NOT DONE YET, WILL BE PRETTIER, SHORTER AFTER DRUGS NOW PUBLISH CAT-PROOFS
It's like people know I have nothing to do on a Friday night but eat cold leftovers with my dog and type on the internet (there is also a cat. Not that one, no).
First thing to clear up: you are not "low" on serotonin. No one is, and I can't even imagine what that would look like, other than extreme constipation and death (which is the same for "high" serotonin). That misconception, at least, is not Stahl's fault, but probably Zoloft marketing with that sad blue gumdrop-thing, and the graphic of two dumbells with a bunch of dots swirling around. The monoamine theory of mood disorder, in bad PowerPoint. Eat some Zoloft and the dots swirl faster and the gumdrop now looks more pathetic but hopeful, and it is partly cloudy outside.
SSRIs don't make more serotonin where there wasn't any before (for the most part, lots of **); they primarily just make it stick around between cells longer, which has all kinds of consequences that aren't even known to be misunderstood yet. For now, look at it as not about the levels of chemicals, and all about the signals they carry. If the cable goes out, it's not because Comcast ran out of internet, IOW.
Second thing--my personal opinion, worth it's weight in electrons making your screen glow, except the parts that are fact--
there's psychiatry and there's neuropharmacology and then's there psychology and schools of therapy and then Dr. Phil. Your doctor will belong to one of those categories and treat you based on the schools of thought she was trained in. Thus, someone like me may:
- have a Social Anxiety Disorder, with its own treatment (medications) and prognosis (life on medications);
- or, have an Avoidant Personality Disorder, who can only hope a lifetime with a (expensive) therapist will at least help alleviate some suffering.
Likewise there is
Obsessive Compulsive Disorder, and
Obsessive Personality Disorder. The personality disorders (PDs) all seem to have many many subtypes and come from old-school sit-on-the-couch and talk-about-your-mother and why you wet the bed still. There's a subclassification based purely on speculation and case studies for every graduate thesis, probably.
The other disorders seem to come from old-school medical curricula and thus lend themselves more readily to drugs. Two convergent fields, impinging on actual science. One sees imbalanced chemicals and clinical trials, the other sees thoughts and lots of talking about thoughts.
I bring this up because you, OP, are probably being placed into the Obsessive PD side, rather than the OCD medical side. One needs Cognitive Behavioral Therapy, the other needs Paxil.
This is based entirely on misremembering a This American Life episode, and Harper's and New Yorker articles on the obsessively lovelorn (I'm a believer in PDs despite a reduction to a SNP in some unknown receptor promoter region; same etiology for several delusional disorders). And I'll throw in Bowe Bergdahl, who gets a Schizotypal PD diagnosis on the TAL-knock-off whatever it's called radio program.
I would just like you to remember at all times that your treatment may be completely different just by changing the letters after your doctors name. It's not always about just which pill you should take, one approach isn't necessarily more correct than the other, either.
THING THE THIRD: you know what else causes sexy thoughts and obsessions and delusions? Stimulants, of the Adderall mixed amphetamine salt type. That was a long time to be on stimulants when it's not that weird for people to get obsessed about a specific person to the point of restraining orders anyway. The term of the art there is Crazy Ex, no need for psychotropic medication or therapists (usually). (No I'm not calling you a restrained psychotic ex, OP, I'm just picturing it, hypothetically, for this third point.)
The segue to fourth thing includes psychotic people and how they shouldn't go near weed ever. But you haven't said anything about psychoses, so smoke on, far as i know.
But you're taking too much stuff, and with the stims and opiates and benzos, are set up for raging addiction problems if they're not there already. Maybe sex addiction too--instead of conscientious compulsive anankastic personality disorder you just
really like fucking. Given all the people-and-substance focusing you might want to stick with the dopamine antagonists like you are now (and avoiding opioids and gabaergics).
Post Two word salad tossing frequency increasing as the loaded bowl stares back ever more impatient:
What's funny is that venlafaxine is on the shitty end of the selectivity spectrum. Of the SSRI's, all of them are going to be, as the name suggests,
selective for SERT over all other brain targets, to a degree that vastly exceeds most other psych meds. The rest are a mash-up of some dopamine antagonism here, some adrenergic there, a lot of potent antihistamine, with a weird imidazoline or orexin now and then. Basically escitalopram/Lexapro, even if it's ultra-super-duper selective, isn't going to be clinically better than the super-selective sertraline.
Did you know that sertraline/Zoloft has the same affinity for the dopamine transporter as methylphenidate/Ritalin? (And a whole lot more than bupropion/Welbutrin or venlafaxine/Effexor.) But nobody's getting hooked on Zoloft, because it prefers the serotonin transporter nearly 100-fold more. The amount needed to affect serotonin is 1% of what's needed to have a cocaine/Ritalin feel.
A lot of meds like mirtazapine will block some dopamine, adrenergic, and serotonin receptors in different ratios, but sadly at only 1-10% of what they do with histamine or cholinergic receptors. So to get an effect on the systems you want, you're going to be doped into a no-memory coma.
Every SSRI works the same way; the differences are in side effects and dosing schedules. I'd have to dig through pay-wall clinical results, and I bet you can find metastudies comparing all the SSRIs with some slick ANOVA and finally a p>0.05, that says which one is best for what. And I bet none of the metastudies agree very well, or have too many asterii--because they all do the same thing, which is very little other than make sex dull.
I don't know why you think Paxil has the most sex side-effects. Some people think it has the worst discontinuation, before venlafaxine came to market. I don't think there's much to any of it, and comes from some bad press for Paxil over bad marketing and other corporate fuckery, rather than confirmed clinical results. Likewise I wouldn't expect any difference between SSRIs for OCD. Attachment disorder is probably a separate thing though, and may not have a validated questionaire for screening enough participants, or however that shit works, this is all me reading too broadly and making stuff up. You should have met me when I still drank.
Your mechanisms kind of contradict each other on the SSRI sex drive. An SSRI would cause mild increases in 2c activation. If there's anything to the "disinhibition" of dopamine release by antagonizing 2c, then that might explain a decreased libido while on SSRIs. Activating 2c would maintain a dopamine inhibition, and dopamine and sex are a tighter match than oxytocin. But that's almost meaningless without knowing more about what "disinhibition" even means, cause I need to handle my own dopamine needs before looking up what might just be a Stahl analogy with little behind it.
Actually, think of MDMA, with its pretty NON-sexual attachments, caused by basically all the HT receptors on full ON position, including 2c. So there's more to consider: is your attachment a sexy-dopamine thing or a obsessional lovey-serotonin/oxytocin thing. (Also remember you need oxytocin to fear strangers too, it's not about "love" really and more like "trust and distrust".)
OK, I really do need to SWIM and life preserver the rest of my methyl-phenylpropanyl-amine order
What is missing from what I quoted, though, was the earlier neuroscience behind everything. Also, for this sort of cocktail, he is explicit about there being a lack of clinical "evidence" but that it may still be good to use for people who are unresponsive to other treatments. I think that's a big part of the speculative aspect that you're picking up on, since he is trying to avoid excessive claims. As for things like "double" or "triple" boosts, the point is more about how the differ in the mechanism of action. There is, for instance, typically a concern when you have one substance that increases serotonin and another that blocks it's reuptake... those situations often lead to life-threatening serotonin syndrome. This combo has a much lower risk. Notice that I said "lower risk" instead of "no risk."