The last set of posts have brought stimulants and dopamine into the frame. In the 1960s and 1970s while stimulants were becoming controlled drugs it was nevertheless denied that they caused dependence.
It is now clear that the closely related dopamine agonists, increasingly the first line treatment for Parkinson’s Disease, cause a host of compulsive behaviors in addiction to marked dependence and a debilitating withdrawal problem – Dopamine Agonist Withdrawal Syndrome (DAWS).
There were early RxISK posts on the compulsive behaviors linked to dopamine agonists and on DAWS, with the DAWS post attracting a lot of comment. There are also RxISK guides on Dopamine Agonists for Takers and Dopamine Agonists and Parkinson’s Disease.
There was an early RxISK story linking antidepressants like Venlafaxine to compulsive behaviors – Gambling on Antidepressants, and there will be posts on Abilify covering similar ground in weeks to come.
The compulsive behaviors lead to High Court Judges and other paragons of society engaging in risky behaviors like gambling, and promiscuity and also as the post below from the Parkinsons’ Society of Ireland shows a range of Punding behaviors. Punding as Johanna Ryan noted last week was widely recognized in the heyday of the stimulants.
These compulsive behaviors are certain to lead to radical changes in medico-legal understandings about the effects of both drugs and insanity on behavior. As things stand, faced with compulsive behaviors, the police and courts turn to standard insanity defenses, but there is a difference between being poisoned and being insane. Under the influence of these drugs many people can still distinguish right from wrong but are helpless to prevent themselves behaving in horribly destructive ways.
These behaviors resemble that shown by junkies with one exception – High Court Judges don’t mug people or engage in crime to feed their habit because their doctor is a free and easy source of supply.
The material here comes from a piece written by Sean o’Sullivan for the Parkinson’s Society of Ireland, which can be accessed in its original form here.
Compulsive behavior is characterized by an inability to resist an impulse or temptation, so the person can’t stop themselves from doing an activity repeatedly, excessively or obsessively. In most cases it is the family members who describe the full social and functional impact of these behaviors on the persons’ lives.
Whilst some behaviors are associated with increased amounts of dopamine-replacement therapies, in most cases the behavior develops in people taking standard doses. It is estimated that up to 14% of people with Parkinson’s taking dopamine agonists experience some problem with impulsive-compulsive behaviors. In a lot of cases, the behavior is out of character for the person. If untreated, they can escalate and lead to uncontrollable addictions that devastate people’s lives.
What kind of impulsive – compulsive behaviors are seen in Parkinson’s?
The most frequently described behaviors include compulsive gambling, compulsive sexual behavior, compulsive shopping and binge-eating or compulsive eating. It is quite common for an individual to have more than one type of impulsive-compulsive behavior.
These behaviors manifest as:
Some people with Parkinson’s become addicted to their dopamine replacement drugs. This behavior is less frequently seen than compulsive gambling, compulsive sexual behavior, compulsive shopping and binge-eating or compulsive eating.
Here, the addiction is so powerful that they start taking more and more of the drug – exceeding the dose prescribed to control their movement. This happens even though they are ‘on’ and experience severe dyskinesia (involuntary jerking). People will often resist the advice of their doctors and families when it is suggested that they try and reduce their dopamine medications.
People with this problem may also have very bad mood swings throughout the day. These can vary from feelings of depression, irritability and anxiety when they are ‘off’, all the way to euphoria and hyperactivity when they are ‘on’.
Punding is a term used to describe repetitive and pointless activities seen in some people with Parkinson’s. Punding includes repetitive manipulations of technical equipment (eg. dismantling and re-assembling household appliances), the continual handling and sorting of common objects, grooming, pointless driving or walkabouts, prolonged monologues devoid of content, excessive cataloguing and computer work.
A feature of punding is that it is never ending, it is disorganized and frequently leaves chaos in its wake. Punding can cause social avoidance, severe sleep deprivation, and disintegration of family relationships.
Excessive hoarding is commonly seen in association with other impulsive-compulsive behaviors in Parkinson’s, and this can represent a significant health hazard to some individuals in terms of fire risk and clutter in the home.
Editorial Note: These new developments shed light on the use of stimulants. There are likely many people out there with difficulties on either dopamine agonist or stimulants – all accounts of what happens on these drugs are hugely important. Please write in.
