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Urgent timeline for response...What is best SSRI with least side effects.. and chest CAT Scan VS Chest MRI

Thank-you for responding about Cymbalta ?.  I am still slightly delaying starting any SSRI/SNRI med until I can research them further & to please obtain valuable feedback from you, as you are an expert in this field. I started on Thurs Clonazepam 0.5 x 2-3 tabs a day & it is definitely reducing my high anxiety/stress feelings & somewhat my mid chest/back pain tight breathing symptoms/insomnia. I am off of Ativan.

I am intrigued about 4 SSRI meds with the least possible side effects, especially reduced sexual ones & no weight gain, which many seem to actually promote. Do any SSRI help with pain reduction?  How is Zoloft, Lexapro, Prozac, Celexa vs Cymbalta in these regards? I am so confused with all tyhe med choices.  I have picked up the Cymbalta at 1 tab 60 mg a day, but I want to make sure I should be on an snri as opposed to ssri prior to starting one. Is Cymbalta 60 mg dose safe to start?

I have had some extensive tests to try & find a physical cause of my mid-back & chest pain/tight breathing sensations. Chest/abdominal/ CAT SCAN/Dye, Bone Scan, Nuclear stress test, Stress test, Gastrocopy, Detailed blood work, Thoracic spine MRI, Chest X Ray, Abdom Ultrasound. My Dr. says he has done all of the appropriate tests & then some. I asked for an echo-cardiogram & he said no because of the normal stress tests and also no to a chest MRI. He says the Chest CAT SCAN is better than a Chest MRI, except for things like identifying MS (e.g nerve issues) Do you feel I have had a very solid work-up that has eliminated chest/abdominal cancer and heart disease, as a cause of my pains. Is a chest CT as good as a chest MRI. My Dr. says there is no way I have cancer or heart disease causing my pain because these tests would  have detected these diseases.  Would I benefit from other tests e.g Chest MRI or echocardiogram Or should I finally let go of my cancer fears from this chronic pain.

Thanks again Dr. Junig.  My Dr wants an answer on ssri/snri by Wednesday afternoon

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666151_tn?1311117976
I'm sorry for the delay-- I have been off the site for awhile catching up on some things.  Let's see... as for the cancer fears, yes, absolutely, it is time to let them go.  Your symptoms don't sound like cancer, and the testing would have found a mass or tumor had it been present.

As for the medications, psychiatrists tend to see the SSRIs as having equal potencies, and the SNRIs as having higher potencies (but all about equal to each other).  We pick the meds mostly based on side effects;  for example paroxetine causes sedation and weight gain, and prozac causes activation and a bit of weight loss.  Citalopram is weight and sleep neutral in most people.  All SSRIs and SNRIs have sexual side effects, EXCEPT perhaps Pristiq, a new SNRI that has very low incidence of sexual side effects in the one or two trials that have been done with the medication.  On the other hand, I don't know why it WOULD have lower sexual side effects, so I take the findings with a grain of salt until we see more studies.  Cymbalta is the only SNRI that has been shown to reduce chronic pain, but the effects are subtle, and I think most psychiatrists assume that all SNRIs are similar in that regard.  I think Cymbalta is a good choice;  starting at 30 for a few days and then going to 60 might cause a bit less initial nausea, but if you take it with food the nausea should be minimal, even at 60 mg.

The MRI findings are interesting, especially the disc protrusion at C6-C7.  Usually, cervical disc herniations push into the 'foramen', the opening where the nerve leaves the spinal cord, putting pressure on the nerve that causes pain down the arm.  Your protrusion is more central;  it is possible, I suppose, that the bulge is pushing against the posterior or 'dorsal' spinal cord, as that would be right under the disc in that area.  The 'dorsal columns' run on the dorsal surface of the cord;  they carry sensation from the legs, and as you move higher also from the chest and arms.  The thing is, the sensations carried in those pathways are touch and vibration sensation, not so much pain sensation. Pain sensations are carried by pathways deep within the spinal cord called the 'spinothalamic tract'.  If you specifically lost vibration sense in the area of your chest (tested with a tuning fork) that would be an interesting theory;  I don't know if it has any relation to the pain.  

On the other hand, a disc bulge putting pressure on the spinal cord could probably cause all kinds of odd sensations and symptoms.  The classic danger signs for cord compression would be incontinence, weakness in the legs, and maybe some sensory loss below the involved level-- similar to a spinal injury at the same level.

I think cymbalta is a good place to start-- for the anxiety as much as for the pain.  Hopefully you will wake some morning and the pain will be gone-- that would not be real unusual.
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881463_tn?1245349249
My blood work to date with normal results are Lipase, Amylase, CBC, CRP, ESR, LDH,  Uric Acid, Creatinine, Protein electrophoresis, ana panel and RF were (negative) Magnesium, Calcium,  Chloride, PTH, all Lytes, Albumin, INR, HBAIC sugar control test, BUN, Plasma 2 hr Blood test to rule out diabetis, normal, lactate,  Triglycerides, Cholesterol, TSH, T4 free, LDL  (HDL Slightly low), Ferretin, B12, Glucose, 4 Heart blood panels and ECG's, urinalysis.

(AST, ALT, alk phos Liver fraction are slightly high due to a benign fatty liver. An HIV HEP B and Hep C Ghonorhram Chlamidya tests I had last August were all negative

Last pending Blood work done today is: Immuno-electrophoresis & another CBC/ ESR, CRP blood test.

