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stimulants/stimulating AD's and anxiety disorders


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Hi,

I've been diagnosed with comorbid ADD and OCD, as well as atypical depression. My history basically reads as: gifted child, lifelong inattentive symptoms (undiagnosed) -> evolving into OCD once I began college and found that my coping techniques no longer worked -> 3 years of major depression after 4 years spent battling severe OCD and ADD. I have also been experiencing some dissociative/depersonalization symptoms since becoming depressed.

I've tried several different SSRIs, as well as Nardil, but found that none helped my executive (dys)function. I immigrated to Australia about a year ago and have spent most of that time ping-ponging between psychiatrists, trying to find someone who would treat (or even acknowledge) my ADD symptoms.

Anyway, I finally did find someone receptive to the idea and who believes that my comorbid OCD may disappear with stimulant use, given that ADD is the root disorder.

The first drug he tried was Dexedrine: I noticed an increase in alertness, drive, sociability, mental energy and ability to stick with a task, but also found that my thoughts would race subtly. This never evolved to the point where they would swarm my consciousness - they felt more like a continual blur in the back of my mind, and would generally interfere with more mentally taxing tasks. This was an improvement on my baseline foggy state where I can barely process text/information anymore, but still not helpful. I also found that by the time I took my third dose of the day, I would suddenly feel like crawling out of my skin and my mind would become very constricted and overfocused.

He decided to switch me to Strattera, which I've been on now for a couple of weeks. I found that at 60mg I experienced the same agitation/crawling-out-of-my-skin sensation and mental constriction, and that now at 40mg I am experiencing an increase in drive, motivation, mental energy, etc. (I feel like I have a thought process again!) but that I'm also getting the subtle racing thoughts. I also feel like there's this dream-like quality to everything, but at the same time, I am able to recall information read etc. during that state. I'm not sure if that dream-like quality is unique to Strattera, since I never experienced it on Dexedrine ..

I found that my depressive symptoms changed after we immigrated - I went from being very anergic to suddenly feeling like adrenaline was pounding through me 24/7, trapping me in this constant state of panic. I tried clomipramine for the depression/anxiety/OCD a couple of months before seeing my current psychiatrist, but also found that it caused horrible agitation that never went away after 6 weeks.

What I was wondering is whether what I describe (the subtle racing thoughts, agitation and inner tension at higher doses etc.) on these drugs can occur in comorbid anxiety disorders or if it's an indication of a mixed state? Is it possible I'm just sensitive to NE now, given how my symptoms evolved after immigrating? Strangely, I found that Neurontin (which I was given for sleep) completely removed that panic-like sensation, but pretty much left me plastered to the bed with lethargy and didn't do my attention any favors.

It's obviously the stimulants have enough benefits to justify exploring them further, but obviously they aren't doing me any favors as monotherapy.

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Thanks SashaSue. A friend who studied psychology suggested that the agitation, irritability and crawling-in-my-skin sensation could be a mixed state, which is why I've been curious ever since.

Likewise, I was also confused about why clomipramine produced physical agitation in me, when it's so well-regarded for OCD; I have only really heard about anti-depressants causing agitation in bipolar.

I would like to try Effexor for my anxiety, but am growing fearful of anything that acts on NE. Is clomipramine quite a powerful NRI, respectively-speaking?

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Too much of the attention drugs can cause the symptoms you list. Sound very familiar with my experience. I have worked my way downward over 4 years on Adderall and Strattera. I find it hard to hit the sweet spot. Too little, poor attention, too much; my eyeballs are bouncing and thoughts racing.

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Too much of the attention drugs can cause the symptoms you list. Sound very familiar with my experience. I have worked my way downward over 4 years on Adderall and Strattera. I find it hard to hit the sweet spot. Too little, poor attention, too much; my eyeballs are bouncing and thoughts racing.

Thanks for your reply AirMarshall. When you find your thoughts racing on stimulants, do they overwhelm your attention/consciousness, or have you experienced the sensation I described as well, where they feel like a kind of subtle blur at the back of your mind?

I have found that there's a kind of progression from subtle racing thoughts to this weird, dazed state where my mind feels blank and my attention becomes completely narrow and constricted, e.g. when reading in that state, I feel like I'm literally absorbing three or four words at a time and end up losing the meaning of the sentence (i.e. no 'big picture focus').