Illustration: Betting your brains on antidepressants, 2012 © Billiam James
I think behavioural effect and overall effect depends on which particular D receptors are being hit by a chemical and to what extent, rather than just dopamine per se. The report is valid though.
I don’t think there is much of a dopamine hit from effexor, certainly not at standard doses.
If a drug really works in terms of making people feel “happy” it will rapidly become a drug of abuse. Not many street corner antidepressant drug dealers out there. Is that because the drugs don’t work and are not being abused, or is it because they are too easy to score from your GP anyway?
It would be wrong to focus too much on dopamine but it is now recognized that up to 1 in 6 people on dopamine agonists may have seriously compulsive behaviors. This is a challenge to medicine, to the law, and to our ideas of what it means to be human. Are these people responsible for their behaviors if they gamble their resources away. There are no easy answers to these questions – except for those who have never seen the problems up close.
Dr. Healy I learned about down regulation and upregulation in college, but i am still confused over it. I watched a video on drugs and behavior where the author uses benzo’s as a point. He states that because the benzo is increasing GABA, the post synaptic receptors will upregulate. When the drug is stopped both old and new receptors will be (so to speak) expecting the drug thereby causing withdrawl. What exactly is this all about????
I’m not sure. For me one of the most interesting things is that Americans much more than Europeans like to talk in a mechanical language about levels of serotonin or upregulation of receptors etc. For the most part what the books contain on these issues is meaningless and wrong. The biggest problem though is not that its wrong but it stops people looking at their own experience on drugs or what’s happening to someone they know and love. Its as though “well their receptors are upregulating so everything else must be okay” when its a better bet to ask the person
Well, I’ll confess to being an American … but I think we do need the science to help us fight this battle. If we each had some inviolable inner core that “just knew” what was really happening to us, maybe each of us could be our own scientist and decide if drugs were doing us more good or more harm. But it just ain’t that way, and I’m a living witness.
It is incredibly easy for a person to be the last to know what is happening to them under the influence of a drug. Especially if the drug-induced harm is a slow, subtle process rather than a sudden crash. Especially if you were physically ill, or in chronic emotional distress, when you began taking the drug and you don’t have recourse to some bright, clear vision of “how I feel normally” or “how I used to feel before I started taking this shit.” Especially if the symptoms of the damage are rather similar to the symptoms that got you put on the drug in the first place. And most especially if the drug comes with withdrawal effects that you are never told about, so that your subjective experience of “freeing yourself from the drug” is guaranteed to be awful.
I have been caught up in this confusion at least twice, both with a Drug of Abuse (alcohol) and a Drug of Appropriate Medical Treatment (antidepressants). At least with the alcohol, my “gut feeling” that I needed it badly, that it was the only thing keeping me sane, had to contend with experts and the whole society telling me that it was actually quite bad for me. On balance, I’m quite glad I finally listened.
In the case of the antidepressants it took twenty years longer, because all the experts, and increasingly the entire society, was telling me they were essential … that I might not be very happy now, but that was NOTHING to the way I’d feel without my corrective pills. And time and time again, my subjective experience seemed to prove they were right.
Us humans don’t even need a drug inside us to get confused about how our life stories really played out and what the lessons are. That’s why so often, even when we do figure out that a drug is a problem rather than a solution, we face loving, well-meaning family members who have been so well “educated” in the “facts” about our illness that they “just know” we are better off on the drug. They will even go to court to have it injected into us against our will, and they will say they are doing this out of love, and actually they are not lying. What they “see right in front of their eyes” has been completely shaped by what they have been taught to see.
It’s also why, in order to know what’s causing autism, we can’t simply “LISTEN TO THE MOMS,” as Andrew Wakefield and Jenny McCarthy keep urging us to do. Even a mother’s detailed and intimate knowledge of what’s happening to her young child can be screwed around with. And the more years go by, the more her memories of that fateful week little Johnny got vaccinated are slowly transformed by her new convictions. She’s not especially foolish — lots of us rewrite our own history, every day, without realizing it.
So I can’t see pharmacology or biology as just a useless technology that seduces American minds. It ain’t enough, for sure. When what you see in the clinic, on the playground or in your home contradicts what the lab-science is telling you, you should go back and ask the test-tubes (and yourself) some hard questions. As it says at the bottom of all those fancy MRI reports, “Clinical correlation is advised.” In other words, Doc, don’t cut it out just because this MRI says it’s busted. Take a look at the patient, too. Please.
