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Hermione

Struggling with eating

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I've been anorexic for 23 years spent years in and out of inpatients, residentials, day programs etc. I have had points of doing ok and right now back in the struggle I recently lost weight and according to my team it is too low and I can't afford to lose more. At work I get weight comments all the time it's just difficult right now to eat as I am depressed too and in part sometimes suicidal my psychiatrist mentioned ECT but I am trying new meds first. I also have PTSD and anxiety and depression and am just struggling with it all I ate what I was supposed to for 2 days and am expected to gain by Saturday when I see my nutritionist so just struggling I don't want to eat but my other option is treatment again...

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I'm going through the same thing, and started Remeron and it's helping. yeah, people can be really rude to someone who is underweight  .... I hope you will feel better soon! 

Edited by grab your bag
english?

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The Remeron (mirtazapine) will definitely help you eat, but it will likely make you extremely tired so you would have to take it at night, which means the appetite benefits might only be there right before you go to bed, at least IME. Seroquel is another one that increases your appetite but make you fall asleep while eating because of how powerful it is. 

I have always had trouble picking up weight and used to get comments about how skinny I was, until I asked my doctor about a medication called cyproheptadine, which has really helped me gain 20-25 pounds in the past 3-4 months so I highly recommend it. It is an anti-histamine but non-drowsy and actually indicated for anorexia. I highly recommend it and hope it works for you if you are able to get it prescribed! Here is a study about cyproheptadine and anorexia

https://www.ncbi.nlm.nih.gov/pubmed/367480
"Cyproheptadine was found to be effective in inducing weight gain in a subgroup of anorexia nervosa patients"

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Thanks everyone for the advice and support my psychiatrist told me to take the medication at night so I will find out if it makes me hungry or not I am scared of being hungry I have never gotten my hunger cues back even times I was eating normally my therapist said I wouldn't know I am hungry I have suppressed it for so long. I am also scared to gain to quickly I took seroquel but it made me gain to much to fast and wasn't helping anyway and I just started restricting even more because it was too much weight but I do need to gain now as I gained barely then lost again. I hope the remeron helps depression wise too and also with sleep as I still struggle even with the trazedone I take. I have such bad nightmares mg psychiatrist wants me to be sedated so I can get some sleep. I have been trying to eat better but I kept my scale and I have still barely gained and I see my nutritionist Saturday and I am supposed to gain at least a little it's just weird and I shouldn't have a scale it's a detriment to me. I always get triggered as I don't want to gain fast. I want to control it if that makes sense. I hate this all.

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https://www.uspharmacist.com/article/treatment-options-for-anorexia-nervosa

SSRIs like fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft) have been studied with varying results. The reason for varied results is believed that SSRIs require some serotonin to work, and in anorexic patients, they may be malnourished leading to a deficiency in serotonin; tryptophan is required to synthesize serotonin and is acquired through dietary intake, so if one doesn't have an adequate intake of tryptophan, one may not have adequate serotonin for a SSRI to work. This link also says that tricyclics are to be avoided, but there are some case studies that clomipramine (Anafranil) is beneficial.

https://www.ncbi.nlm.nih.gov/pubmed/6994086

https://www.ncbi.nlm.nih.gov/pubmed/3664105

http://www.tandfonline.com/doi/abs/10.3109/08039489409078150

Treating anorexia nervosa may not just be about encouraging weight gain to a target level, but may also be about treating obsessive-compulsive tendencies to restrict, weigh constantly, etc. Clomipramine is regarded as "the golden medicine" for treating OCD and obsessive-compulsive symptoms. So while Remeron may be beneficial for flashbacks (of your PTSD), sleep, and appetite/weight (of AN), and cyproheptadine (of AN) may also help with appetite and weight gain, it's also important to try to address and treat the root of the aforementioned symptoms of AN like obsessional tendencies, etc.

https://www.uspharmacist.com/article/treatment-options-for-anorexia-nervosa

Antipsychotics may also be of benefit to treat possible symptoms about delusional beliefs about body image and help the patient comply with treatment. Zyprexa and Seroquel have apparently been the main ones studied, and are especially associated with weight gain, but I'm sure some of the other antipsychotics that are more weight neutral may help too.

I am not an expert, but this is just some information I picked up around the Internet from searching about treatments of AN. I know you have PTSD too, which Remeron can help, and I'm certain you've tried all the SSRIs if you say you've tried so many meds, but perhaps your serotonin levels are/were not high enough for them to have worked. This could possibly (ask your pdoc) be mitigated by supplementing with L-tryptophan or 5-HTP (generally this would be problematic while taking a serotonergic antidepressant, but if you're deficient in serotonin, it might be a good thing to take for a brief period of time). Remeron also enhances serotonin and norepinephrine release, but more so at higher doses than lower doses, at which it mostly acts as an antihistamine (hence its sedating and appetite-stimulating effects). I hope this information helps. I wish you all the best. 