I've been wondering if I am just naturally sensitive to stimulants (metabolically or whatever) or if my high anxiety/OCD is leaving me more prone to overstimulation, or whether these are 'mixed states' as my friend suggested.

Is it possible an anti-depressant would help mediate that overstimulation?

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too much NE can bring on physical anxiety symptoms. For me it feels like Im in a constant state of butterflies in stomach, on edge, hypervigilance.

Ive only tried a couple but wellbutrin was the worst on anxiety. Desipramine was the best for fatigue with low anxiety.

When I take my adderall I get really anxious. I go to public places and I can feel people watching me, I get really self-conscious.

The busy thoughts is more worrisome. Id wonder if you are going a little mixed there. Be on the look-out for any irritability and rage.

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Too much of the attention drugs can cause the symptoms you list. Sound very familiar with my experience. I have worked my way downward over 4 years on Adderall and Strattera. I find it hard to hit the sweet spot. Too little, poor attention, too much; my eyeballs are bouncing and thoughts racing.

Thanks for your reply AirMarshall. When you find your thoughts racing on stimulants, do they overwhelm your attention/consciousness, or have you experienced the sensation I described as well, where they feel like a kind of subtle blur at the back of your mind?

I have found that there's a kind of progression from subtle racing thoughts to this weird, dazed state where my mind feels blank and my attention becomes completely narrow and constricted, e.g. when reading in that state, I feel like I'm literally absorbing three or four words at a time and end up losing the meaning of the sentence (i.e. no 'big picture focus').

I've been wondering if I am just naturally sensitive to stimulants (metabolically or whatever) or if my high anxiety/OCD is leaving me more prone to overstimulation, or whether these are 'mixed states' as my friend suggested.

Is it possible an anti-depressant would help mediate that overstimulation?

Look, if you're hoping to treat adhd, ocd, depression, and some kind of panic disorder, all with stimulants, that's just not going to happen. I gather you think your ocd somehow evolved from your ADHD, but that's not really how it works. They are two different disorders, different neural substrates, different symptoms, benefitting from different treatments. And depression is another disorder as well, requiring different treatments.

Honestly, your response to stims sounds an awful lot like that of people who don't actually have adhd. So, I hate to say it, but I find myself wondering if the pdocs who were skeptical of that diagnosis might not have been onto something.

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too much NE can bring on physical anxiety symptoms.

I'm a little wary of this statement. For starters, we don't know what "too much NE" actually means, since the only technology we have to see how much of a given chemical is in the brain at a given time involves surgically implanting probes. As far as I know, this has never been used in humans - only mice. At any rate, each person is likely to have a different "set point" for NE turnover, and will respond to changes differently. Finally, desipramine is very, very selective for the NE transporter, but apparently doesn't give you as much anxiety as less selective drugs.

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  • 2 weeks later...

The dream-like state that you're describing sounds like depersonalization, probably due to anxiety. My gut reaction is that you probably need to tackle the anxiety, depression, and/or OCD before you add a stimulant for ADD. Your ADD may have been the root cause of your OCD, but once the other axis I disorder gets started, it takes on a life of its own.

My other thought is that maybe you are one of those people who does best on Ritalin, which it doesn't sound like you've tried.

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Thanks for your replies everyone.

I never claimed that my ADHD caused my OCD, as if the two were magically intertwined; rather, it was the psychosocial stress brought about by the ADHD which triggered the OCD's emergence. My pdoc is not stupid - in fact, he's reputedly one of the best psychiatrists working in my state - and is well aware of the guidelines which advise treating anxiety first in comorbid cases. But he also told me that he doesn't believe in those guidelines; I suppose it's a matter of seeking out the most elegant solution to the problem, and if the anxiety disappears on a stimulant, then great! Since it didn't, he's now looking to treat it separately .. but why fall into messy polypharmacy when a single med may have sufficed .. ?

Anyway, I'm still not clear on the difference between mixed states and med-induced "overstimulation" (to use a fairly broad term)? Can stimulants induce bipolar symptoms in unipolar patients (who would have otherwise never experienced the symptoms off the med)? I vaguely brought the issue up with my psychiatrist, but he said that irritability + racing thoughts on a stimulant is not sufficiently diagnostic of Bipolar.

