Thread by @Altostrata

With all due respect to the fine @awaisaftab, these are the varieties of #antidepressant withdrawal syndrome:

1) WS with only physical, no emotional symptoms
2) WS with both physical & emotional symptoms
3) WS with only emotional symptoms
4) WS manifested as emotional anesthesia

https://twitter.com/awaisaftab/status/1443721094989484034

@awaisaftab Of the above, types 1 & 2 are WS, not "relapse", even if "depression" is present. Emotions such as those that compose "depression" do not exist apart from experience. Emotional reaction to feeling neurobiologically out of control should not be diagnosed as "depression".

@awaisaftab Type 3 may include the waves of intense anxiety, fear, & "black holes" characteristic of WS. Characterized by intense sensations with interludes of relative calm. Typically, these very gradually abate over months.

@awaisaftab An unrelenting, grueling insomnia often accompanies types 1, 2, & 3. Emotional alarm, a normal reaction to a loss of sleep that seems without end, should not be misinterpreted. Typically, WS insomnia very gradually improves over months, but can be torturous all the way.

@awaisaftab Type 4 WS, emotional anesthesia, deserves special mention. People may have acute withdrawal (brain zaps, etc.) for a couple of weeks or no obvious WS, then find they have an unprecedented lack of emotional response to anything. This may be the unmasking of drug effect or WS.

@awaisaftab Emotional blunting from #antidepressants is well documented (Goodwin et al., 2017). Off the drugs, may be felt more acutely. Or it may emerge as WS. Sufferers may call this "depression". Like other WS, it tends to slowly dissipate over months. Highly distressing, nevertheless.

@awaisaftab I cannot stress strongly enough that post-drug emotional anesthesia is not "depression", but a consequence of long-term drug use. Also seen in WS from addictive drugs. It is not "relapse" & can resolve naturally if not provoked with adverse effects from additional drug treatment.

@awaisaftab Another withdrawal effect that may emerge in all 4 types of WS is Post-SSRI Sexual Dysfunction (PSSD). This can bring on intense reactive distress, often seen in males. Ranges from absolute lack of sexual sensation to weak sensation. We have also seen PSSD gradually resolve....

@awaisaftab ....over months, but #PSSD lasting many years is reported. Intense reactive distress due to PSSD has been known to lead to suicide (Hengartner, 2020), but that is not "relapse", either. It is an extreme but understandable reaction to an iatrogenic situation that seem untenable.

@awaisaftab In all types of WS, the realization that there is no medical solution, that clinician after clinician will not even grasp the problem of WS, brings on that sense of total hopelessness. That is not "relapse", either. (cf David Foster Wallace, suicide after 1.5 years of Nardil WS)

@awaisaftab Frankly, I do not know what you might call true "relapse" after #antidepressant discontinuation. After x years of drug modification, the person's nervous system is not the same as before the drug. Given neuroplasticity, it is bound to change gradually after the drug is removed.

@awaisaftab As ever, true "relapse" means the patient & clinician agree it's relapse. If the person has subsequent poor reaction to treatment, this is an indication symptoms were due to WS & not relapse. But then they'll probably be made worse, & on the road to "treatment resistance".

@awaisaftab It is the clinician's responsibility to carefully review discontinuation method, emergence of withdrawal symptoms, & post-drug symptom pattern for differentiation. Sadly, since hardly any can recognize even an obvious withdrawal symptom, patients cannot rely upon them for this.

I hope this informs your model. No, "depression" does not exist as a recognizable entity when someone is in the throes of obvious or non-obvious #antidepressant withdrawal syndrome. "Depression" is not a standalone disorder. Emotions are changeable & dynamic per situation.