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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by Rakken on October 28, 2001, at 12:44:21
What works well for panic attacks and anxiety? I have heard that xanax works well but is short acting. Klonopin lasts longer and seems more of a therapeutic choice. Any other things (like a list - pos/neg)? And what would work well combined with Adderall? I'm also working on cognitive strageties for the anxiety/panic attacks. I'm just trying to figure out how to approach my pdoc about everything on the next visit. Adderall isn't very effective for me at under 30 mg and wears off early in the afternoon so I have to take 10 mg dextrostat. It's the only thing that has worked for me in my med history. I like it and don't want it adjusted. I'm worried about my pdoc wanting to try ssri's and tricyclics on me for the anxiety. I've been on ssri's and they haven't been effective. Neither has risperdal. And I hear zyprexa doesn't help very well in combination with adderall. I don't want to go through another trial and error chain of meds like I have constantly done in the past. And I am worried that my pdoc will rule out some treatments since I have overdosed on lorazepam and smoked marijuana in the past. A year ago for the lorazepam. I feel that I've grown up a lot over the past year and am a lot more mature. I'm out of the abuse stage, but I can't shake the worry that she won't believe me. I'm really working myself up about it and its making things worse. Sorry about getting off topic sortof.
Posted by Elizabeth on October 28, 2001, at 17:37:43
In reply to Best thing for panic attacks/extreme anxiety, posted by Rakken on October 28, 2001, at 12:44:21
Hi there. This is going to be pretty long, partly because there were some things in your post that confused me a lot. I hope I can be of help, but there are some things that didn't make much sense to me. I'm hoping you can clear up my confusion.
> What works well for panic attacks and anxiety? I have heard that xanax works well but is short acting. Klonopin lasts longer and seems more of a therapeutic choice. Any other things (like a list - pos/neg)?
Any benzodiazepine would probably work; Xanax, Klonopin, and Ativan (the "high-potency" benzos, in decreasing order of potency) are the ones most commonly used. Lower-potency ones may work at equivalent doses, but they'd probably be very sedating at such high doses (like, 60 mg/day of Valium).
The other major treatment for panic disorder is antidepressants. SSRIs, MAOIs, and some tricyclics are effective, but it may take several weeks at an effective dose before they start to help. Antidepressants, especially SSRIs, often make the anxiety worse at the beginning, so it's a good idea to start at a very low dose and increase it gradually, as tolerated. You should also be able to take a benzodiazepine as-needed until you've reached an effective dose of the AD. Xanax is probably best for as-needed use, since it's fast-acting. (You can also make Ativan work faster by dissolving it under your tongue; you can probably take Xanax this way too, but it tastes very bitter.) The tricyclic imipramine was the first drug used in the treatment of panic disorder, but not all tricyclics are effective. Maprotiline and protriptyline are not effective, and I would not expect amoxapine to be very effective either although I'm not sure about that one. My experience has been that desipramine (even at very high levels) does not work as well as the MAOIs and other antidepressants do. Amitriptyline and doxepin would probably work, but they are both often very sedating and often have other unpleasant side effects. I'm not sure about trimipramine. I think the best tricyclics for panic disorder are probably imipramine, clomipramine, and nortriptyline. (These are just the ones that are used in the USA. There are others that may be preferable if you're in a country where they're available.) All the irreversible MAOIs work very well for panic and most other anxiety disorders. I think Nardil is particularly effective.
The "atypical antidepressants" Wellbutrin and trazodone are known not to work. I don't think that Serzone and Remeron have been studied much, and Effexor probably has the same advantages and disadvantages as the SSRIs. (Some people need to go up to very high doses of Effexor for depression, and they sometimes get a lot of side effects. If your problem is strictly anxiety, a lower dose would probably be fine for you.) BuSpar, an antidepressant which is approved for generalized anxiety is *not* effective for panic disorder but may help in combination with an antidepressant or a benzodiazepine.
Some anticonvulsants, such as Depakote and Neurontin, may work also, but these usually aren't used except when other treatments have failed or if you have bipolar disorder too.
Now, the above treatments are for panic disorder (spontaneous panic attacks). You said you have panic attacks and anxiety, but you didn't say what sort of anxiety, or what (if anything) triggers the panic attacks. That can make a lot of difference. Do you know what you have been diagnosed with?
> And what would work well combined with Adderall?
Benzodiazepines, and most antidepressants and anticonvulsants, are fine to take in combination with Adderall. You might want to monitor tricyclic serum levels if you're taking one of those. Combining MAOIs with stimulants should only be done with a great deal of caution.