If antidepressants make people feel good, why isn’t there a street market for them? Good question! Actually, not only are people NOT trying to buy them on the sly … about 40% of those who get them from their doctors end up quitting early on. They feel nothing–or feel something they don’t like.
Of course they do provide an effect that many people value, and some think has saved their lives. As far as I can tell, it’s a “calming” effect that quiets down anxiety and despair by making you less reactive, less sensitive. But it’s by no means reliable; some people react by feeling intolerably anxious. A few people report feeling Totally Awesome within hours of their first pill; sometimes those are exactly the people who will wind up dangerously agitated later.
For most people the effects take a couple of weeks to kick in. You can’t pop an extra pill and feel extra chill right away. Still, they turned out to be addictive in their own way: your nervous system will adapt to them, that adaptation may be permanent, and it may be as hard to kick antidepressants as speed — even if they never made you feel all that good.
The funny thing is, they can help relieve compulsions in some people, and cause them in others. The strange thing about compulsions is, their strength often has nothing to do with the amount of pleasure they bring. Even in the course of a “spree” of gambling, casual sex or midnight pizza, people may be berating themselves, wondering what in hell they’re doing and in general not having much fun at all. It’s one way to define addiction: Are you doing it more, and enjoying it less?
It can’t be all about dopamine, at least not directly. Paxil/Seroxat is supposed to affect only serotonin, and it seems to have as many compulsion complaints as Effexor. It’s got 25 for shoplifting or kleptomania, and 340 or so for OCD or “obsessive thoughts,” not to mention 19 for “poriomania” which is another term for the compulsive wandering Dr. O’Sullivan refers to as “walkabout.” What’s going on here? Does anyone know?
One thing you can be sure of, and I am in no way advocating the use of cannabis here, but if cannabis did not exist in nature, but had been developed by a drug company, it would be being prescribed for a whole host of conditions and the drug company would be raking in the money!
Regarding antidepressant addiction, and one can play all sorts of games in defining the nature of addiction and what addiction is, but with antidepressants, in my experience, the need to keep taking the drug and the inability to quit, is because the brain simply cannot work without it once it has been administered, even if only for a short period. It is as if the drug causes some change in the brain and the brain can then no longer work without it. The ‘you’ on the drug is never who you were before, but you cannot get back to who you were before, because the drug has caused an irreversible change in your brain.
Also in my experience, antidepressants certainly can cause OCD behaviours which did not exist before and can send you very, very fast and speedy at times.
I think the truth is they don’t really know what these drugs do at a molecular level, certainly not in total. Researchers create molecules that do not exist in nature and observe their effect on subjects for a short time only, then having never taken the drug themselves, purport to know all about everything the drug does. Eventually papers are written extolling the drug’s virtues by people with a financial interest in the drug’s marketability and these are read by Doctors who have also never taken the drug, but believe every word and merrily prescribe away.
There are many street drugs which an unknowing Doctor could prescribe to a downhearted patient, who when he comes back to see the Doc the following week will tell him how great he feels now. The Doc can then feel very self satisfied with his magician-like powers and issue a further prescription.
No one knows what it is like to take LSD, for instance, better than someone who has taken LSD. Someone who has not taken LSD, but has read a report written by someone else who has never taken LSD, but briefly engaged with someone who was on LSD, cannot claim to have the first idea of what the real and total effects of taking LSD are, but Doctors’ knowledge and justification for prescribing head meds are pretty much based on this kind of flawed foundation.
Sorry, bit of an off topic ramble there, but that’s what us crazy people are like. Best prescribe me something new to alleviate my symptoms.
More rambling. The mickey mouse questionnaire used to assess depression; what a joke that is. I particularly enjoy the “do you feel like a failure” bit. If you are someone who has failed against your own goals and expectations then of course you feel like a failure. This does not mean you need drugs; you need to assess the reasons for your failure, learn the lessons, set new goals etc. The crazy person would be one who is a failure, but says he is not, but then he would be diagnosed as perfectly normal. Also if the questionnaire had more questions the diagnosis could be completely different, e.g. do you have a fever and are you sneezing? If yes, then the correct diagnosis is ,you have the ‘flu and that is why you are feeling so cr@p overall!
