a different pyschiatrist.

Starting on tegretol today so add that to the list.


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## TDX (Jul 12, 2014)

Carbamazepine might work against the pain, but against the depersonalization it will most likely do nothing.


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## apoplexy (Jan 4, 2013)

Aside from TDX, Elliott and myself are there any other science types on this forum? Show yourselves if so.


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## thy (Oct 7, 2015)

apoplexy said:


> Aside from TDX, Elliott and myself are there any other science types on this forum? Show yourselves if so.


Unfortunately I don't think there are any.


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## TDX (Jul 12, 2014)

King Elliott seems to be absent. His last post was on 20 June 2016 - 04:13 PM.

I think my suggestions are sufficient for the moment. What is the Carbamazepine doing?


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## Guest (Jul 5, 2016)

In my personal experience (so far), I have found that 5 mg of Zyprexa and 50 mg of Lamotrigine so far has helped tremendously. My target dose for the Lamotrigine is 150mg and I'm working up to that, BUT I have noticed vast symptom improvement after taking 50 mg for only one week.

Although, I am honestly not sure what is helping more or if they are helping together. Because I started Zyprexa and Lamictal at the same time.

I would even be as bold to say that my DP/DR is basically gone. Maybe 25% at times and sometimes not even there. I hope it stays that way.

I'm diagnosed with Generalized Anxiety Disorder and Panic Disorder and my pdoc thinks the DP/DR is a result of these two disorders. (it was triggered by a marijunana panic attack)


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## apoplexy (Jan 4, 2013)

TDX said:


> King Elliott seems to be absent. His last post was on 20 June 2016 - 04:13 PM.
> 
> I think my suggestions are sufficient for the moment. What is the Carbamazepine doing?


Nothing whatsoever.

Just saw this. I inboxed you earlier, not sure if you got it or not. Maybe there could be a more efficient way we could speak? I am very accessible and I feel like we should team up for this endeavor I have... it won't take much work.


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## apoplexy (Jan 4, 2013)

thy said:


> Unfortunately I don't think there are any.


Sad to hear.

I'll update this thread after my ketamine infusions are done. Starting Monday.

Cheers.


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## BanterDPD (Sep 21, 2016)

I was on Effexor for many years as i could not tollerate the SSRI's like prozac and lexapro - the Effexor helped a tiny bit with anxiety but did nothing for the DPD. I am now trying Cymbalta which to be honest feels very similar to Effexor, so no progress!

I also just tried Abilify but after four days it was making me feel very restless so had to quit - might try one of the others like Seroquel if my psych says it is worth it. It seems the aytipical class make one very tired and stupid and I need to try hold down a job ......


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