I (25F) was diagnosed with Generalized Anxiety Disorder, Panic Disorder and Mood Disorder (which I believe is just depression) when I was 18.

I am on a waitlist for a neuropsychiatric assessment. My therapist thinks I have autism and CPTSD.

My thyroid has been checked and was normal and I am waiting for a sleep study to check for sleep apnea. I do wonder if I have a heart condition (three of my family members have atrial fibrillation) or postural orthostatic tachycardia syndrome. I am iron deficient and suspect vitamin D deficiency as well. I take supplements for both of these in addition to omega 3, vitamin B complex, multivitamin, magnesium, etc.

I live with a painful disease called endometriosis of which I’ve had three surgeries and have experienced a lot of medical trauma. I have been sexually assaulted twice, once by a stranger on public transit. I also live with an emotionally immature parent who is constantly criticizing, rude, negative, manipulative and aggressive with yelling and slamming things. I am working very hard on trying to move out.

My most pressing issues are:

• very physical anxiety all of the time (heart palpitations, shortness of breath, trembling freezing cold hands, nausea, gagging, dizziness, and a feeling of dread)

• panic attacks/meltdowns/shutdowns (heart palpitations, shortness of breath/hyperventiliating, trembling freezing cold hands, nausea, gagging, dizziness, a feeling of dread, dissociation, crying uncontrollably, numbness in face and hands, having trouble speaking, intense suicidal ideation, negative self talk, and feeling like I’m going to die)

• chronic depression with episodes of worsened depression (fatigued, sleeping much more, hard time with eating and drinking, hard time with showering/brushing teeth/brushing hair, hard time with attending work, isolation, not wanting to be social, lack of motivation, executive dysfunction, crying, suicidal ideation, negative self talk, hopelessness). Worsened depression happens if too many bad things happen, if my disease symptoms are worse, if my mom’s behaviour is worse, if I am hopeful about a treatment and it doesn’t help or it makes me sick, daylight savings time)

I have done three weeks of right low frequency rTMS and six weeks of bilateral (right low frequency and left high frequency rTMS) through a research study in 2022. My scores slightly improved once we started doing bilateral treatments and then dipped due to my cat almost dying. I then experienced a big depressive episode after due to having been hopeful about the treatment but it didn’t help.

I have avoided inpatient care but did go to the mental health urgent care centre in 2022. They got me connected to outpatient DBT but I was not able to attend as it was during my work hours. I have had two abandoned suicide attempts that were both me just desperately taking ibuprofen and acetaminophen and then making myself vomit right away after realizing what I had done.

I have seen a variety of counsellors who have done ACT, CBT, and EMDR. I have been working with three counsellors on a regular basis for quite a while now and have developed a good working relationship with each of them (an expressive arts therapist, a somatic-based trauma therapist, and a DBT and talk therapist). I have also used peer support in the past and am currently trying to find a way to access peer support again.

After trying several psychiatric medications that either did not help or caused adverse reactions, I used pharmacogenetic testing to see what medications might work better for me. I found that I do not metabolize any psychiatric medication normally except three antipsychotic medications, but I do not have psychosis.

My psychiatrist who I have been working with since I was 19 doesn’t seem to know what to do next and he has referred to me as a complex case. He has also referred to me as treatment resistant.

I have tried the following medications and have held out for at least six weeks for the vast majority of them except a few that were incredibly intolerable:

Amitriptyline - adverse reaction, induced suicidal ideation, worsened anxiety, panic attacks and depression (did not last six weeks)

Sertraline - helped a little bit and then no effect

Venlafaxine - adverse reaction, worsened anxiety and panic attacks

Fluoxetine - no effect

Aripiprazole - adverse reaction, induced suicidal ideation, worsened anxiety, panic attacks and depression (did not last six weeks)

Bupropion - adverse reaction, worsened anxiety and panic attacks

Citalopram - no effect

Buspirone - no effect

Methylphenidate - helped for one week and then no effect

Escitalopram - no effect

Paroxetine - adverse reaction, induced suicidal ideation, worsened anxiety, panic disorder and depression, induced brain zaps (did not last six weeks)

Mirtazapine - worked wonderfully for two weeks and then adverse reaction, very sedative, induced sleep apnea, rapid weight gain and urinary incontinence

Vortioxetine - no effect

Quetiapine - very sedative and calming and then no effect

Topiramate - no effect

Propranolol - adverse reaction, orthostatic intolerance

Lorazepam - used as needed, sometimes very sedative and calming and sometimes no effect

Clonazepam - used as needed, no effect

Fluvoxamine - no effect

Moclobemide - helped a little bit and then no effect

Diazepam - used as needed, sometimes very sedative and calming and sometimes no effect

Clomipramine - adverse reaction, increased anxiety and panic attacks (did not last six weeks)

I’m at the point now where I do not want to put myself through any more psychiatric medications as so many have either made me so sick or have not worked at all. I have thought about perhaps trying phenelzine (Nardil) or tranylcypromine (Parnate) but I know these are strong medications with some dietary restrictions which scares me a bit. I have already tried a less strong MAOI - moclobemide - which was not too bad but was stressful when trying to make sure I wouldn’t have a drug interaction when I had surgery.

I was thinking of asking to try ondanestron (Zofran) as I was given it after my last endometriosis surgery and I found it had a beneficial effect on my anxiety, maybe because so much of my anxiety is nauseating. It is a bit expensive. My psychiatrist has been willing to try off label treatments before.

I am interested in possibly Spravato or IV ketamine guided by a counsellor (which seems to be quite expensive where I live in Canada), microdosing psilocybin, psilocybin guided by a counsellor, or CBD. The problems with ketamine and psilocybin are that they are expensive, and I am afraid of getting high as I have never used alcohol, marijuana or any other drugs before. If I were to microdose psilocybin, I wouldn’t know where to get it or how to microdose.

I just feel very lost and confused. I don’t know how accepting my psychiatrist would be of the above. He seems a bit old school and he doesn’t seem to know what to try next.

Any guidance would be very appreciated. Thank you.