PSSD After Reinstatement of SSRI

[tfurquhart]

Hi all,

I am a 33 yo male, and have been on and off Fluoxetine about 3 or 4 times over the past 15 years. I am now suffering terrible withdrawal symptoms, and having stopped at 10mg 3.5 months ago. Thankfully, I do not have PSSD in the sense of genital numbing, low libido etc. Rather, it is the opposite. I noticed some low libido whilst on Fluoxetine, but now that I am off it I am experiencing a rebound, or "over-shooting" of sexual function. I believe this may be called Persistent Genital Arousal Disorder. Essentially, I have nocturnal emissions about once a week, despite having never had these even as a teenager. I also experienced extreme sexual urges from about 1.5 months off Fluoxetine. However, each time I orgasm/ejaculate, I suffer a significant uptick in my other withdrawal symptoms - severe depression, panic, anxiety, agitation, anhedonia, headaches, rapid heartbeat, among others.

Because I am suffering severely from other withdrawal symptoms, I am considering reinstating Fluoxetine and then gradually tapering again. I have received plenty of useful advice on survivingantidepressants.org re the pros/cons of reinstating.

However, my question for this forum is this. Having been on and off an SSRI for significant periods of my life until now, I have never had PSSD. Does make it less likely that if I go back on I will get PSSD? In other words, might it be the case that I am just not one of the unfortunate people who will develop PSSD through an SSRI? I ask because my wife and I are at that time of our lives where fertility is extremely important.

I ask this question with all possible humility - and people suffering from PSSD have my sincere sympathies.

[TalkingAnt]

A taper is unlikely to resolve those "withdrawal" symptoms, in quotes because I suspect after 3.5 months it would be better to classify them as psychological rather than drug induced. You simply numbed yourself while on SSRI and now you are facing the underlying negative emotions. Something in your life is out of whack and/or you fear something, maybe the difficulties of fatherhood if you are trying to start a family. Several of your symptoms likely stem from pure anxiety (ex panic, agitation, rapid heartrate).

You've got to figure out what you are afraid of, what possible negative future outcomes you worry about, and work on fear extinction. In my experience this is down in two ways. Firstly you practice self-assurance. When you find yourself worrying about future suffering, you tell yourself "you've got this," "you can handle it," "be courageous" etc. Secondly you practice non-reaction. When you feel the anxiety, practice acting like everything is fine. Ask yourself what would you be doing/thinking if you didn't have anxiety, and go do that. When you act like it's ok, this downregulates the fear response to the trigger. But when you react to the anxiety, for instance by taking an SSRI to numb it, this reinforces the fear, because you are telling your brain that yes you did need to do something in response to that fear, when you should be telling it there is nothing to do. This means you must develop some acceptance to feeling anxiety, rather than trying to do something to make it go away. And yes feeling anxious sucks, but only when you have a willingness to experience it will you get rid of it. Check out the book "Untangle your Anxiety" for more tips along these lines.

The risks of SSRI are simply not worth it, especially if you are trying to conceive. IMO, go for 6 months without any drugs or psychiatric medication before conceiving to avoid any sperm quality issues.

[tfurquhart]

Hi, thanks for your consideration of my situation and your advice - while I disagree with you I am grateful for you taking the time.

I am afraid I do fundamentally disagree with your view that this is not withdrawal. The reasons are many, but here are some. I didn't have any of these symptoms before I went on an SSRI over 8 years ago - I just flippantly went to the Dr because I had situational low mood, with none of the other debilitating symptoms. The mechanism is that the SSRI provides too much of the neurotransmitters involved in mood enhancement and anxiolysis, so the brain/body adapts by producing less of them. Once the SSRI is removed, there is therefore not enough of them, hence anxiety, depression and so on. It is also well-established that SSRI withdrawal can be protracted, and particularly so for Fluoxetine, which has a long half life. Withdrawal will last as long as it takes for the brain/body to return to its previous state. Worryingly, it may never do so fully.

What I am looking for in this post is whether the fact that I have not had PSSD when coming off Fluoxetine before means that I will not get it this time? Are there people who have been on an SSRI, come off and not had PSSD, but then gone back on, off again and then got PSSD?

[TalkingAnt]

Are there people who have been on an SSRI, come off and not had PSSD, but then gone back on, off again and then got PSSD?

Yes this has been reported before. If you already feel like SSRI is negatively affecting you, I don't think its worth the risk to chance it again.

However your reasons for believing your symptoms are withdrawals are flawed logic:

I didn't have any of these symptoms before I went on an SSRI over 8 years ago

Surely your life circumstances have changed in 8 years. It could be the case that there are certain things worrying you now that were not previously.

the SSRI provides too much of the neurotransmitters involved in mood enhancement and anxiolysis, so the brain/body adapts by producing less of them. Once the SSRI is removed, there is therefore not enough of them, hence anxiety, depression and so on.

Yes there is a theory that serotonin levels are reduced for a while after SSRI, and that this may have something to do with the so-called brain zaps withdrawal symptom. The downstream effects of this on anxiety and depression are less clear, as the low-serotonin hypothesis of depression is mostly ruled out at this point. Furthermore it's not clear how long it takes the brain to restore normal serotonin levels. So for you to blame your mood on "lack of neurotransmitters" is not well supported by the science.

When I stopped fluoxetine, I had brain zaps for 3-4 months, but I couldn't really tell if it worsened my depression/anxiety or if I was just more upset at my life situation.

Whether you believe me or not, working on addressing the root causes of anxiety and depression in your life is zero risk, and you ought to exhaust all your options there before you re-taper an SSRI thinking it will somehow improve your condition.