Antidepressant Withdrawal: An Unknown Disorder?

Fiammetta Cosci, MD, PhD
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In 1977, George Libman Engel (December 10, 1913 – November 26, 1999), an American internist and psychiatrist who spent most of his career at the University of Rochester Medical Center in Rochester, NY and gave a seminal contribution to medicine via the formulation of the biopsychosocial model,1 criticized the dominant medical culture of those days. He said that biomedical dogma requires that all disease, including “mental” disease, be conceptualized in terms of derangement of underlying physical mechanisms. He added that this allows only two alternatives in medical doctors’ behavior and approach: the reductionist, which says that all phenomena of disease must be conceptualized in terms of physicochemical principles; and the exclusionist, which says that whatever is not capable of being so explained must be excluded from the category of diseases. The reductionists concede that some disturbances belong to the spectrum of disease, categorizing these as mental diseases. The exclusionists regard mental illness as a myth.

Let’s translate into practice the consequences of the above-mentioned reductionist and exclusionist approaches based on the following clinical history:

John is a 35-year-old man treated for a diagnosis of panic disorder with paroxetine (Paxil) for five years. Two months ago, John decided to decrease and discontinue paroxetine because he had been in good health for three years. A few days after discontinuation of paroxetine, John presented flu-like symptoms, fatigue, dizziness, confusion, and mild rapid mood swings. He first thought he had the flu because of the winter season and because many colleagues at work had it, but when after two weeks he still presented with these symptoms he decided to go to the general practitioner.

Here the exclusionist enters the scene. The GP reassured John that this was flu and when John pointed out that everything began just a few days after paroxetine discontinuation, the GP said that these symptoms were not capable of being so explained, thus they must be excluded from the category of mental disease and simply considered a flu. The GP suggested John take non-steroidal anti-inflammatory drugs for a few days. Since after two further weeks John still had flu-like symptoms, fatigue, dizziness, confusion, moderate rapid mood swings, and also nightmares and tachycardia, he decided to ask for a consultation with the psychiatrist who had prescribed him paroxetine the first time.

Here the reductionist enters the scene. The psychiatrist conceded that antidepressant discontinuation syndrome has been documented in the medical literature and that the symptoms described by John might belong to this spectrum of disease. However, stating that discontinuation syndromes are rare and symptoms are short-lasting, the psychiatrist excluded the possibility that it was discontinuation and explained John’s symptoms as the initial phase of a relapse of panic disorder. Thus, the psychiatrist suggested that John go back on paroxetine to eliminate the symptoms. John went back on paroxetine and in two days the symptoms were gone. He informed the psychiatrist of this rapid improvement and the psychiatrist suggested that he not discontinue paroxetine again.

In 1977, George Libman Engel proposed an alternative to the reductionists and the exclusionists. He suggested that medical doctors, and psychiatrists among them, need a biopsychosocial model. Its scope is determined by the historic function of the physician to establish whether the person soliciting help is “sick” or “well” — and if sick, why sick and in which ways sick — and then to develop a rational program to treat the illness and restore and maintain health.

Let’s translate this concept into practice once again using John’s history, which I invented although it resembles the clinical history of many patients I visit daily.

Let’s imagine that John is not convinced by the psychiatrist’s opinion, and instead of going back on paroxetine, he decides to consult another psychiatrist that he found mentioned on a web page about paroxetine and problems related to its discontinuation (for instance, this one). This second psychiatrist listens to John’s history and agrees with John that he is “sick,” and that there is a link between the discontinuation of paroxetine and the symptoms that occurred. This psychiatrist asks John if he agrees to be assessed via an interview which was developed to assess withdrawal after discontinuation of antidepressants and lets the psychiatrist know more about these symptoms (Cosci et al. 20182). John agrees to be interviewed. Thereafter, the psychiatrist, taking into account his clinical evaluation and the results of the interview, gives his feedback to John. The psychiatrist tells John that the symptoms that occurred are withdrawal symptoms, that they are due to the discontinuation of paroxetine and they are well-known in the literature (for example, Fava et al., 20153; Cosci & Chouinard, in press4). In addition, the psychiatrist tells John that “withdrawal” is a general term which, in reality, includes three different well-known and well-described syndromes. These three syndromes are: new withdrawal symptoms, rebound, and persistent post-withdrawal disorder (Chouinard & Chouinard, 20155).

