by Julie Santall
Judy (not her real name) walked into my room clinging to the arm of her partner. A tall elegant looking woman of 69, she appeared frightened, vague and uncertain. She sat down in the chair and did not let go of her partner’s arm. I noticed immediately her dependence on him and his ambivalence toward this dependence, as the session commenced it became apparent that he was in fact impatient with her. She did not seem to notice and every time he moved away, she reached for him more. Judy had brought her partner for support, however it was clear that he wasn’t helping.
Judy had been referred to me by the local Wellness clinic. She had been seeing a psychiatrist who had initially started her on Cymbalta, a Selective Norepinephrine Reuptake Inhibitor (SNRI). The theory behind SNRIs is based on the “monoamine hypothesis” of depression. They block the serotonin transporter (SERT) and also block the norepinephrine transporter (NET) in the brain. In theory this increases signalling in certain brain circuits including the limbic system (mood), the prefrontal cortex (attention and regulation) and the descending pain pathways in the spinal cord. However, the true mechanism of antidepressants and antipsychotics are unknown.
In Judy’s case, she had been prescribed over 10 yrs ago and originally was on 30mg. she had had one attempt at coming off the drugs several years ago and had successfully come down to 5 mg but had reduced the last 5 mg to 0mg to quickly and had withdrawal symptoms, and because she had felt so ‘awful’ she had gone back to her Dr who had put her back up to 60mg Cymbalta, he then reduced to her to 30mg and started her on Lexapro 30mg which is an SSRI (Serotonin Reuptake inhibitor) to ‘assist’ the withdrawal. Her pharmacist was concerned about serotonin syndrome which had cause Judy a great deal of worry. (Serotonin syndrome (SS) is a potentially life-threatening drug reaction caused by having too much serotonin in your body. It most often occurs when two or more medications that affect serotonin levels are taken together. It usually resolves when the medications are stopped. However this is where the complication lies, because you cannot just stop psychiatric drugs).
This led to her using Chat GPT to examine every symptom she was experiencing which further compounded her fear.
In effect what she was dealing with was a too rapid withdrawal from psychotropic drugs, multiple prescribing with drugs interacting with each other and giving rise to anxiety, poor sleep, and ultimately akathisia.
(Akathisia is a movement disorder that causes an intense, inner sense of restlessness and an overwhelming urge to move — especially in the legs. People often describe it as feeling like they can’t sit still or must constantly shift positions. It’s most commonly a side effect of antipsychotic medications, but can also occur with antidepressants, anti-nausea drugs, or withdrawal from certain substances. While not life-threatening, it can be very distressing and may lead to anxiety, agitation, or even suicidal thoughts).
Judy’s brain had over the years adapted to the drugs she had been prescribed. Called Neuroadaptation, the receptors change sensitivity, the neurotransmitter systems recalibrate and if the client is withdrawn too quickly, which had been the case with Judy back when she was anorexic in her 20’s and then again when she had withdrawn from Cymbalta too quickly at the advice of her prescribing doctor. Unfortunately, her psychiatrist had assumed, as many do, that her withdrawal symptoms were a sign of relapse and he immediately put her back onto 90mg Cymbalta.
Withdrawal Vs Relapse- The Key difference:
Withdrawal symptoms typically begin within days of a dose reduction and include physical symptoms such as dizziness, nausea, electric sensations in the body and brain – brain zaps, insomnia and akathisia. They can also cause violent thoughts. Often they will resolve if the drug is reinstated to the last dose where the client was stable. However rapid increases and decreases in drug dosage, adding other drugs and sometimes supplements can cause what is called kindling.
Kindling is a phenomenon where repeated cycles of substance/drug use and withdrawal make each subsequent withdrawal episode more severe — even if the person is using the same or smaller amounts of the drug.
It’s most commonly seen with alcohol and benzodiazepines, and now in psychotropic drug withdrawal and is thought to result from long-term changes in brain chemistry and neural sensitivity. Over time, the brain becomes more reactive to withdrawal, increasing the risk of seizures, delirium, or other dangerous symptoms.
Relapse typically develops gradually weeks to months after stopping. The symptoms mirror the original presentation, in other words they return to baseline prior to the introduction of drugs. It does not improve with a dose increase.