I've tried Ritalin LA (20mg), MorningDew, which I didn't like, but never the IR ..

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I think it's pretty rare for stimulants to induce either a mixed state, or a hypo/mania. In any case, mood states caused by medication rule out a diagnosis of bipolar disorder.

BTW, I really don't think your narrative of adhd somehow setting the stage for your OCD is all that likely to be the case. And your pdoc's notion that stimulants will somehow treat anxiety is so, um ... unusual, it would concern me greatly.

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BTW, I really don't think your narrative of adhd somehow setting the stage for your OCD is all that likely to be the case. And your pdoc's notion that stimulants will somehow treat anxiety is so, um ... unusual, it would concern me greatly.

Really? Doesn't it make sense that OCD might be a biologically latent condition that then emerges/accelerates in intensity based on environmental triggers? Sure, I had a few minor quirks as a child, but those mostly disappeared up until I entered college, which is precisely when the reality of my limitations set in. Until that point, I had been safeguarded by a high school environment that pampered me at every turn, afforded me the opportunity to collaborate with peers, share notes etc. etc. effectively masking my deficits. In college I was stranded, and with no knowledge of my diagnosis, threw myself into reading-intensive subjects like English lit. etc., which predictably swamped me. I simply could not keep up with college reading demands, and growing intensely more envious of people who could, began to feel that I was stupid. I remember the exact day/moment/setting that my first major OCD breakthrough happened and it was precisely in response to the psychosocial stress brought on by ADHD; once my typical defenses (i.e. "I could concentrate if I wanted to") began to fail me, I would use the OCD symptoms as an alibi to explain why I couldn't perform at a capacity that matched my IQ.

Again, I'm not claiming my ADHD is the root cause of my OCD, but it was one trigger that contributed to its emergence at that point in time.

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But treating OCD with a stimulant makes no sense. It's just going to make it worse. If you do indeed have both, you generally need to treat treat the OCD/anxiety first before the ADHD.

Not necessarily. A recent-ish study at Yale showed that Dexedrine improved symptoms vs. placebo in treatment-resistant OCD patients.

IQ really doesn't say much about your scholastic performance or ability, so trying to get treatment to make you perform towards an IQ score is absurd. College is hard, and the people once "the smart ones" in high school might just be middling students in college for various reasons, some not due to cognitive skills at all. Maybe you couldn't keep up with the reading just because... you couldn't keep up with the reading. No diagnosis required.

Why is everything I say twisted to sound like it's the basis for my treatment? I'm not paying my psychiatrist to allow me to perform at some supra-human capacity. Most capable people generally don't have a 30-minute attention span, which renders them completely unable to read or study material that isn't immediately novel and/or highly stimulating. The only reason I passed college was due to my coursework; I couldn't retain information, even in subjects I loved.

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But treating OCD with a stimulant makes no sense. It's just going to make it worse. If you do indeed have both, you generally need to treat treat the OCD/anxiety first before the ADHD.

Not necessarily. A recent-ish study at Yale showed that Dexedrine improved symptoms vs. placebo in treatment-resistant OCD patients.

Unless this this study has a treatment cohort that represents an appropriate sample (>150 subjects, demographically balanced, etc.) and has been repeated at least once, it doesn't really mean anything. It also means nothing if you don't show it to me. Finally, I'm not sure what "treatment-resistant OCD" is, since most cases of OCD don't respond well to medication, but do respond to therapy (often strongly).

The only reason I passed college was due to my coursework; I couldn't retain information, even in subjects I loved.

This would be why coursework exists. Most people don't retain information they don't use. Doing the coursework aids in retention, but if you don't continue to reinforce it (for instance, by continuing to work in the field you studied), chances are you won't retain the information. I'm not seeing how your statement disagrees with dianthus, particularly in that you wish to perform to the standards of a meaningless test score.

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Not necessarily. A recent-ish study at Yale showed that Dexedrine improved symptoms vs. placebo in treatment-resistant OCD patients.

Did the study also compare the two vs an SSRI? I ask because not only is "treatment-resistant" is not synonymous with "no improvement at all", but the amphetamines induce serotonin release in addition to noradrenaline and dopamine. This assumes of course that the researchers thoroughly screened for undiagnosed instances of comorbid ADHD in the study cohort, which could also bias the results upward.