  1. New withdrawal symptoms consist of symptoms which were not present before the beginning of the antidepressant treatment and were not present before reduction or discontinuation. They can be both unspecific or specific serotonin-related symptoms. Among the unspecific serotonin-related symptoms, nausea, headaches, tremor, sleep disturbances, decreased concentration, anxiety, irritability, and depression are common. Among the specific serotonin-related symptoms, flu-like symptoms, electric shock sensations, and confusion are common. These symptoms are usually short-lasting — that is, they last no more than six weeks — and spontaneously reversible, thus the best to do for patients is to wait until the symptoms fade away.
  2. Rebound consists of the return of symptoms which were present before the beginning of the antidepressant treatment but were not present before reduction or discontinuation. The symptoms are more intense than the ones that occurred before the beginning of the treatment. For example, if a person undertook antidepressant therapy to treat anxiety, after the reduction or discontinuation of the antidepressant therapy anxiety is back and is more intense than before the treatment. In addition, rebound symptoms occur rapidly after the reduction or discontinuation of the antidepressant treatment, are transient since they can come and go, and are reversible — which means that if the patient goes back to the antidepressant treatment or if the patient waits until they fade away they will really disappear. Rebound is commonly associated with a psychological belief to be in need of the drug which can erroneously drive the patient to go back to the antidepressant. These symptoms are short-lasting, that is they last no more than six weeks, and spontaneously reversible, thus the best to do for patients is to wait until the symptoms fade away.
  3. Persistent post-withdrawal disorder consists of the return of the original symptoms which were present before the beginning of the antidepressant treatment but were not present before reduction or discontinuation. These symptoms present both with greater intensity and together with new symptoms that the patient has never suffered before. For example, if the antidepressant therapy was taken to treat depression, depression rapidly recurs after the reduction or discontinuation of the antidepressant treatment, it is more intense than before the antidepressant treatment and is associated with other non-depressive symptoms, such as for instance panic. These symptoms persist longer than six weeks and they might be partially or totally reversible. Being so long-lasting, the patient usually benefits from adequate pharmacological or psychotherapeutic support.

Thereafter, the psychiatrist informs John that he currently presents new withdrawal symptoms and encourages him not to go back on paroxetine but to manage these symptoms, making a few sessions with a psychologist who will provide more information on withdrawal and on how to manage it in daily life. The psychiatrist schedules a follow-up visit in one month. At the follow-up visit, John has only mild fatigue and informs the psychiatrist that he has concluded the sessions with the psychologist and feels well.

Just a brief conclusion, since I already told a long story. The exclusionist and the reductionist were not able to help John since they based their evaluation on a biomedical model which needs physicochemical or biological probationary evidence to allow the doctor to recognize an illness and formulate a specific diagnosis. Thus, the exclusionist missed the diagnosis by denying withdrawal syndrome (and, as a consequence, gave the wrong treatment) and the reductionist made the wrong diagnosis by confusing withdrawal with relapse of the original disease, thus, once again, suggesting the wrong treatment. In both cases, they based their interventions on the biomedical model and prescribed medications.

The second psychiatrist was able to help John since he based his evaluation on a biopsychosocial model. The second psychiatrist listened to John’s history, observed John to identify possible signs of illness, assessed him via a specific interview and, taking into account his clinical evaluation and the results of the interview, told John that he was sick because of withdrawal from paroxetine, and suggested to him what to do to improve — that is, to not go back on paroxetine, since it was clear that paroxetine had triggered the current withdrawal syndrome, and to run a psychological intervention aimed at educating John on what was going on and how to manage the daily symptoms.

Withdrawal syndromes which occur after dose reduction or discontinuation of antidepressants are iatrogenic psychiatric disorders, that is, psychiatric disorders triggered by a pharmacological treatment. Since the majority of psychiatric disorders cannot be recognized and diagnosed on the basis of physicochemical or biological probationary evidence, despite numerous attempts by neuroscientists to provide us with evidence, similarly withdrawal syndromes, for their nature of being psychiatric disorders, cannot be recognized, diagnosed, and treated on the basis of the biomedical model. However, antidepressant withdrawal is no longer an unknown disorder since knowledge on this topic has grown enough to be translated into practice. As proposed by George Engel, medical doctors, including psychiatrists, can observe and listen to their patients and develop a program to treat withdrawal and restore health. According to what I have seen in my clinical practice, what Engel proposed in 1977 is still in 2019 the approach that works and produces health!