Judy stated that she was feeling very anxious and her memory and cognition were compromised. She had been back to her psychiatrist and he had started her on propranolol (a beta blocker, commonly used for helping to lower blood pressure but many doctors use it to address anxiety as it slows the heart rate.) and then because she had complained of not being able to sleep he had put her on Olanzapine, a drug commonly use as an antipsychotic. Olanzapine blocks dopamine receptors and serotonin receptors and also works on the histamine receptors which gives rise to sedation at low doses of 1-2.5 mg. He had started her on 5mg. This then led to morning sedation which she complained of and she went back to the psychiatrist who put her on Dexamphetamine 10mg in the morning to help with the morning sedation caused by the Olanzapine.
All of these drugs were now working antagonistically in her system to create increased agitation and increased anxiety. If I went into the complete list of how these drugs interact with each other here, I would fill another 2 pages. Suffice to say, I did and it was clear to me why she was in so much discomfort.
Judy had explained that in 2008 she was not on any medication, was working as a social worker in an adolescent Mental health Unit. She had 4 adopted children, one child who is neurodiverse with autism and was doing this alone. She had never married and used work as a means of escaping the heaviness of the responsibility at home. She told me that she had been her mother’s confidant and ‘friend’ and had helped her mother a lot as a child. She had been anorexic between the ages of 16 into her early twenties and had been prescribed antidepressants then. She couldn’t remember which one but knows that she had come off them cold turkey and had experienced withdrawal affects then.
Judy had been using red wine to manage the overwhelm and had been admitted to a detox program which is where she met her psychiatrist and had started the Cymbalta.
Already Judy had had one attempt to withdraw from the Cymbalta, her psychiatrist, following the (pharmaceutical) guidelines, being that withdrawal affects are mild and self-limiting and can be done in a linear fashion, had reduced her rapidly from 60mg to 30mg of Cymbalta. This fact was significant when we consider the kindling effect. I knew that she would have to be tapered very slowly to minimise any further withdrawal effects.
Judy’s brain had not only become dependent on the drugs, she had also experienced too fast drops in dose which had put her at risk of kindling and it was clear that she would find it difficult to be with any sort of discomfort.
Judy had described the symptoms of ‘PTSD” she had discovered from a mindfulness exercise she had done at a workshop in 2008. When questioned further it became clear that it was the uncomfortable feelings and emotions underlying her experience, that she had found difficult.
The “PTSD” was the sudden realisation that she was in fact overwhelmed. Up until then parts of her had masked this awareness with work and wine.
The difference between dependence and addiction:
“The term “dependence” has traditionally been used to describe “physical dependence,” which refers to the adaptations that result in withdrawal symptoms when drugs, such as alcohol and heroin, are discontinued. Physical dependence is also observed with certain psychoactive medications, such as antidepressants and beta-blockers. However, the adaptations associated with drug withdrawal are distinct from the adaptations that result in addiction, which refers to the loss of control over the intense urges to take the drug even at the expense of adverse consequences (764)”
Drug Addiction vs. Drug Dependence
These two terms are often used interchangeably, but they refer to distinct concepts:
Dependence is a physiological/biological response to a substance. It means your body has adapted to the presence of the drug and needs it to function “normally.”
The key characteristics of dependence:
- Tolerance: You need more of the drug over time to achieve the same effect
- Withdrawal symptoms: Physical symptoms (sweating, shaking, nausea, etc.) appear when you stop taking the drug
- Can occur without addiction — for example, a cancer patient taking opioids for pain may become physically dependent but not addicted
- It is largely a medical/biological phenomenon
Addiction is more psychological and behavioural
Addiction is behavioural. A part of us has learned to put out the emotional fires by numbing with a substance or a behaviour. It involves compulsive drug-seeking and use, or compulsive behaviour despite harmful consequences. In holistic counselling or Internal family systems language would you call this part a ‘firefighter’ – the part in the middle of our ‘manager’ part that presents to the world and a part that is ‘exiled’, wounded or traumatised.
The key characteristics of addiction are:
- Loss of control over drug use or compulsive behaviour (like playing video games, online shopping, sex/porn, eating etc…
- Compulsive craving and urges
- Continued use despite negative consequences (health, relationships, work)
- Often involves psychological dependence (feeling you need the drug or behaviour to cope emotionally)
- It is both a psychological and social phenomenon.
In Judy’s case, her brain had become dependent on the drugs she had been prescribed.
The Brain’s Adaptation to the Drug
The brain becomes dependant on a certain level of the drug.
