Xanax, Pseudoephedrine, and the Mind...

[david1968]

Does anyone have a scientific explanation for the following scenario to cause anxiety attacks?

 

A person takes 120mg of pseudoephedrine for sinus congestion daily for several months. They are experiencing physical symptoms related to anxiety (e.g. globus hystericus) and are given a prescription for 0.25 mg Xanax to be taken daily. The person takes the Xanax for 3 days and on the 4th day begins to experience short, intense anxiety attacks. The person then stops taking all medications and within about a week begins to feel much better.

 

I'm wondering how taking the Xanax could have triggered the anxiety attacks? I welcome your thoughts.

 

- David

[PhDwannabe]

David:

 

Difficult to say anything at all from a distance, thirdhand, without making some kind of more comprehensive assessment. I can think of an hour's worth of questions I'd want to ask this person to really tease things apart. So, you'll have to consider all of this quite blindly speculative and not suggestive of diagnosis or treatment in any fashion.

 

Pseudoephedrine, as you know, can cause some uncomfortable excitation or anxiety, so that's obviously sort of the first place to look here, Occam's Razor and all. Though it is, admittedly, unusual for those side effects to onset so far into treatment. And the onset of new and powerful anxiety symptoms around the time of the introduction of the Xanax does seem to suggest cause there.

 

There are some individuals who experience paradoxical responses to benzodiazapines, so there's another possibility, though it strikes me that this would also be fairly unusual, since .25mg q.d. is a nearly negligible dose of alprazolam for an adult. Nonetheless, given the story of "anxious person given Xanax, person starts getting panic attacks," it's actually a fairly decent guess. This is particularly likely in individuals already elevated "on their own"--by some mental health condition, let's say--or "artificially," as by pseudoephedrine. Anecdotally, people given an upper and a downer all at once can sometimes wig out a little bit.

 

Since the duration of useful treatment effects for such a fast acting drug--particularly at such a low dosage--is within such a small window, it might be useful to know if those panic attacks actually occurred within that window. If we're seeing attacks a few hours after dosing, I'd be inclined to think paradoxical reaction. If we're seeing them 8 hours later, as most of the drug is metabolized, I might almost suspect a mini-rebound phenomenon--essentially, anxious withdrawal symptoms from a single dose of the drug.

 

The final possibility I can think of is that the individual may have had a couple of days of useful placebo effect--three of them, sounds like--and for whatever reason (the triggering effect of some uncomfortable somatic event, let's say) that placebo effect fell off the cliff on the fourth day, and you saw not only a return to anxiety symptoms, but a bit of a rebound bounce as well. These are all my best guesses, and indeed they are guesses.

Edited October 26, 2011 by PhDwannabe

[Appolinaria]

Since you're welcoming thoughts, I can butt in with my uneducated opinion.

Every time I've taken a drug that's supposed to calm me down I get anxiety because I'm so paranoid of not being able to react properly... I feel sedated and inefficient, I feel weak and susceptible. I can register the basics of my surroundings without picking up on any other subtle cues that I normally do... and this drives me crazy.

 

After a red bull, I can guarantee I have less symptoms of anxiety than I would if I smoked 100 bowls of weed.

[matty]

David:

 

Difficult to say anything at all from a distance, thirdhand, without making some kind of more comprehensive assessment. I can think of an hour's worth of questions I'd want to ask this person to really tease things apart. So, you'll have to consider all of this quite blindly speculative and not suggestive of diagnosis or treatment in any fashion.

 

Pseudoephedrine, as you know, can cause some uncomfortable excitation or anxiety, so that's obviously sort of the first place to look here, Occam's Razor and all. Though it is, admittedly, unusual for those side effects to onset so far into treatment. And the onset of new and powerful anxiety symptoms around the time of the introduction of the Xanax does seem to suggest cause there.

 

There are some individuals who experience paradoxical responses to benzodiazapines, so there's another possibility, though it strikes me that this would also be fairly unusual, since .25mg q.d. is a nearly negligible dose of alprazolam for an adult. Nonetheless, given the story of "anxious person given Xanax, person starts getting panic attacks," it's actually a fairly decent guess. This is particularly likely in individuals already elevated "on their own"--by some mental health condition, let's say--or "artificially," as by pseudoephedrine. Anecdotally, people given an upper and a downer all at once can sometimes wig out a little bit.

 

Since the duration of useful treatment effects for such a fast acting drug--particularly at such a low dosage--is within such a small window, it might be useful to know if those panic attacks actually occurred within that window. If we're seeing attacks a few hours after dosing, I'd be inclined to think paradoxical reaction. If we're seeing them 8 hours later, as most of the drug is metabolized, I might almost suspect a mini-rebound phenomenon--essentially, anxious withdrawal symptoms from a single dose of the drug.

 

The final possibility I can think of is that the individual may have had a couple of days of useful placebo effect--three of them, sounds like--and for whatever reason (the triggering effect of some uncomfortable somatic event, let's say) that placebo effect fell off the cliff on the fourth day, and you saw not only a return to anxiety symptoms, but a bit of a rebound bounce as well. These are all my best guesses, and indeed they are guesses.

 

 

This thread has bothered me days...

 

Just curious, PhD, on an opinion...

 

If pseudoephedrine --an alpha ADRENergic stimulator--is contraindicated with maoi's, why isn't it with benzodiazeprines--a (parallel) relaxant, sedative, hypnotic anti-anxiety prescription? In the same way maois are antidepressants, benzos being an antianxiety should mean contraindication by default... You find incidence of this sort of thing all over the medical field, in every capacity of experienced physicians, why do you imagine that is???

 

Uhm, also, with a chronic sinus congestion, why wouldn't a preVENtative measure be in order, an antihistamine BEFORE the onset of congestion, and then we're dealing with a nonaxiety related supplement.-- Diphenhydramine is Over tje Counter, but get a high enough dose to tackle something so stubborn, maybe. 25mg lasts hOurs, get loe doses and seems useless but makes you a little sleep, some are resistent to the sleepiness though, doesn't bother me to much in midday but knocks me out at night.

 

Have it at any dollar store too, usually, so you can avoid $20 Claritin.

 

Not that I endorse trusting dollarstore China-exported meds who enjoy a lax system, again, without a body of oversight in the FDA, or what it should be but this med seems trustworthy.

[PhDwannabe]

In the same way maois are antidepressants, benzos being an antianxiety should mean contraindication by default

What you seem to be saying is that drugs with effect/side effect profiles that point in the opposite direction should be automatically contraindicated to take together. The answer is simple: this alone is simply not a basis for contraindication, that's all.