> Adderall isn't very effective for me at under 30 mg and wears off early in the afternoon so I have to take 10 mg dextrostat.
I'm confused, I guess. What is the amphetamine supposed to be helping with? Adderall seems like an odd choice for anxiety -- it sounds like there is something more going on for you, and this can affect the choice of treatment for your anxiety. (For example, some anti-anxiety drugs can worsen the symptoms of other disorders.)
> I'm worried about my pdoc wanting to try ssri's and tricyclics on me for the anxiety. I've been on ssri's and they haven't been effective.
Which SSRIs have you taken, and what happened exactly (how long did you take them, etc.)? Have you tried other antidepressants? ADs do usually work, but you have to have patience.
> Neither has risperdal. And I hear zyprexa doesn't help very well in combination with adderall.
Again, this is sounding weird. Why would your doctor prescribe Risperdal for anxiety? It's just not effective (and is also liable to cancel out whatever benefit you might be getting from the Adderall). Antipsychotic drugs are a totally inappropriate treatment choice for panic disorder and most other types of anxiety. Is there some other condition that the Risperdal was supposed to treat? What kind of anxiety do you have, other than panic attacks?
> And I am worried that my pdoc will rule out some treatments since I have overdosed on lorazepam and smoked marijuana in the past. A year ago for the lorazepam.
How old are you, and do you still use marijuana? Was the Ativan overdose a suicide attempt (and if not, what was it?), and did you do it more than once? How much Ativan did you take (approximately)? Was the Ativan prescribed to you, and if so how did it work in the prescribed dose? I think the answers to these questions should affect the doctor's choice of medication.
-elizabeth
Posted by Rakken on October 29, 2001, at 18:31:36
In reply to Re: Best thing for panic attacks/extreme anxiety » Rakken, posted by Elizabeth on October 28, 2001, at 17:37:43
Sorry I wasn't very clear. I have been on Adderall for one month so far, and I was on Dexedrine for a month before hand. Other stimulants have not been effective for me. I have tried Provigil, Ritalin, and a few anti-depressants.
I was diagnosed with major depression a little over 2 years ago. I tried Prozac, Remeron, Paxil and Risperdal (for anxiety with the depression). I may have been on some other anti-depressants, but I can't recall right now. My pdoc told me that people who didn't respond to SSRI's usually responded to the tricyclics. So she prescribed anafranil and depakote. She had me get an EEG before I started the anafranil. It was slightly irregular so she didn't want me to take it. The EEG wasn't too weird. Some EEG expert said that some people just have different heart rythms or something. And that what I had could just be normal for me. Anyways, nothing was effective. The anti-depressants changed my personality a lot and more or less put me in a daze. I had a lot of trouble getting off Paxil and when the depersonalization from the withdrawal went away I was left extremely scared of anti-depressants. I don't like how they "work" or moreso don't work.
I have a lot of difficulty concentrating and staying awake. I also had a problem with motivation (not linked to pot which a few doctors have tried to claim, it was more connected to the depression). I wasn't very alert or intouch with the world before I went on Dexedrine/Adderall.
I am 18 years old now and feel that I have matured a lot. I no longer smoke pot or abuse drugs. The lorazepam incident happened exactly a year ago on October 31st. I had taken 3 a few days before and felt practically nothing. I got them from a kid at school. They were very powdery (white, little round pills). I didn't believe that they were real or that they would even work. So I took about 11 plus all the remaining powder and broken pieces. I didn't intend to overdose. I didn't even think they'd work. Unfortuanately for me, they did all too well. I woke up the next morning not remembering a single thing from the previous night. I went to the hospital and explained to a doctor what had happened. It was very stupid of me and I can't belive it was only a year ago. To me it seems like it was five.
I think that I have ADD (without the hyperactivity) with an anxiety/panic disorder. The Adderall may make the anxiety more intense, but it is the only thing I have responded to well. It has made my life much better even with the increase in anxiety. I take 10 mg of Dextrostat in the afternoon so that I can stay awake until I want to fall asleep (10 PM or so). That way I can control my sleep schedule. I take clonidine which makes it a little easier to fall asleep.
I have been looking around a lot for info on anxiety/panic disorders. I have high baseline and high anticipatory anxiety in between attacks. They can be brought on when any sort of attention is brought near me (not to me directly), or if I think that people are looking/talking about me. I am extremely self conscious. I also get them when I am alone worrying about things or thinking about future events. I have had them when I am with friends at work or when driving to school. I also have them sometimes when walking to a class or anticipating the end of a class. They are spontaneous it seems, but are very easily brought on when attention is brought near me.