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Thanks for the advice and research i will look through it and read the articles you have shared. I don't think i have tried everything but most SSRI's  I think there are so many out there I am trying my PTSD is really a killer so i need something to help that because that is what triggers a lot of my eating disorder is trauma issues i have been on seroquel it caused weight gain but did not help adn the weight gain was too much so i just restricted more so it didn't really do the job. I have also been on zyprexa which didn't help. so idk...just keep trying...this is a list of what i am on and also the past ones i can remember. 

Diagnosis: Depression, Anxiety, Complex PTSD (officially diagnosed as chronic but only because Complex not in DSM), Anorexia

 

Current Psych Medications: Remeron 15mg, Trazedone- 100mg, Lamcictal-300mg, Vyvanse-20mg, Risperdone-4mg, Clonopin- 4mg 

 

Other Meds- Zofran 4mg as needed for nausea,  Linzess 145mg as needed, Lansoprazole-30mg (for GERD), Align, Colace, Multivitamin, Calcium, Magnesium and Zinc, Iron 45mg

 

Past Medications that i can remember doing my best here- Zoloft, Abilify, Seroquel, Lithium, Prozac, Lexapro, Noritryptoline, Wellbutrin, Effexor , Zyprexa, Xanax, Paxil, Cymbalta  (could be more that’s what I remember and I don’t remember dosages)

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8 hours ago, Hermione said:

Thanks for the advice and research i will look through it and read the articles you have shared. I don't think i have tried everything but most SSRI's  I think there are so many out there I am trying my PTSD is really a killer so i need something to help that because that is what triggers a lot of my eating disorder is trauma issues i have been on seroquel it caused weight gain but did not help adn the weight gain was too much so i just restricted more so it didn't really do the job. I have also been on zyprexa which didn't help. so idk...just keep trying...this is a list of what i am on and also the past ones i can remember. 

Diagnosis: Depression, Anxiety, Complex PTSD (officially diagnosed as chronic but only because Complex not in DSM), Anorexia

 

Current Psych Medications: Remeron 15mg, Trazedone- 100mg, Lamcictal-300mg, Vyvanse-20mg, Risperdone-4mg, Clonopin- 4mg 

 

Other Meds- Zofran 4mg as needed for nausea,  Linzess 145mg as needed, Lansoprazole-30mg (for GERD), Align, Colace, Multivitamin, Calcium, Magnesium and Zinc, Iron 45mg

 

Past Medications that i can remember doing my best here- Zoloft, Abilify, Seroquel, Lithium, Prozac, Lexapro, Noritryptoline, Wellbutrin, Effexor , Zyprexa, Xanax, Paxil, Cymbalta  (could be more that’s what I remember and I don’t remember dosages)

13

I'm surprised you're not on prazosin (Minipress) for PTSD. That's one of the main go-to meds for PTSD for nightmares and flashbacks. Do you think you might have tried it and might have forgotten about it?

What exactly are you on the Vyvanse for?

 

According to Epocrates, the medications used for PTSD are as follows:

  • fluoxetine (Prozac)
  • sertraline (Zoloft)
  • venlafaxine/venlafaxine ER (Effexor/Effexor XR)
  • amitriptyline (Elavil)
  • paroxetine (Paxil)
  • mirtazapine (Remeron)
  • risperidone (Risperdal)
  • phenelzine (Nardil)

Of those, the ones with official indications for PTSD are paroxetine (Paxil) and sertraline (Zoloft), so so much for that. Of course, it may be that any SSRI will do, so citalopram (Celexa), escitalopram (Lexapro), or fluvoxamine (Luvox) may be able to help too. But of the ones listed that are used, you're already on two of them (Remeron and Risperdal), so that's a good thing. Amitriptyline (Elavil) is another tricyclic like nortriptyline (and in fact, it produces nortriptyline as a major metabolite), so it may or may not work for you. Phenelzine (Nardil) is a MAOI, which has rather strict dietary and drug restrictions due to the possibility of serotonin syndrome and/or hypertensive urgency/crisis

As for the SNRIs, you've only tried venlafaxine (Effexor) and duloxetine (Cymbalta). It may not be of much benefit to pursue trying desvenlafaxine (Pristiq) or Fetzima (levomilnacipran)...

Of the TCAs, you have quite a lot more to chose from, albeit I'm not sure how much they would benefit your PTSD.

  • amitriptyline (Elavil)
  • imipramine hydrochloride (Tofranil), imipramine pamoate (Tofranil-PM)
  • clomipramine (Anafranil)—(may benefit anorexia symptoms too)
  • doxepin (Sinequan, Silenor) (VERY sedating!)
    • May or may not have beneficial results...
      • desipramine (Norpramin) (the main metabolite of imipramine, stimulating for some rather than sedating)
      • protriptyline (Vivactil) (stimulating rather than sedating)
      • trimipramine (Surmontil) (acts more like an antipsychotic, so may have beneficial results, or not)

There are two tetracyclics which are commonly grouped with the tricyclics:

  • amoxapine (Asendin) (has both antidepressant and atypical antipsychotic properties)
  • maprotiline (Ludiomil) (not really much better than any TCA or TeCA, plus has an increased chance to cause seizures, especially in high doses)

Of the atypical antipsychotics, you've tried aripiprazole (Abilify), olanzapine (Zyprexa), and quetiapine (Seroquel) and are on risperidone (Risperdal).

