Drug review: clomipramine (Anafranil)

Generally amphetamine helps with OCD-spectrum symptoms (an advantage to which relatively few mental healthcare providers avail their patients), but it has an unfortunate tendency to encourage skin picking and other “body focused repetitive disorders” for some people. It turns out I’m one of those people, so I asked my psychiatrist what he recommended.

Before I reveal his suggestion, I feel the need to go off on a particular tangent. You see, I could spend all the hours of the day studying psychiatry – delving into its history, poring over its arcane trivia, hypothesizing, cooking up experiments. But I can hardly imagine a more loathsome fate than that of becoming a clinical psychiatrist, because what could sap the excitement and joy from a subject as quickly or thoroughly as the Hippocratic oath? A profession which advertises a prohibition against risk-taking as its central tenet is one that values stability over progress, bureaucracy over creativity. And when your field’s knowledge base is as underdeveloped as psychiatry’s is, you can’t really afford stagnation.

So he suggested Lexapro, an SSRI. Boring. I floated the idea of trying a tricyclic antidepressant instead. TCAs comprised the second generation of antidepressants, following the MAOIs, and were in use from the 1960s until the institution of our Great SSRI Overlords in the 90s. The folk wisdom in psychiatric circles is that there’s a negative correlation between an antidepressant’s age and its efficacy, but rather inconveniently a positive one with its deadliness, and it was decided that providing depressed patients with a potential means to commit suicide wasn’t very sensible. Now the TCAs and MAOIs were left to gather dust in the backrooms of pharmacies as second- and third-line options for treatment-resistant depression, while all the doctors went and swore fealty to their new master, fluoxetine. Yet still they knew, in their heart of hearts, that the ways of old truly possessed superior efficacy and diminished sexual and metabolic side effects.

I selected clomipramine on the basis of its reputation for OCD and its position as number three on the official SSC list of things you should try instead of whatever your doctor recommends. It’s supposed to be milder than its parent, imipramine, but the lowest dose commercially available (at 25 mg per capsule) is still subjectively pretty striking. The most immediately noticeable effect was on my sleep, as it woke me the first couple of nights after four dreamless hours, and the next couple after six. Despite this, I felt not only well but happy, a rare occurrence first thing in the morning even with adequate sleep. I concluded that the loss of the REM-heavy tail end of my sleep was likely due to the well-known fact that serotonergic drugs inhibit REM, a sleep stage that is generally disordered in the clinically depressed, and which incidentally has various theories attached to it implicating it in depression’s pathogenesis. On several occasions I fell asleep before taking my nightly dose, and on all of these I slept for exceptionally long periods of time and had exceptionally vivid and memorable dreams – “rebound REM”.

The other very robust effect was a reduction in hyperactivity and impulsivity, possibly larger than with stimulant treatment. When I was much younger I was able to read for many hours on end, and I lost this ability sometime in adolescence. I could force myself to read while on amphetamine, with frequent endogenous and exogenous interrupts. But clomipramine seems to allow me to get completely absorbed into things, rather than having to refocus my ever-errant attention back on them continually, making extended reading sessions not only possible but enjoyable. And I suspect that this quality of absorption is related to my subjective sense of the world having more “color” and “meaning”, and possibly to the fact that my initial impression of this drug was that it felt like a very low dose of MDMA. The dark side of absorption is that I have had a couple of panic attacks in the last month, one understandably after fainting for the first time ever, the other somewhat less so after a plausible but still overblown serotonin syndrome scare, both of which resulted in unnecessary (and unusual) usage of emergency medical services.

Apart from those few isolated incidents, background anxiety has been down, and my frustration threshold has raised significantly. More surprisingly, I’ve found that unpleasant sensory sensitivities are mitigated to the extent of allowing me to work to music for the first time ever, and to wear my hair down without constant aggravated fiddling to prevent it from touching my skin or pulling at my scalp. And my improved mood has caused my sociability to soar from Emily Dickinson levels to near-JD Salinger heights.

The least noticeable effect was on the very thing I requested the drug for, skin-picking, but considering all the incidental benefits, I can’t muster up too much disappointment. I’ve been on it a month, and overall I’d say I’m pretty sold on clomipramine. Having heard from a lot of people put on SSRIs or SNRIs who weren’t sure whether or when their drugs did something, I can wholeheartedly recommend clomipramine as a drug that definitely does something, even if it’s not the thing you expected or necessarily wanted. But all those little surprises are what make psychopharmacology so fun, aren’t they?

Find more nuggets of pharmacological knowledge on clomipramine and the TCAs here.

Update: It looks like I failed to mention this before, but clomipramine is an anticholinergic. Acetylcholine is a rather important neurotransmitter that does things like initiate REM sleep (I’m unsure of whether clomipramine’s anticholinergic effect is great enough to make a noticeable dent here), and chronic antagonism tends to impair learning and memory, and could be associated with dementia. I suppose one could try pairing a cholinesterase inhibitor with it, but racetams are more common, and I’ve started taking a noopept/choline complex now and again that seems to perk me up.