I think that benzos are the best choice for my anxiety, but I don't think that my pdoc will consider them. I don't want something that have lots of side effects or changes my personality/perceptions. Not that the anxiety doesn't change my personality. It definitely does. I can recall my pdoc saying something about lorazepam when I visited her after the incident. She said something like, "I never prescribe those for longer than 11 or so days. They're muscle relaxants. Very dangerous." Or something along those lines. I think she is very close minded and stubborn in some ways. She asked if I wanted to go back on the Risperdal or the Paxil for the anxiety when I saw her last. I quickly said no and that I was afraid of Paxil. Her immediate thought was "oh it was the sexual side effects huh?" As though she'd completely ignored how I'd responded to it before hand. The risperdal never helped the anxiety before either. I just think she'll continue running around avoiding benzos as an option and I'll go on another long drug hunt where I go through failure after failure. I am worried that I'll go there and come home like always with nothing helped or accomplished. Then I have another month and a half before I can even see her again, and she is impossible to reach on the phone. And if you leave a message she doesn't respond for weeks. I don't trust her, her methods, or her opinions. I think I should get another pdoc.
Oh yea, the previous visit I had with my pdoc, I only told her aout the anxiety, not the panic attacks. But I still feel she'll keep a closed door to the benzos.
Posted by Gracie2 on October 29, 2001, at 23:58:16
In reply to Re: Best thing for panic attacks/extreme anxiety, posted by Rakken on October 29, 2001, at 18:31:36
Not much I can add to Elizabeth's advice except for my own personal experience. A year ago, when I was going through a very traumatic experience, I started to experience severe anxiety, which I differentiate from panic attacks.
My anxiety became debilitating. I had terrible insomnia and I became so paranoid, I refused to answer the phone. I over-reacted to every event;
if my son was late coming home, I was sure he was dead on the highway - if my husband was late coming home, I was sure he was having an affair.
I cried constantly; it became harder and harder for me to pull myself together. Going to the store for a gallon of milk was a major undertaking for me, sometimes more than I could manage. Often, I could not get out of bed.My first psychiatrist prescribed a regimen of Prozac, Seroquel and Depakote. Although they didn't work immediately, I began to feel better
after a couple of weeks. I don't believe the Prozac had any effect, but the Seroquel was a blessing; it calmed me down and let me sleep. The Depakote, while I believe it was necessary and beneficial at first, began to over-sedate me after six months; my anxiety was gone, but I had no inclination to remove my butt from the couch.
I was so lethargic and disinterested in everything
I used to love, I stopped taking the Depakote AMA
when my pyschiatrist disagreed with me.I had trouble quitting the Seroquel; my insomnia returned immediately. I lived with it for a few months, and then started having panic attacks. These were different than the anxiety I had before, because the anxiety had always been triggered by some reason, imagined or real. The panic attacks came on for no reason at all; one minute I was fine, and the next minute I was gasping for air and sure I was going to die - sometimes they were so bad that I would vomit. I had the name of a psychiatrist I had never seen, and I drove to his office and asked the receptionist if I could possibly see him without an appointment. She said that was impossible, and I burst into tears right there in the waiting room in front of all the other patients. Normally I'm a rather shy person, and wouldn't do such a thing if you paid me, but I was in agony.
I wish I had sent her a thank-you card for not sending me away. After waiting a couple of hours,
she fit me in. I was honest with the doctor about my former drug use and, although he said I needed a benzo, he was reluctant to give it to me. I promised to give the pills to my husband, which I did, so he prescribed some Klonopin for me. It did help me.I am now taking Seroquel and Xanax as prescribed
(well usually - needed a few more pills when Mom was in town) given to me by my GP, who doesn't know about my drug history. The only reason I've been dishonest with him is because I worked in a medical office for many years and drug-abusers -
while their charts were not actually "flagged" as
I've heard of - were well-known to both the doctors and nurses, and there was always a lot of eye-rolling going on when these patients came in with a new injury. In short, the staff was skeptical when one of these patients showed up with a new injury,
meaning that their injuries were not taken as seriously as other patients', and they were sometimes even prescribed pain medication that was not as strong as the injury warranted. I have no intention of joining this unfortunate group of patients, and leaving my doctor's office with a shattered ankle and some samples of Advil. Screw that.Still, I think I like my present psychiatrist, because he trusted me to be responsible with the Klonopin. My GP doesn't want to refill my Xanax until I see my pdoc again, and I thought that was a fair deal.