You guys are dead on. Stopping antidepressants for me was harder then coming off Klonopin. The withdrawl is crazy. Fatigue, nausea, feeling like you have the flu etc. In retrospect I feel better now then when I was taking that garbage. Sertraline
GSK puts out that Paxil only effects serotonin. SSRI means so many things to many scientists. Some may think that by selective we are only effecting serotonin others think that selective means targeting the re-uptake mechanism or serotonin receptors. Yes, I took Zoloft for the longest time. I noticed that I didn’t persevarate as much. Was a good thing though. My Dr. was aware of that effect of Zoloft and of course praised it. I like your question at the beginning of your post asking why if SSRI’s are making people feel good, why aren’t they sold on the streets?? Its a question that needs to be considered because I have heard of Prozac being sold on the street. Not sure who would be stupid enough to buy it when their Dr. would be thrilled to prescribe it. Take care 🙂
One more thing is that when you manipulate serotonin by blocking re-uptake you in turn pay a price because you’r indirectly effecting other neurotransmitters IE. Acetylcholine, dopamine. These two NT’s have a reciprocal relationship and balance each other out. An analogy would be a see-saw with DA @ one end and ACH at the other. Serotonin is considered by many to be the Master NT. Its manipulation indirectly effects the other NT’s.
Again Take Care.
Many good comments, mine is about Oliver Sacks, the author and scientist behind the Movie “awakenings”.
Even the Movie itself briefly touched the problems that arose after the initial therapeutic benefits of “L-dopa”, in my laymans knowledge an early version of medication that affects human dopamine.
But if you start to read a bit about the story behind the Movie, Oliver describes in great detail and even documenting on film how his patients experience sexual compulsive and sometimes sexual abusive behaviour, among many other seemingly compulsive behaviours.
And all this right Before the Eyes of the pioneer doctor who wanted to help people in a living hell locked inside themselves.
Dr. Healy often describes this observation as the way we used to learn how the Chemicals affect humans, the prescribing doctor saw it with his own Eyes, told others and simply stopped prescribing the pill.
Today, with Everything on a nano-scale, we still prescribe drugs that affect the same areas, but with less crued doseages, and low and behold: we get the same behaviours!!!!
Now don’t get me wrong, it’s just as easy to see the benefit of dopamine treatment, the Changes seen in the Movie was phenomenal, but at a cost.
Today we might be closer to being able to “correct” whatever dopamine-related issues humans can suffer from.
But until our nanoscale is so tiny, that we can measure each individual response to treatment, these drugs should not be found on the market.
As long as we find [B]any[/B] remnant of a behaviour that can be linked to the initial observation by dr. Oliver Sacks, we can’t use them in treatment, no exceptions.
That is the lesson we must learn, that if the Rainbow promises a pot of gold, we can’t be keen on keeping the rusty bucket we found.
This is very good, Fred,
It’s great, when someone ‘get’s it’.
Most of us reflect on where it all went wrong for us and why we were persuaded to take a pill in the first place.
Mickey Mouse questions take on a sinister turn when almost the first thing you are asked is “are you suicidal?”
I was so shocked at the “word” suicide thrown at me; sitting innocently with someone I didn’t know who was sitting in my house. It’s almost as if he had a premonition for the sinister route I was about to undergo…..suicide was an anathema to me…he used this word casually…I can only think that he was very used to suicide, working in a mental hospital where suicides are routine?
Reflecting, back on his questions and how we did not discuss the good times.
I can now see quite clearly his goal – why did he want to do this?
Why did he only look down the tunnel of ‘depressive’ questions?
Why didn’t he realise that he had a huge responsibility towards me?
Why didn’t he realise that he had given me a psychiatric label?
Why didn’t he realise that my local surgery might treat me completely differently now that I had become a ‘depressive’?
Why didn’t he think through how others might think of me?
His time spent discussing the pill whereby this innocuous pill would break up the cycle of anxiety and depression, his words. Stopping the cycle should have been the clue. Stopping emotions, the cycle, in mid flow.
What happens when a cycle is stopped?
Emotional castration – this pill halting ‘my cycle’ of normal emotions mid-track?
I was stuck, my wheels no longer going round…the brakes were on permanently…my bi-cycle seized up….
Of course, you can’t just drop off your pill, like a passenger…
How can anyone think that dropping off your pill suddenly is a good idea…you might as well throw your passenger out of the car on the motorway and it’s pot luck as to whether they are run over by a ten ton truck or miraculously avoided by someone’s skilful driving….
