Posted by Toby on September 8, 1998, at 10:27:00
In reply to Much appreciation for your thoughts, posted by DL on September 6, 1998, at 0:56:23
Regarding the sleep study: it won't hurt to call the insurance company and find out if they will cover the test and what kind of info is required in the referral in order to get coverage. If it is covered, then check with your doctor to see if he will make the referral.
You said you'd tried Pamelor without much sleep relief; Imipramine in tiny doses has been tried with better results for sleep. Pamelor usually helps sleep in bigger doses which you may not tolerate.
Regarding your experiment with the Klonopin: you are indeed exqusitely sensitive. The body usually becomes tolerant to the sedating effects of Klonopin after about 7-10 days (sometimes faster when the dose is small) so you may still want to try an increase in it when you have a longer holiday (like Christmas or Thanksgiving) when you don't have to drive or work. Was the quality of you sleep any better with the extra Klonopin? And was the eye fatigue different from the usual sleepiness you feel in the evening and could you tell any difference in the sleepy feeling that day? If no difference in sleepiness but the quality of your sleep was better, then the lack of restful sleep at night may not be the main factor in your daytime sleepiness. In which case I still recommend the sleep study if possible.
By "waffle in baseline mood" I mean small, frequent changes in your mood rather than the huge, longlasting changes that characterize full blown mania. Those small changes still greatly affect your ability to function and feel good or normal, and are probably related to bipolar disorder without exactly fitting medical criteria for bipolar. In which case, those medications I mentioned still would be helpful.
Regarding the social phobia: This is not the same as agoraphobia which is anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having a panic attack. People with agoraphobia typically avoid any situation that involves being outside the home alone, being in a crowd or standing in a line, being on a bridge, or traveling in a bus, train, or car. Social phobia, on the other hand is the fear of being in a social or performance situation in which you could be exposed to unfamiliar people or to scrutiny by others and there is the fear that you will act in a way that will be humiliating or embarrassing (such as showing anxiety symptoms of shakiness, sweating, stuttering, or anything else like that). Many people with social phobia can't put that fear into words like the above without pretty close examination, but they know that they just get really nervous in situations like you described before. These folks know that their fear is excessive or unreasonable but can't stop it and so they avoid these kinds of situations or else endure them with intense distress. You asked about cognitive-behavioral therapy and it is very helpful for social phobia. You work on finding those thoughts that start the train of anxiety when you see a friend in the grocery store, and then you work on stopping those thoughts before they can get you revved up. It's very effective. Most courses take 6-10 weeks.
In regard to the EMDR: It is used for recent trauma and also for trauma that is very old, even up to 50 years old in one patient of mine (WWII trauma). It is used for PTSD and also for what they are calling "little trauma" which would be anything that might fail to cause full blown PTSD in a particular person, which could be an abusive husband, a frightening father, a car wreck, death of a loved one who might have left without saying goodbye, sexual harrassment at work, being fired from work unfairly, all of which I have treated successfully in addition to the big traumas of rape, attempted murder, tornados, heavy machinery accidents, sexual abuse. Some people need only 1 session, others need 2-4 sessions and some people use it intermittently during long term therapy to address issues as they come up, and usually that would be in cases of long term abuse or a chronic problem like eating disorders. A session is usually about 2 hours long, just you and the therapist, no drugs or hypnosis involved. The therapist has you think about a particular incident that is distressing to you, along with the negative thought about yourself that that memory causes and the negative physical feeling that occurs in your body (anything from pain to anxiety). Then the therapist moves his fingers in front of your eyes (just so your eyes have something to track on) while you focus on those things listed above. This is related to REM sleep which is involved in memory and learning. By focusing on several distressing aspects of the memory at once and doing the REM movements, the brain is able to rapidly sort out what is important, what is no longer needed for your survival, and is able to let go of the physical sensations that are no longer needed in order to "catalog" the memory. Once the physical feelings are gone, the memory becomes tolerable, and is able to be properly filed away without causing distress anymore. For example, when you lie down at night, if you didn't feel the same feelings of anxiety that your dad caused when you were a kid, you probably wouldn't grip the sheets and be tense and would be able to sleep.
In regard to which medication to try first, I'd think about Buspar first since it is pretty benign and doesn't interact with much else.
In regard to the Remeron, it takes about a week to get used to the daytime sedation, but if you tolerate it, I usually increase it from 15 mg to start with up to 30 mg at bedtime after the first 3 days which takes care of the sedation in most people.
poster:Toby
thread:511
URL: http://www.dr-bob.org/babble/19980901/msgs/562.html