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What Causes Anxiety And Panic Attacks While On Amitriptyline And Nortriptyline?

Posted on Mon, 17 Jul 2017

Question: Hello! I have been having severe anxiety w/panic attacks. Tricyclics have worked best 4 me in the past, but now amitriptyline & nortriptyline are giving me tachycardia. Any ideas why? SSRI Zoloft caused me to have a sudden increase in anxiety & lasted 30 hours before finally clearing my system. Any idea what would cause that?

Answered by Dr. Seikhoo Bishnoi (33 minutes later)

Brief Answer:
This could be due to anticholinergic actions.

Detailed Answer:
Hello thanks for asking from HCM

I can understand your concern. Amitriptyline and Nortriptyline both are associated with anticholinergic side effects. This action is responsible for rapid heart rate and thus resulting in sinus tachycardia. Though its not possible to find clear cut reason why these drugs are resulting in tachycardia now while they worked in past, but this can be avoided by starting with low dose and then gradually increasing the dose of the drugs. Addition of beta blockers like Propranolol or Atenolol along with these drugs can also become a good option. This will reduce the sympathetic outburst and will reduce the heart rate.

You can discuss with your doctor for either of these options. Also get your blood pressured checked, low blood pressure could result in tachycardia and this could be the reason for the symptoms you are having.

Thanks and Take care

You are welcome to ask follow up doubts.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Seikhoo Bishnoi (3 hours later)

Thank you, Dr. Bishnoi!

Thank you for your explanation on the tachycardia.

When prescribed Zoloft, I had a response like akathisia for 30 hours. Any idea what would cause this & if anything could be prescribed to counter act the 'start up' phase of increased anxiety that SSRIs can cause in some patients?

Answered by Dr. Seikhoo Bishnoi (5 hours later)

Brief Answer:
SSRIs cause increase in anxiety during first week of therapy

Detailed Answer:
Hello again

Zoloft is a SSRI drug and is one of safest SSRI drug. But when ever any SSRI drug is started the drug causes slight worsening of anxiety symptoms and also akathisia especially during first week of starting the drug. This happens because of immediate blocking of serotonin receptors and thus causing serotonin deficient state. With time (1-2 weeks) the drug blocks other receptors which reduce the uptake and thus improves serotonin neurotransmission and this is the explanation of the effects of the drug.

This can be prevented by reducing the drug in very low dose like Zoloft with 25 mg and then increasing the dose to 50 mg after a week and doses can be increased more after one more week. Gradual dose escalation will prevent rebound increase in anxiety. Starting with low dose Clonazepam or Alprazolam is another option which will minimise the side effects. Even Propranolol can be used in 10-20 mg while prescribing a SSRI and this will prevent akathisia.

So you can talk with your doctor for these options. I used slightly difficult medical terms just to explain you about the mechanism of action. If you need to clarify anything you can ask again.

Thanks and Take care

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Seikhoo Bishnoi (3 hours later)

Dear Dr. Bishnoi,

I follow what you are saying, I love the details & I thank you for answering my questions so promptly.

Answered by Dr. Seikhoo Bishnoi (9 hours later)

Brief Answer:
Thanks and Take care

Detailed Answer:
Hello again

Thanks for your kind words. You can contact again if you have more doubts.

Take care

Note: For further guidance on mental health, Click here.

Above answer was peer-reviewed by : Dr. Prasad