In the case of opiates, someone can become addicted to an opiate because of the feeling it gives them. Heroin users will continue to ‘chase the dragon,’ the bliss of the first hit to escape from emotional pain. After a while the body becomes dependant on that drug. They never experience the absolute bliss of the first hit, and as tolerance builds, it leads to the ever-increasing doses and the subsequent risk of overdose.
Someone in severe pain will take, for example an opiate pain killer for the physical pain and perhaps enjoy the relaxed feeling they get from the opiate. They start to take the drug when they don’t have pain, just for the feeling, after a while they find they can’t stop. What started as an addiction- ends up as a dependence.
In the case of anti-depressants and anti-psychotics, the body/brain becomes dependant on the level of drug in the brain’s receptors. I use these names (antidepressants etc) as this is the common language around these drugs, in reality they are neither. They are not discreet and they do not specifically target ‘depression’ or ‘anxiety’, what they do is sedate, or numb emotions by changing the chemistry of the brain.
The ‘chemical imbalance in the brain’ theory of depression was a marketing tool used by Eli Lily in order to sell the drug to psychiatry and the general public (see “Anatomy of an Epidemic” by Robert Whittaker, 2010 Crown Publishing Group).
Ironically it was discovered that the drugs create the chemical imbalance rather than there being a chemical imbalance in the first place.
The brain, striving for homeostasis, blocks its receptors in order to become less sensitive to serotonin in the case of SSRIs or Norepinephrine in the case of SNRIs , or dopamine in the case of antipsychotics. This then is dependence. The brain becomes used to the drug and via neuroplasticity, changes to accommodate.
Judy wanted to come off her medication however to be successful and to minimise withdrawals she would need to taper hyperbolically. This would address the physiological symptoms with the aim of minimising the potential withdrawal effects in the body, giving her the opportunity to begin to work on the emotional and psychological effects of the inevitable feelings she would begin to experience once the receptors emptied.
Hyperbolic Tapering
MRI’s have shown that the receptors in the brain can become almost fully occupied with the drug at small doses. Hyperbolic Tapering addresses this:
- Instead of reducing by, say, 10mg every week (linear), you reduce by a smaller and smaller amount as the dose gets lower.
- For example: 40mg → 20mg → 10mg → 5mg → 2.5mg (each cut is half the previous one). Or we can reduce by 10% of the last dose each time with periods of holding in between in order to allow the brain to stabiles and find homeostasis.
Why does this matter?
At lower doses, the drug has a disproportionately larger effect on brain receptors. Therefore a small cut at a low dose can feel just as intense as a big cut at a high dose. Hyperbolic tapering accounts for this by making the steps progressively smaller near the end.
Below is a picture of the hyperbolic curve in antidepressant tapering. As you can see, the receptor sites are mostly full at a low mg of the drug. This means that adding extra doses has no effect on symptoms. However, on the way down, even a small drop in dose has a big effect on receptor occupancy. In real life, this shows up as intensely uncomfortable withdrawal effects when someone drops from say 5mg to 0 in one go.
In his book ‘Crossing Zero’ (2025), Anders Sorenson explains the receptor occupancy/dose relationship. For example, at only 20mg of Prozac – 86% of the brain’s receptors are occupied with serotonin from the drug. This means that the smaller the dose the greater the impact it has on the brain. Mark Horowitz and David Taylor also describe this in their comprehensive book ‘The Maudsley Deprescribing Guidelines’ (2024)
In this interview Mark Horowitz discusses the difference between withdrawal and relapse, the effects of long-term antidepressant use and the role of clinicians and peer support in de prescribing and hyperbolic tapering.
Judy had been using work, wine and eventually psychotropic medication to move away from painful feelings. That’s natural, we all dislike emotional and physical intensity. However, her journey of tapering would mean that these feelings would surface, and our role as counsellor, is to assist the client to begin to be with these feelings, to understand that they are not ‘broken’ and that it is possible to manage the physical symptoms by learning techniques to be with them and understand the parts of her that had learned to protect her in the way they had.
Antidepressants numb all emotions; they do not address the underlying causes of why someone would be feeling that way. Judy had never really looked at what had made her adopt 4 babies, 1 every 2 yrs at aged 25 whilst still living with her parents. She had never stopped to question why she had stopped eating at 16 years of age. She had never questioned the fact that she worked a full-time job and then came home to look after 4 children one of which was smearing faeces over the walls and not sleeping due to autism. She drank and eventually was prescribed a cocktail of drugs that have caused Iatrogenic damage. (Iatrogenic damage refers to harm caused by medical treatment itself).