The atmospherics of flow

The flow state appears to be an altered state of consciousness, quite like being hypnotized. As with hypnosis, people vary widely in their inclination to it, and many seemingly trivial background factors influence susceptibility (in addition to obvious ones like medication state). Since flow is the most efficient and pleasurable state to work in, it would seem only natural to take stock of these factors in order to optimize them, and yet I hardly ever run across recommendations in that vein! Perhaps I don’t get out enough. Along analogous lines, but for a more clinical purpose, the idea of manipulating environmental conditions to modulate mental state is taken to the extreme with the Snoezelen, and I invite the adventurous to explore that more creative avenue. However, I’ve found a relatively easy and inexpensive set of tweaks that will do the job nearly as well, and so the following is a collection of recommendations based completely on my n of 1.

The first order of business is to figure out what doesn’t belong. Getting knocked out of flow is so much easier than getting into it, so rid your environment of attention vampires: movement in your field of vision, noise of all sorts but especially the high pitched variety, and what I like to call “distractables” – shiny or otherwise desirable things within easy reach that threaten to capture precious attention. Humans are the most egregious offenders, what with all their movements, and their variable pitches and rhythms, and their secondary sexual characteristics. Keep humans to a minimum.

What does belong is ultimately a matter of personal taste (and budget), but it’s typically better to delineate The Space Where Work Is Done in some way, usually with physical separation. It’s also nice if you can stick to working in that space, but if you’re hyperactive or ergonomically problematic you may find that impossible. My own work time is split between a desk in the corner of my room and my bed, because I am both of those adjectives. Even if I don’t intend to stay there long, I find that beginning the day at my desk provides the activation energy necessary to throw me into the proper frame of mind, and it has the practical advantage of allowing me to use things besides my laptop. Select your furniture on the basis of how long it will sustain a comfortable posture, and whether it allows for whatever amount of position-shifting you like, because sometimes you really do just need to sit with your entire body compacted into a tight ball. Also consider “alternative” furniture, such as kneeling chairs.

Visuals are an important component of a work space, yes, even in the 21st century when we’ve all got our heads in The Cloud. Some people enjoy the aesthetic of clutter, but it tends to make me prone to overload, and I think the vast majority of people are better off without it. I encourage tasteful (and preferably muted) decoration, and if you have beneficial associations with a particular image, color, or texture, try to include it. My most important visual elements are an analogue clock, which doubles as a medication tracker through the use of carefully placed stickies, and my calendar, which is necessary to remind me that days exist as discrete time periods, tend to follow one another, and will coalesce into weeks if they get out of hand.

The most dramatic way to control ambiance is with lighting. Light draws the eye, so make sure everything you want your attention focused on is better lit than everything you don’t. Bright, cool-toned light promotes wakefulness and is recommended if you tend toward the depressive, but those with manic tendencies may be better off keeping things dim. Especially if your workplace functions as something else, such as your bedroom, it’s good to have modifiable levels and/or colors of light, which can be done fancily with remote-controlled LED strips or dimmable fairy lights, or lamps for the lazy.

Some people like to dress up in real clothing to work, but this is unnecessary. The proper work attire is soft, doesn’t restrict movement, and is not at all distressing to tactile sensitivities. It should also provide adequate thermal regulation. And be clean.

The feeding state is a delicate balance. It is easy to over- or underfeed, neither of which are conducive to concentration. The variety matters as well: now is not the time for virtuous food. Eat stuff that tastes good, but not good enough to reminisce over, and pick something that won’t overburden your digestive tract (I’m looking at you, oatmeal). Food that is too boring will bore you, making you likelier to seek out other forms of easy stimulation, so save your virtue for dinnertime. And water! Drink water. An astounding number of people don’t replace the fluids that coffee has caused them to pee out, and then feel tired, and try to remedy it by drinking more coffee. Don’t get caught in this ridiculous loop.

Finally, and perhaps most importantly, is noise. Until very recently I preferred to work in complete silence and wore noise-cancelling headphones constantly, but an addition to my medication regimen has cured a bit of my misophonia and lately I’ve taken to listening to music while I work. This playlist is composed exclusively of tracks that are rhythmic, repetitive, and of course free of human-sounds (now and again I’ll indulge in some Sigur Ros). Ambient music, soundtracks and unremarkable classical music would also be sound choices. Noise does still tax executive function, so I prefer to make decisions without it, but once I’ve chosen a course it can set the tone, soothe anxiety and push me through tedious bits.

Most of these modifications are what you might call “facilitators”: they make it slightly likelier that you’ll enter or stay in a flow state, and tend to have an anxiolytic quality. (Flow generators are another worthy topic, but not one I’ll get into here.) The individual effect size of each of these is probably not large, but the overall effect of cultivating an environment filled with small cues that you’re supposed to be doing something productive is an excellent supplement to pharmacological aids. There may be a danger in getting too attached to such conditions – I’m unable to work effectively without them, although that was also true before they were available to me. So it’s possible an optimized workspace will spoil you for the coffee shop experience.

But I think we all know that real work isn’t done at coffee shops anyway.