FWIW, this is why on sites like this you'll often get asked for your source - a request that should be familiar from college work - it's much easier to look to the original journal article to see if such questions have already been answered by the authors.

Why is everything I say twisted to sound like it's the basis for my treatment? I'm not paying my psychiatrist to allow me to perform at some supra-human capacity.

Your posts to date do give the impression that you see all of your mental illness as strongly linked to comorbid ADHD, even though your description of your response to the ADHD medication and the overall list of symptoms suggests that they aren't so closely related.

There's simply no one med that works equally well on anxiety, OCD, and ADHD, although a multiple reuptake inhibitor like Cymbalta, Tofranil, or maybe even clomipramine might provide a lot more relief than expected (or, admittedly, a lot less.)

Most capable people generally don't have a 30-minute attention span, which renders them completely unable to read or study material that isn't immediately novel and/or highly stimulating. The only reason I passed college was due to my coursework; I couldn't retain information, even in subjects I loved.

This fits the "oooh, shiny!" stereotype of ADHD, but an ADDer who's hyperfocusing (or completely zoning out. Those "plasma" screensavers are Evil!) can have an attention span of *hours*, sometimes for the dullest material you can imagine, and it can be nearly impossible to shift away to something productive.

By the way, making a distinction between "capable people" and people with ADHD is a bit insulting. I'd recommend reading You Mean I'm Not Lazy, Stupid, or Crazy?, by Kate Kelly, for an idea of how much little things like that can hurt.

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BTW, I really don't think your narrative of adhd somehow setting the stage for your OCD is all that likely to be the case. And your pdoc's notion that stimulants will somehow treat anxiety is so, um ... unusual, it would concern me greatly.

Actually, there may be some connection between ADHD and OCD. Albeit not a strong or completely causative one. If the ADHD does cause a high enough level of stress for this person via the mindset it invokes, it's not completely impossible that that this stress has a small impact on the OCD that is already there due to other unrelated things. The reason why I think this is possible is because a personal experience that I had regarding a different type of situation. I tend to ruminate alot. So much so that it ends up being a trigger for my already present anxiety. Without it, I would still have the anxiety of course, but with it, it just makes it that much harder to control. I never thought of this connection before I started Risperdal. See, the Risperdal had a huge effect on my ruminations - to the point where they almost stopped all together. This, in turn, removed that trigger and actually did help my anxiety. I was very surprised, but it did happen. I was still anxious of course.. but an improvement is an improvement. Now I'm not saying that ADHD causes OCD, however, I don't believe it's completely impossible that one could affect the other. This may be not what the OP or the pdoc means, and it is definitely an unusual idea, but it could actually be a possibility. Anyway, it's something to think about.

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BTW, I really don't think your narrative of adhd somehow setting the stage for your OCD is all that likely to be the case. And your pdoc's notion that stimulants will somehow treat anxiety is so, um ... unusual, it would concern me greatly.

Actually, there may be some connection between ADHD and OCD. Albeit not a strong or completely causative one. If the ADHD does cause a high enough level of stress for this person via the mindset it invokes, it's not completely impossible that that this stress has a small impact on the OCD that is already there due to other unrelated things. The reason why I think this is possible is because a personal experience that I had regarding a different type of situation. I tend to ruminate alot. So much so that it ends up being a trigger for my already present anxiety. Without it, I would still have the anxiety of course, but with it, it just makes it that much harder to control. I never thought of this connection before I started Risperdal. See, the Risperdal had a huge effect on my ruminations - to the point where they almost stopped all together. This, in turn, removed that trigger and actually did help my anxiety. I was very surprised, but it did happen. I was still anxious of course.. but an improvement is an improvement. Now I'm not saying that ADHD causes OCD, however, I don't believe it's completely impossible that one could affect the other. This may be not what the OP or the pdoc means, and it is definitely an unusual idea, but it could actually be a possibility. Anyway, it's something to think about.

I can totally see how stress from one disordernmight exacerbate another. I just doubt one causes the other.

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I can totally see how stress from one disordernmight exacerbate another. I just doubt one causes the other.

I agree. Following that, I also think that medication to help one my indirectly help another. Just not to the same extent as a med made specifically for the other condition.

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