For Judy to be successful in her tapering she would need to learn to be with and understand the impatient parts of herself and the parts that are intolerant of discomfort and befriend them, along with the grief of losing her functional self. In her attempt to numb out her overwhelm in her life, she has now become dependent on government assistance to be able to function.
In his book “Anatomy of an Epidemic” (2010) Robert Whitaker summarises a World Health Organisation study (1998) showing that people diagnosed and treated with psychiatric medication for depression had worse outcomes than those not exposed to drugs.
He also says that studies showed that people not treated usually resolved and went back to their life as a functioning member of their community whilst those treated with drugs often became lifelong patients.
Drugs will mask symptoms, but it won’t remove the underlying life causes that perhaps gave rise to the anxiety, sadness, grief , shame, fear or worry. Our emotions have been categorised and reduced to numbers on a scaling sheet in the psychiatric realm to then medicate accordingly! Anger turned inwards becomes depression, burnout becomes anxiety fear becomes sleeplessness rather than messengers or ‘parts’ of us trying to be heard. Drugging them may feel like a relief, however it ignored the innate wisdom of the body and what the emotion or symptom points to either systemically in the family system or in relation to dealing with trauma.
Judy manages the effects multiple psychotropic drugs and of tapering too quickly. Her journey so far has been challenging as she is unable to be with any discomfort in her body. We have been working with finding physical resources that will help her body to find safety. Judy has never learned to be with her body sensations that do not overwhelm her rather than overworking, using wine and being the mother to 4 adopted children as a means of escaping her own discomfort.
In her desperation to be free of the drugs she is taking and their side effects, she has not adhered to the tapering plan her integrative doctor and myself developed for her. She did not hold at the first 10% drop because she thought she felt fine and dropped too quickly. She is now blended with the parts that are terrified of the body. This psychological and emotional response is compounded by the sensitivity of her now kindled brain and nervous system. There is no drug she can take to alleviate the symptoms because now, anything she takes will impact her nervous system. The unfortunate reality of a kindled nervous system is that the only way out now is to learn to be with the sensations.
Judy has also developed cognitive issues with the amount of drug changes and additions her psychiatrist has made. Her situation is also compounded by the fact that her partner, despite being given the information around withdrawal symptoms, blames her and is aggressive towards her. This will also be having an effect, through the attachment wounding, lack of true safety as he now, via her subconscious, is her primary caregiver and as such her body, via neuro-ception, will not be feeling safe with him. Her memory is poor and even when she writes things down she is unable to remember what we have discussed and her go to when she is overwhelmed, is to ring her psychiatrist and since he only has a hammer-drugs- every symptom she brings to him is a nail.
My main focus with Judy (and any client withdrawing from any substance) is to predominantly find resources, in other words, how can they find a small window of peace in the body and mind? Only then then will they be able to do the deeper work of understanding themselves as opposed to using substances to numb their reality.
Judy’s story continues, and I hold for her the knowledge that this can be a journey of understanding herself as opposed to a disaster. I have worked with people who have successfully tapered from their medication… I am one of them. Judy’s story is extreme and highlights the sometimes difficult withdrawal from dependence on the system. It is not hopeless; the journey is as individual and unique as we all are. Many people successfully wean from their medication if the taper is slow, client led and supported.
References
O’Brien CP, Volkow N, Li T-K.. What’s in a word? Addiction versus dependence in DSM-V. AJP. 2006;163(5):764–765. [DOI] [PubMed] [Google Scholar] In this article “Drug Dependence is not Addiction – and it matters” https://pmc.ncbi.nlm.nih.gov/articles/PMC8583742/#CIT0006 The authors highlight the dangers of conflating addiction with dependence.
In many cases someone prescribed opiates will be stigmatised as being addicted to the drug and Dr’s, mindful of liability, will withhold the drug which will inevitably lead to withdrawal. However, dependence AND addiction can be present in the case of opiates. Having this understanding helps us to see where our clients are when they present with issues around drug use.
Crossing Zero (North and Vale 2025) Anders Sorenson
“The Maudsley Deprescribing Guidelines” .(Wiley Blackwell 2024)
“Anatomy of an Epidemic” (2010) Robert Whitaker summarises a World Health Organisation study (1998)
Further Reading
Farmer, Adele ‘What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications’ https://pmc.ncbi.nlm.nih.gov/articles/PMC7970174
