Ask a doctor on the topic of Neurology

2. Opinion of a psychiatrist on the diagnosis / further questions about medication

May 26, 2011 | 20,00 EUR | answered by Dr. med. Ralf Berg

Hello,

Some background information: in the summer of 2009, I had panic attacks and then spent 2 months in a clinic. I had developed strong health anxiety due to dizziness attacks, and stress (separation from the mother of my son and work-related stress/escaping into work) also played a role. Looking back, I am still unsure about the exact trigger for the panic attacks. When I bring up the topic of burnout with my (current) therapist, he just says that it is not a standalone illness and it mainly focuses on treating accompanying conditions such as depression and anxiety. By the way, my current therapist believes I have a generalized anxiety disorder. However, when I was discharged from the clinic, I was still not much better - I still had anxiety and panic attacks. The panic attacks only stopped when I started taking Citalopram 20mg three months later.

Since then, my sleep (I also suffered from health anxiety related to the consequences of insomnia or the fear of dying from lack of sleep) and general mood have improved significantly.

However, I have recently noticed that I am very restless, have difficulty breathing, tremble, and feel dizzy immediately upon waking up in the morning. Sometimes I also have headaches and tingling/burning sensations in my hands and face. Sometimes I also have a strange feeling that rises up to my head - everything then feels somehow fuzzy/different and I'm not sure how to describe it ... I wonder what this could be - it doesn't feel like the panic attacks and anxiety I used to have. In the evenings, I usually feel much better.

- Are these symptoms of exhaustion (burnout)? How can I relatively safely determine that I am in a state of exhaustion - how does it manifest itself?
- Are these side effects of Citalopram? (Are the 20mg no longer necessary for me? Too much serotonin? Serotonin syndrome?)
- Is it possible that I need more Citalopram (should I increase to 30mg)?
- Is it still the underlying illness (whatever it may be) that is only being "masked" by Citalopram and therefore manifests differently?

When I once tried to stop Citalopram, I felt much worse after about 5 days (anxieties became stronger again and previously existing compulsions reappeared). I was also particularly anxious about a symptom that occurred both when discontinuing and when resuming Citalopram: I felt dizzy when falling asleep and saw blurry and distorted images with my eyes closed - I felt drunk. I had only experienced this once before when I drank alcohol while taking Citalopram - since then, I only drink non-alcoholic beer. How can this phenomenon be explained?

Thank you and best regards.

Dr. med. Ralf Berg

Dear seeker of advice,

What you are experiencing in the morning is most likely a so-called hyperventilation syndrome. This is not a separate medical condition but rather part of your anxiety disorder/depression. Through (conscious or unconscious) increased breathing, there are electrolyte imbalances in the blood that are the cause of your symptoms (tingling, feeling faint, etc.). By breathing SLOWLY and calmly with conscious pauses, all of this will subside.

I believe that you should be closely monitored by a psychiatrist. It should not be up to you to experiment with starting or stopping medication on your own. Please seek guidance in this matter. Both alcohol and citalopram affect brain metabolism. Taking both together can lead to unpredictable reactions. Overall, you should have a discussion with your therapist. Citalopram may not be the right medication for you. (It is usually the first choice because the side effects are generally less pronounced compared to others. However, its effectiveness in treating anxiety may not always be sufficient.)

There are many different types of medications available, and in addition to talk therapy to overcome your anxiety disorder, a suitable medication can be found for you until you have your fears better under control. It is important to have direct and consistent contact with a therapist you trust, with whom you can discuss any potential complaints. You are correct in understanding that these medications are meant to help you better manage your fears. Identifying the triggers of these panic attacks, or at least training yourself on how to handle them, is the main goal.

If your compulsions and fears become stronger, please do not immediately rule out a stay in a mental health facility. Your therapist, who knows your medical history, can best determine if this is necessary at this time. And as mentioned, your hyperventilation symptoms are not cause for concern, but rather a physical "anxiety response."

PS: Please let me know how long you have been taking citalopram. With this information, I can decide if it is too early to consider switching medications.

With best regards,
R. Berg