Show 5 footnotes

  1.  Engel, George. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–136.
  2.  Cosci F, Chouinard G, Chouinard VA, Fava GA. Riv Psichiatr. 2018;53(2):95-99. doi: 10.1708/2891.29158.
  3.  Fava GA, Gatti A, Belaise C, Guidi J, Offidani E. Psychother Psychosom. 2015;84(2):72-81.
  4.  Cosci F, Chouinard G. The monoamine hypothesis of depression revisited: could it mechanistically novel antidepressant strategies? In Neurobiology of Depression, edited by de Quevedo JL, Carvalho AF, Zarate CA. Elsevier, in press.
  5.  Chouinard G, Chouinard VA. Psychother Psychosom. 2015;84(2):63-71.
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Fiammetta Cosci, MD, PhD
Fiammetta Cosci, MD, PhD, is a psychiatrist with professional experience of managing reduction and discontinuation of psychotropic medications. In recent years she has devoted her clinical activity to providing treatments to aid people in reducing or discontinuing antidepressants, and she has devoted her research activity to examining psychotropic medication withdrawal and creating an instrument to assess people wishing to withdraw. Dr. Cosci is an Associate Professor in Clinical Psychology at the University of Florence.

23 COMMENTS

  1. “Antidepressant Withdrawal: An Unknown Disorder?” It was unknown to, or at least denied by, all my doctors. My PCP functioned as the “exclusionist.” She misdiagnosed the antidepressant withdrawal induced, flu like symptoms as other illnesses, and inappropriately prescribed drugs for the flu, a non-existent pneumonia, etc. for months.

    My second opinion doctors, a couple of whom were from outside my insurance group, all functioned as reductionists, and misdiagnosed the common symptoms of antidepressant discontinuation syndrome as “bipolar.” Despite the fact this was blatant malpractice according to the DSM-IV-TR at the time:

    “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”

    And I know with 100% certainty that since this disclaimer was taken out of the DSM5, many “mental health professionals” now believe misdiagnoses of the ADRs and withdrawal symptoms of the antidepressants as “bipolar” is acceptable, rather than malpractice. So I’m sure this type of iatrogenic pathway to “bipolar” misdiagnoses will only increase.

    And, of course, trying to cure the adverse effects of the antidepressants, by adding an antipsychotic, is not going to help the clients. Because combining the anticholinergic drugs is likely to cause anticholinergic toxidrome, which can make the clients psychotic, and mimics the other symptoms of the “psychotic disorders.” And since anticholinergic toxidrome is not listed in the DSM billing code “bible,” this will always be misdiagnosed as one of the billable disorders. Thus resulting in further iatrogenic harm.

    I agree with you, Fiammetta, and “George Engel” that “medical doctors, including psychiatrists,” should “observe and listen to their patients and develop a program to treat withdrawal and restore health.” But, unfortunately I don’t see this as the direction they wish to pursue, given the DSM5 changes, and because this is not financially in their best interests.

        • Thank-you, Rachel777, for not actually linking to that site. I just went to “depressionisreal.com”, using that phrase typed into a search engine.(google).
          The site is about as unprofessional as I’ve ever seen, for something that purports to be “real”. It appears to have been written by somebody who is NOT a native, or particularly fluent native English speaker. (It’s written in American English, not British). The “science” is highly questionable, and the site appears to exist solely to link to online drug ordering. The site appears to have photos of 3 actual doctors, but I bet they do not know their name, image and likeness is being used in this way. I’d say it’s a SCAM SITE….
          Kinda’ like psychiatry as a whole….

          • Depression is real. I have experienced it. But it’s an extreme feeling, not a brain disease.

            Churchill experienced this. So did Lincoln.

            The cure? Figure out if my thyroid levels are normal. Eat better. Sleep and exercise. If there’s a non physical reason for the depression–fix the problem or learn to live with it.

            My mom’s counselor helped her overcome depression by helping her figure out she was disappointed at never finishing college. Mom got her BS in education and became an elementary teacher. Depression solved!

  2. Do persistent post-withdrawal disorders always consist of a return of the original symptoms? It seems like some people just develop new symptoms.

    I also think that it’s only a matter of time before damage from SSRIs will be able to be detected via some kind of biological test (although it may be a long time). I can’t say the same for many psychiatric disorders, although maybe I’m being too much of a reductionist.