  • If risperidone (Risperdal) ends up not working for you, maybe paliperidone ER (Invega), which is related to Risperdal, may have better (or not, or no) benefits than Risperdal.
  • The rest of the atypicals include:
    • Saphris (asenapine) (sedating)
    • Rexulti (brexpiprazole ) (related to Abilify, sedating for some, stimulating for others)
    • Vraylar (cariprazine) (sedating for some, stimulating for others)
    • clozapine (Clozaril) (regarded as a drug of last resort due to serious and possibly fatal side effects...)
    • Fanapt (iloperidone) (orthostatic hypotension and cardiovascular side effects are a big deal with this one)
    • Latuda (lurasidone) (indicated for bipolar depression and schizophrenia; for me, low doses are stimulating, mid-range doses are neutral, and higher doses are sedating)
    • ziprasidone (Geodon) (dosage effects are similar to Latuda for me and most people from what I've read and heard)
  • I'm not sure how much benefit any of the older typical agents would have for you, but it may be worth asking about after trying several of the atypicals and you don't have any results.

https://www.ptsd.va.gov/professional/treatment/overview/clinicians-guide-to-medications-for-ptsd.asp#meds

According to this link, trazodone (Desyrel), nefazodone (Serzone), and mirtazapine (Remeron) are being used more and more for PTSD.

Also, anticonvulsant mood stabilizers may be used.

  • carbamazepine (Tegretol, Tegretol XR, Carbatrol, Equetro)
    • Maybe oxcarbazepine (Trileptal, Oxtellar XR) or even Aptiom (eslicarbazepine acetate)?
  • divalproex sodium (Depakote)
  • lamotrigine (Lamictal)
  • topiramate (Topamax) (may cause appetite suppression and weight loss though)

Benzodiazepines may alsoi be used, but should be used with caution since they cause disinhibiton and may exacerbate flashbacks.

  • lorazepam (Ativan)
  • clonazepam (Klonopin)
  • alprazolam (Xanax)
  • chlordiazepoxide (Librium)

Of the ones not listed, drugs.com lists a few that are used off-label for PTSD.

  • prazosin (Minipress) (very commonly used off-label)
  • dronabinol (Marinol) (cannabinoid used as an antiemetic for cancer patients, only schedule III med)

Some other meds I've read that are used for PTSD but can't find the links for:

  • buspirone (BuSpar)—5-HT1A agonist = anxiolytic
  • Viibryd (vilazodone)—SSRI + 5-HT1A agonist
  • haloperidol (Haldol)—typical antipsychotic
  • loxapine (Loxitane)—typical antipsychotic, but behaves more like an atypical and produces the aforementioned tetracyclic antidepressant, amoxapine, as a metabolite
  • trifluoperazine (Stelazine)—typical antipsychotic (very good for quelling anxiety)
  • hydroxyzine pamoate (Vistaril)/hydroxyzine hydrochloride (Atarax)—antihistamine with 5-HT2A antagonism = more anti-anxiety effects
  • clonidine (Catapres)—α2 agonist (blood pressure med like prazosin but a different mechanism of action), mixed evidence regarding efficacy for PTSD
    • guanfacine (Tenex)—another med with the same mechanism of action as clonidine, probably would have about the same efficacy (or non-efficacy) as clonidine
  • gabapentin (Neurontin)—an anticonvulsant commonly used for anxiety
  • Lyrica (pregabalin)—another anticonvulsant similar to gabapentin that is also commonly used for anxiety
  • The nonbenzodiazepines (for insomnia)
    • zolpidem (Ambien), zolpidem CR (Ambien CR)
    • zaleplon (Sonata)
    • eszopiclone (Lunesta)

 

I hope this information is of value and isn't misguiding. Again, I'm no expert, but this is just from what research I've done. I wish you all the best in finding a successful treatment medicine or medicines. :) 

Edited by mikl_pls

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Thanks for all this I have taken prazosin I was on a high dose didn't work for me also tried vybrid and also Latuda forgot those 3 I will read through this closer when I get a minute there is a lot of information. 

Edited by Hermione

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I struggle just trying to eat. I don't enjoy the food I once did, or any for that matter. I'm down to about a half a meal a day on average, and losing weight. I usually maintain 140-145 because of my metabolism, which is already a low weight for being 6' 1", but I weight about 125 right now. I'm always hungry, but anytime I start to eat, I eat about half, then want to puke, not feel like puking, I just want to. I used to eat alot. 2 pizzas for dinner, 3 bowls of cereal for breakfast with toast, but I just can't bring myself to eat. I waste so much food because I know I won't eat the rest of it. Over the last three days, I've had toast, two corndogs, and a sandwich. With how fast my metabolism is, I need to intake 3000 calories a day to maintain my with, and I'm getting about 800 a day. Does anyone have some advice, or ideas to get me to eat?

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If it's any help, I'm on Clozapine and I have BALLOONED up. I was anorexic at 6 1/2 stone and now I'm closer to 13 stone. It makes you crave fatty, salty foods and then makes you retain the bad stuff. And I'm only taking half the maximum dose.

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