When all is said and done I want to be on the right SSRI or SNRI & an anti-anxiety medication, offset by seeing my psychiatrist to help me deal with chronic pain and the hypochondriosis fears of diseases, psychosomatic problems, depression, anxiety and stress and panic attacks I suffer from.

Please be as up front as you possibly can be about the med options and especially tests that I have had to date. My Dr. is completely adamant that I am done with testing and  there arent many other tests even available and an echocardiogram and chest MRI wont make any difference after all the normal tests I have had to date. He promised me at this time based on all the diagnostic and blood tests his expertise, physical examinations that I don't have cancer or heart disease causing the mid chest or back pain.

I really  want to let go, take my meds, see my psychiatrist, work on pain fears and control and be happy with life again because i have been so worried and miserable the past 2 months, What do you think Dr Junig??

Thanks again.

      
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881463_tn?1245349249

My last set of blood work was okay,  including the immuno & protein electrophoresis blood work & the repeated CBC, ESR, CRP, CBC, LDH, CK, T4 Free, Creatinine & urinalysis. Even my liver enzymes that are usually elevated due to a benign fatty liver were almost normal.

Turns out after all the tests I have had in the past 7 weeks (See above) I will be having two more. Even though I passed two stress tests (One Nuclear) I pressed for and am having an echo cardiogram Ultrasound today. Dr. Junig, I know I have some other important questions pending(above) but is this a Ultrasound of the heart a good test and if the nuclear stress test  was normal is this test likely to find any problem that the Nuclea/treadmill might not have detected.  

I also yesterday had an Spiro LFT test (Last one 6 years ago), as I have asthma and besides the mid-chest & back pain I get these tight (non asthma related) breathing sensations)..Results pending

My Dr. really wanted me to make a decision on the SSRI/SNRI options today, but I have put it off until Monday, as I value your opinion & the questions listed above are very important to me when trying to choose one of these meds, as well as determining  the work-up I have had is sufficient and if there are any other tests that should be considered for my pain/tight breathing. Is it possible to develop this type of chronic pain without a detectable physical cause given all of the normal tests and that most oif it is psychosamatic pain and or fibromyalgia? I wish I wasnt so worried still, as all of the tests to date have been good/normal

Thanks again
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881463_tn?1245349249
Hi Dr. Junig

Sorry for all of the latest questions in this post with the above comments, which are really important to me, as I try hard to prepare to move on with Psych meds & psychiatric counseling.  I would really appreciate your review of these posts and detailed feedback on them as soon when you have some time, especially about any further thoughts on further testing suggestions chest CT vs chest MRI etc. Nuclear heart scan VS the Echo Cardiogram I just had done (See above posts) and the important SSRI/SNRI questions.

Do you think I have been very well tested and should feel very confident that there is no heart disease or cancer causing my chest and back pain? This is my biggest fear.

I really want to let go of the crippling worry about my pain and  thoughts of cancer & heart disease and have no more tests, as I have had so many and can't take the high anxiety feeling of waiting for results.

Based on all my comments/questions in this post & the tests that I have had etc should I truly finally accept that for whatever reason I have developed chronic mid chest and back pain with tight breathing sensations from an undetermined origin, but not caused by anything serious (Malignancy/heart disease) and embrace this and move on to the next phase away from my Family Doctor and the testing phases to e.g Depression/anti anxiety Medications and seeing a psychiatrist on a regular basis to deal with the pains that really frighten me and my anxiety, stress, depression hypochonriosis and Somatization disorders.

This theory is interesting about my pain and it may be nothing, but worth asking you about, as I wonder if it migh possibly be causing my mid-chest and back pain. My recent Thoracic MRI was normal, however in January 2009 I had a Brain & Cervical Spine MRI. The Brain MRI was normal, however my cervical MRI shows the following: C2 Unremarkable, C3-C4- Mild Diffuse Disc Osseous bulge.No stenosis.  C5-C6 Mild Diffuse disc osseous bulge.No stenosis. C6-C7 mild broad based left paracentral disc protrusion. This extends approx. 4 mm into the central canal with mild stenosis. C7-T1 is unremarkable.

Impression: Mild disc bulges and a small disc protrusion of the cervical spine with no significant stenosis.   Question: Could these be hitting nerves in my neck and referring pain into my mid chest and back??  

I had my last two scheduled tests, a  Spiro Lung Function test & A Heart Echo Cardiogram yesterday (June 10) and the results are pending for about a week causing me more anxiety.

No other diagnostic  tests are scheduled & My final set of blood work from June 8 was normal including Protein & Immuno-electrophoresis (No M protein was detected)

This will be my last sizable post to you and I appreciate your answers/responses to date and would appreciate as much feedback as possible on these questions in this post that you can provide, as there are quite a few. Again sorry for the length of the posts.

Thanks again for everything Dr, Junig, I have really appreciated your help, expertise and feedback over the past month.

Mark
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881463_tn?1245349249
Hi Dr Junig,

I was hoping and would be appreciative if you could respond to the questions in this post, which are really important to me and have utilized 5 comment sections including this one.

I am delaying taking an SSRI or SNRI until I hopefully receive a response. I also have a few other questions about  a chest Cat Scan VS a Chest MRI, the tests I have had to date and any further testing suggestions or should I just accept I have chronic pain move to the next phase of medication and seeing a Psychiatrist. I want to move on and stop worrying about my chest and back pain and the heart and cancer worries caused by the pain and my apparent somatization  disorder, hypochondriosis, anxiety and depression conditions

I have tried to send a one question post with everything in it, but it states the daily question limit has been reached.

Thanks again for your help, much appreciated
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