    • It is not always the same symptoms that were “treated,” but it’s very common for the target “symptoms” to come back with a vengeance. Which is frequently considered by our “mental health professionals” to mean you’re having a “relapse.” At least that’s my understanding.

      • Mr. McCrea: Dr. Cosci answers the question from “andy013” in the article above, in the 3 numbered paragraphs.
        1. New Withdrawal Symptoms.
        2. Rebound.
        3.Persistent Post-withdrawal disorder. (Which of course may include EITHER so-called “new”, or “rebound” “symptoms”.)

        You also didn’t answer another (implied) question from “andy013″…. **IS** he being “too much of a reductionist”….????….
        The most concise answer to the 1 explicit question which “andy013” asks is:
        No.

  3. Why speak in terms of “disorder” when clearly it is a form of physical brain damage, which has not been shown to occur in mental disorders?
    I surely hope they never put withdrawal syndromes in the DSM because they don’t belong there at all.

    • Yes. I came off Ativan over three years ago and I still suffer from physical symptoms. Symptoms that started when I began to taper and never left. Burning, stabbing electrical sensations all throughout my body. Sometimes I don’t know how I am still alive. I often wonder if these symptoms could lead to cancer, or other kinds of diseases. I am literally burning on the inside. Sick sick sick.

  4. The reductionists concede that some disturbances belong to the spectrum of disease, categorizing these as mental diseases.

    Are you presenting this as an example of a contradiction on the part of reductionists, as there are no physiochemical pathologies which cause psychic “disturbances”?

    The larger question is why would any kind of reaction to a poison which does not even exist in nature be considered a “disorder”?

      • True. Perhaps reaction is the wrong word. Still the emergence/unmasking of akathisia when stopping SSRIs and even months after stopping SSRIs seems to be a huge problem for some people.

        I would not be too harsh about the use of the word “disorder” in this article. The concept is that there are a lot of people ill from SSRI toxicity related to stopping the drugs, and this is horribly underappreciated.

        • Not discounting the importance of Dr. Cosci’s work at all, it is admirable. I’m picking at the term “disorder,” as it implies that something is faulty with the physiology of someone whose immune system is probably reacting to a strange toxicity in about as “ordered” a way as it has at its disposal.

  5. Is there any way to convince, or induce, Dr. Cosci to respond here in the comments section?
    IMHO, the ENTIRE article from Dr. Cosci, above, consists solely of psychobabble and gobbledygook, both arising from, and supporting, the pseudoscience drug racket and means of social control known as “psychiatry”. Psychiatry is 21st Century Phrenology, with potent neuro-toxins. Psychiatry has done, and continues to do, far more harm than good. But that’s just my opinion.

    So this George Libman Engel invented the “biopsychosocial” model? Cool. That’s the BEST possible arrangement of deck chairs on the Titanic of psychiatry….. Sadly, millions of iatrogenically harmed persons are also going down with the sinking ship of psychiatry…. I’m sure that Dr. Cosci means well, and I intend no professional or personal disrespect to her.

    But even the “bio-psycho-social” “model” of “mental illness” is just so much psychobabble and gobbledygook….
    Real people have real problems, and sometimes some people take some drugs. Why can’t we better understand REALITY?….
    There’s plenty of money, power, and drugs for everybody, if we’d all do a better job of sharing…..
    RSVP, Dr. Cosci?________________________________?

  6. On SurvivingAntidepressants.org, a peer support site for tapering and withdrawal syndrome that I’ve been running since 2011, I use quite a different model than these outdated medical philosophies.

    I myself recovered from Paxil withdrawal syndrome over 11 years. After about 5 years of research on my own, I concluded many of my symptoms were related to autonomic dysfunction. At that time, I happened to receive corroboration from a highly trained psychiatrist who had also come to that conclusion.

    Dysautonomia fit my experience like a glove, I’m pretty sure it fits most in cases. I use the model of autonomic dysfunction in counseling people on my Web site every day. It aids in interpreting the many symptoms and the many ways people describe their symptoms on my site. (Our language is not quite up to capturing these events so novel to our poor nervous systems.)

    I’ve collected and read thousands of longitudinal case studies of tapering and withdrawal syndrome. Sometimes people develop symptoms that are not dysautonomia; the stress of withdrawal may promote what may have been a subclinical condition that may never have blossomed into a full disorder, such as an autoimmune disease. And who knows what’s going on in the gut. But for the most common symptoms, it’s dysautonomia.

