Thread by @Altostrata

@awaisaftab Hello, Awais. I will attempt to answer your excellent questions. @HengartnerMP may wish to add his perspective as well. /1

@awaisaftab @HengartnerMP Re your #2: This was a retrospective study. Duration & symptom criteria from Chouinard & Chouinard, 2015 were used in selecting subject population. Other of C&C's criteria (C) were addressed in analysis & discussion. The paper only weakly corroborates C&C's criteria (C). /2

@awaisaftab @HengartnerMP "Greater severity of illness": We relied upon subjects reporting symptoms were qualitatively different than prior to treatment. It is impossible to quantify "greater severity", the symptoms being so various & most unlike original condition. They certainly were distressing. /3

@awaisaftab @HengartnerMP Reversibility & reinstatement per C&C, 2015: We show complete or in-process natural recovery for 16/69. #PWS resolved in 9 of the 20 subjects who tried reinstatement. Please note that in the throes of a severe adverse drug effect, people are reluctant to take more drugs. /4

@awaisaftab @HengartnerMP Reversibility & reinstatement per C&C, 2015: From our results, indications that natural recovery is possible, but we don't know the odds. Indications are that reinstatement sometimes works. Conditions of successful reinstatement for PWS need to be researched. /5

@awaisaftab @HengartnerMP But before it can be treated with reinstatement or otherwise, #PWS itself needs to be recognized. Historically, it has been mislabeled relapse. Clearly, for 69 people, this has not been helpful. They are in this population because "relapse" diagnosis didn't make sense to them. /6

@awaisaftab @HengartnerMP Re your #3: We do not know the rate of incidence of PWS. From lack of recognition, it's almost invariably misdiagnosed as "relapse". However, we do know it's continuous from acute withdrawal syndrome, rate of which is >40% per Davies & Read, 2019; Jauhar & Hayes, 2019, etc. /7

@awaisaftab @HengartnerMP How many of people with #antidepressant withdrawal syndrome #AWS go on to #PWS? We don't know, because #AWS itself is so poorly recognized among clinicians. Does the possibly erroneous assumption #PWS is rare underlie the lack of curiosity about it? /8

@awaisaftab @HengartnerMP Both acute withdrawal & #PWS are known across psychotropics, with strikingly similar patterns. Lerner, A., & Klein, M. (2019). Dependence, withdrawal and rebound of CNS drugs.... Brain Communications, 1(1). doi.org/10.1093/brainc… /9

@awaisaftab @HengartnerMP What is risk of #PWS overall, across psychotropics? It seems to be quite common in addiction medicine treatment, where tapering schedules tend to be unforgiving.

Note similarity of description to #antidepressant PWS:
hazeldenbettyford.org/articles/post-… /10

@awaisaftab @HengartnerMP Why should the class of psychotropics known as #antidepressants be considered to be immune to the Law of Psychotropics™?:

Frequent ingestion >
Neurobiological adaptation >
Neurobiological dependence/tolerance >
Potential acute withdrawal upon cessation >
Potential PWS

/11

@awaisaftab @HengartnerMP I would like to see a full explanation about how #antidepressants must be an exception to the Law of Psychotropics™ aside from the lack of inquiry about this in #psychiatry. In fact, there's plenty of discussion about it in neurobiology, especially regarding tolerance. /12

@awaisaftab @HengartnerMP Re your #4: You are correct. The relationship between #PWS and #PSSD needs to be elucidated, as well as the relationship between #antidepressant-induced sexual dysfunction while taking the drug continuing post-withdrawal, as with finasteride. /13

@awaisaftab @HengartnerMP (This was not part of the paper, but we do see #antidepressant-induced sexual dysfunction resolving upon dosage reduction or cessation -- or continue or intensify. Plus, we see true #PSSD emerging upon reduction or cessation of the drug.) /14

@awaisaftab @HengartnerMP (If there are any academic researchers who want to write up a case series of #antidepressant-induced sexual dysfunction continuing after cessation of the drug, please contact me.) /15

@awaisaftab @HengartnerMP Re your #4: As explained, to ascertain #PWS, we relied upon subjects' reporting symptoms as qualitatively different after #antidepressant cessation. Given the vast catalog of withdrawal symptoms per Chouinard & Chouinard, 2015 & back to Kramer et al., 1961 & earlier... /16

@awaisaftab @HengartnerMP ....yes, any adverse symptom post-discontinuation may be a withdrawal symptom. This is true across psychotropics. *The nervous system is rocked by ending the drug.* This affects the entire body. It's all interconnected. /17

@awaisaftab @HengartnerMP Consequently, as we pointed out, there is a high co-occurrence of physical symptoms & affective symptoms. We urge clinicians not to compartmentalize affective symptoms, accurate #PWS diagnosis depends on drug chronology as well as holistic history, not solely psych symptoms. /18

@awaisaftab @HengartnerMP You say: "Such use would seem to stretch the meaning of the word "withdrawal" beyond what is typical usage in medical contexts."

In citations, we provided many medical contexts to support our use of the term. Again, psychotropics have many #PWS characteristics in common. /19

@awaisaftab @HengartnerMP Re your #5: We do not lack for criteria. Criteria for diagnosis of #antidepressant withdrawal have been published dozens of times. What we lack is clinician recognition. They cannot continue to demand criteria when they don't pay attention to what their patients tell them. /20

@awaisaftab @HengartnerMP #PWS had a tough road to recognition in addiction medicine, too, because of a medical culture that tended to attribute patient complaints of PWS to weak character & general wallowing in sin. You can easily see this in the literature. /21

@awaisaftab @HengartnerMP A question for you: For what cultural reasons does #psychiatry find it so hard to integrate the very obvious problems of #psychiatric drug withdrawal syndromes, which may continue into #PWS? Surely it's an outcome no one wants. /22

@awaisaftab @HengartnerMP Re your #6: If anything needs further criteria, it's "relapse". Forensic thinking what it is in #psychiatry, prior episode of "depression", "anxiety", etc. or a close relative with serious mental disorder NOS can be found for anyone. So what the heck is "relapse"? /23

@awaisaftab @HengartnerMP If a person is sad during a divorce, goes on 20mg citalopram for 6 years, happily remarries, goes off drug & has nausea, brain zaps, insomnia for 2 months, then lack of concentration, #PSSD, & insomnia for 2 years, is that person suffering "relapse" when sad about their #PWS? /24

@awaisaftab @HengartnerMP "there will never be a sharp distinction between withdrawal and relapse as mutually exclusive entities."

As long as "relapse" = "any negative emotion", this will be true. This is what comes of #psychiatry taking emotions out of context & compartmentalizing them as symptoms. /25

@awaisaftab @HengartnerMP As @HengartnerMP so elegantly put it: "Emotional states cannot be isolated as a separate phenomenon apart from the neurophysiological condition; the individual may be reacting in a habitual way emotionally to the distressing physical and neurological states of PWS." /26

@awaisaftab @HengartnerMP Thank you for this opportunity to review our work, Awais. 🙂