There is no science in all this…it is just one person bad mouthing another…sinister people putting the fear of god into you when within weeks of dropping you off your pill there is talk of your precious child being taken away, your mother 500 miles away being accused of being responsible for your mood, your partner doing you no good whatsoever and ALL your history of minor medical ailments, including pregnancy, put under the spotlight as an accrued ‘depression’.
This is all a terrifyingly everyday occurrence, not, perhaps, as savage as this, but, it is a reason for reflection, over years, to learn that Mickey Mouse questions, however, innocently begun, can take a sinister turn when popping Paroxetine has led Ben Goldacre of Alltrials to publicly hold up GlaxoSmithKline as the first pioneer of transparent clinical trials – and, for this, I am not thankful.
And, as Johanna, asked:
What is going here?
Does anyone know?
Personal experience of various street drugs and prescription drugs enables me to identify (I think) just how increased dopamine, or serotonin, or noradrenaline feels. Increased dopamine (to a high level) will, without a doubt give you an incessant and unrelenting sexual urge (among other things). I have also experienced the gambling urge, to a degree. That was with selegiline. It was only weak in terms of mood effect, a bit of something and then nothing; really a very, very weak dopamine hit with selegiline, but other weird dopamine driven behaviours going on. Dopamine can be complex. The thing with the dopamine high though, it always burns out and it burns out fast and it takes a long time to get any back, but it really does make you want to take loads more of whatever it was that got you high in the first place. I think dopamine solutions would be great if they didn’t burn out, but they do. Dopamine is a weird one; the feelings and effect are harder to nail down than with 5-HT or NA. Pharmaceutical dopamine drugs can be complex – weird things start going on. Coke and speed are simple.
I used to love getting high, I was sensible with it, didn’t stop me graduating, didn’t stop me becoming a fellow of one of the senior professions, didn’t stop me having a high flying career, but I did really enjoy getting high, that’s why I thought antidepressants would be good – cheap, legal, clean – what could go wrong? Antidepressants had hold of me in double quick time. They have destroyed my mind and my body. I am in no doubt about that and there is no recovery from it. My life has gone from guaranteed success to now facing homelessness. It’s the pills ‘what done it’ and I know at some point I will have to end this dead existence. The indoor barbeque seems favourite. I haven’t touched the recreationals for more years than I can remember. When things started going wrong I blamed the recreationals and feasted on the Doctor’s pills. Now I know I had it the wrong way round. It was the Doctor’s pills which burned me out; I’d put my life on it……
I can’t help posting a quote here – one that’s often come back to haunt me as I struggled to make sense of, and recover from, a couple of decades on antidepressants “augmented” with Adderall, modafinil and every other stimulant on the menu. It’s from The Screwtape Letters, C.S. Lewis’ compendium of advice from a senior devil to a junior devil on the art of stealing souls:
“The Christians describe the Enemy [Screwtape’s euphemism for God] as one ‘without whom Nothing is strong’. And Nothing is very strong: strong enough to steal away a man’s best years not in sweet sins but in a dreary flickering of the mind over it knows not what and knows not why, in the gratification of curiosities so feeble that the man is only half aware of them, in drumming of fingers and kicking of heels, in whistling tunes that he does not like, or in the long, dim labyrinth of reveries that have not even lust or ambition to give them a relish, but which, once chance association has started them, the creature is too weak and fuddled to shake off.
“You will say that these are very small sins; and doubtless, like all young tempters, you are anxious to be able to report spectacular wickedness. But do remember, the only thing that matters is the extent to which you separate the man from the Enemy. It does not matter how small the sins are provided that their cumulative effect is to edge the man away from the Light and out into the Nothing.
“Murder is no better than cards, if cards can do the trick. Indeed the safest road to Hell is the gradual one—the gentle slope, soft underfoot, without sudden turnings, without milestones, without signposts.”
Absolutely! Effexor, so different 150mg… Yes, obsessive, I bought three second hand kitchens when i didn’t even have a house plan. Crazy. I lost my house, everything, had no idea on this poison how to budget, what was important, what wasn’t. Lost 10 years of my life, a marriage, everything I had worked for. Now off it, I have to cope with the emotional agony of what that drug made me.
“Murder is no better than cards, if cards can do the trick. Indeed the safest road to Hell is the gradual one—the gentle slope, soft underfoot, without sudden turnings, without milestones, without signposts.”
WOOW, Johanna, that’s exactly how psychoactive drugs take lives! They so slowly suck out the soul. By the time that we see what is happening, it is too late.