    (As medical diagnoses go, dysautonomia is not much of one. It’s autonomic or parasympathetic; it has many manifestations and can morph from one to another; it can arise spontaneously, wax and wane, and disappear. Nobody knows how to treat it, except regular gentle exercise and sleep generally help.)

    Understanding withdrawal symptoms as iatrogenic dysautonomia does not require either reductionist or exclusionist membership. One merely needs to be a realist. Withdrawal symptoms are unrelated to any mental illness except those DSM entries for withdrawal syndrome.

    (Joanna Moncrieff’s 2005 paper, Rethinking Models of Psychotropic Drug Action, may be of use here.)

    While we indubitably all live in a biopsychosocial model, my belief it that difficulties going off psychiatric drugs are mainly due to the biological effects of the drugs. People in all kinds of living situations, from the most supportive to the least, have similar difficulties.

    It’s undeniable that psychiatric drugs act upon the nervous system, though for some it’s mysterious exactly how this happens. To say that psychotropics change neurology is tautological.

    Therefore, while the drugs are ingested, the nervous system is affected and adapts. This includes autonomic and parasympathetic functions, with downriver effects on hormonal systems. Desirable effects are called therapeutic. Undesirable effects are called dysfunctions.

    The very common drug side effect of sexual dysfunction is evidence of autonomic and possibly hormonal alteration. (Antidepressants cause this dysfunction far more reliably than they therapeutically lift mood.)

    Similarly, through action on the body’s web of feedback loops, psychiatric drugs may derange insulin regulation and cause weight gain and even diabetes.

    The body and its systems adapt, comfortably or not, to the presence of the drugs — incurring physiological dependency. When the drug dosage changes, those systems may again be disrupted.

    Most frequently in withdrawal, autonomic symptoms, particularly a grueling sleeplessness, come to the forefront. This second wave of disruption may cause sexual dysfunction when taking the drug did not.

    From what I’ve seen, “rebound” symptoms are coincidental, not a type of symptom. Who among us, for example, has not had a spell of deep unhappiness? Or the occasional spell of anxiety? This is even more so for those who sought treatment with psychiatric drugs. However, withdrawal syndrome can cause spontaneous waves of profound existential despair or terror in people who never had an inkling of such things.

    That is an effect emanating from a dyregulated nervous system, not an emotional trigger. “Rebound” suggests these are the same old emotional symptoms, amplified. They are not, they are biochemically induced by the artificial state of withdrawal. (The content of the symptoms, however, might be the same old content, which no doubt will confuse the psychotherapists reading this.)

    I am dubious that, across the board, psychotherapy is the secret sauce for going off psychiatric drugs with minimal autonomic dysregulation. (It’s slow tapering, and even that doesn’t always work.) As so very many people are taking psychiatric drugs for no good reason, not everyone has pre-existing distress to work through, and psychotherapy has little to say about withdrawal symptoms, except to coach people how to ride them out — if the therapist actually understands that’s what’s going on.

    On the other hand, who among us wouldn’t like a little extra understanding when going through a trying time?

    • I think that this article is important because illness after stopping SSRIs is underappreciated and the first steps to change are clinical observation and categorization.

      On the other hand, I agree with Altostrata that relapse and rebound are uncommon, and when people stop these drugs the symptoms are generally far different from symptoms that led to starting the drugs.

      I also agree with Altostrata that the therapy that toxicity people benefit from the most is coaching on how to cope with the withdrawal toxicity symptoms. The notion that old emotional wounds are kept at bay by the drugs and will resurface without the drugs is really a new twist on the chemical imbalance theory.

  7. I quit 80mg of Paxil cold turkey.
    I was sick with flu like symptoms and “brain zaps”. My Psychiatrist was aware of the withdrawal symptoms. He was supportive when I told him that “I will be needing my brain back.” I quit because I had become so toxic from forced drugging that I could not eat. I went to my medical doctor who tried to tell me I had iratable bowl syndrome and gave me another prescription. I realized that she was an idiot and that if I wanted to feel better it was all up to me. The medical profession is very harmful. They treat symptoms and never get to the root of the problem. I knew what was causing my symptoms but my “hollier than thou” MD thought she knew better. She didn’t realize that I am the expert because I live in my body and I know when something is not right. Thank G-d I never took that idiot seriously! I’m sure I would be permanently disabled by now. I guess I was lucky that my shrink had a brain!