So you must work these things out for yourself. I think a good doctor will allow you a fair chance
to be responsible with your medication before he labels you as an abuser. (Fool me once, etc.)
-Gracie
Posted by Mitch on October 30, 2001, at 23:12:08
In reply to Best thing for panic attacks/extreme anxiety, posted by Rakken on October 28, 2001, at 12:44:21
> What works well for panic attacks and anxiety? I have heard that xanax works well but is short acting. Klonopin lasts longer and seems more of a therapeutic choice. Any other things (like a list - pos/neg)? And what would work well combined with Adderall? I'm also working on cognitive strageties for the anxiety/panic attacks. I'm just trying to figure out how to approach my pdoc about everything on the next visit. Adderall isn't very effective for me at under 30 mg and wears off early in the afternoon so I have to take 10 mg dextrostat. It's the only thing that has worked for me in my med history. I like it and don't want it adjusted. I'm worried about my pdoc wanting to try ssri's and tricyclics on me for the anxiety. I've been on ssri's and they haven't been effective. Neither has risperdal. And I hear zyprexa doesn't help very well in combination with adderall. I don't want to go through another trial and error chain of meds like I have constantly done in the past. And I am worried that my pdoc will rule out some treatments since I have overdosed on lorazepam and smoked marijuana in the past. A year ago for the lorazepam. I feel that I've grown up a lot over the past year and am a lot more mature. I'm out of the abuse stage, but I can't shake the worry that she won't believe me. I'm really working myself up about it and its making things worse. Sorry about getting off topic sortof.
Rakken,When I was taking Adderall and getting anxious/panicky from it, but getting excellent anti-cycling effect and resolution of ADHD symptoms, I found Serzone (just a tad-25mg twice daily) helped a LOT. I had an allergy to it and had to stop it, but it stopped my anticipatory anxiety quite well and it didn't upset my stomach like SSRI's.
Mitch
Posted by Elizabeth on October 31, 2001, at 9:31:25
In reply to Re: Best thing for panic attacks/extreme anxiety, posted by Rakken on October 29, 2001, at 18:31:36
> Sorry I wasn't very clear. I have been on Adderall for one month so far, and I was on Dexedrine for a month before hand. Other stimulants have not been effective for me. I have tried Provigil, Ritalin, and a few anti-depressants.
It's interesting that the other stimulants didn't work but Adderall does. How much Adderall are you taking, and if you remember, what were the doses of the other stimulants (especially Ritalin and Dexedrine)? Also did Dexedrine work (something you said further down suggested that it had) and if so, why did you switch?
> I was diagnosed with major depression a little over 2 years ago. I tried Prozac, Remeron, Paxil and Risperdal (for anxiety with the depression). I may have been on some other anti-depressants, but I can't recall right now. My pdoc told me that people who didn't respond to SSRI's usually responded to the tricyclics. So she prescribed anafranil and depakote. She had me get an EEG before I started the anafranil. It was slightly irregular so she didn't want me to take it.
Tricyclics lower the seizure threshold, and clomipramine (Anafranil) is one of the worse ones in that respect. Nortriptyline would be a better choice, I think; it has fewer side effects in general.
> The EEG wasn't too weird. Some EEG expert said that some people just have different heart rythms or something.
EEGs measure brain waves, not heart rhythms! (But it is true that a lot of people have EEGs that are slightly "off" but don't have seizures or anything. I assume you've never had any seizures?)
> The anti-depressants changed my personality a lot and more or less put me in a daze.
In what sense did they change your personality?
You mentioned a couple of SSRIs and Remeron. Did you ever try Effexor, Wellbutrin, Serzone, Desyrel (trazodone), Nardil, or Parnate?
> I have a lot of difficulty concentrating and staying awake. I also had a problem with motivation (not linked to pot which a few doctors have tried to claim, it was more connected to the depression). I wasn't very alert or intouch with the world before I went on Dexedrine/Adderall.
Stimulants, or activating antidepressants (such as Wellbutrin or MAOIs), seem like they would probably work for that sort of depression, and antipsychotics like Risperdal seem like a bad choice, IMO. Antipsychotic drugs are often sedating and can dull your concentration, motivation, and alertness.
> I am 18 years old now and feel that I have matured a lot.
The reason I asked is that doctors do often understand that some people experiment with drugs as teenagers but don't go on to become addicts. If you've stopped doing drugs altogether then doctors shouldn't be too concerned. I also think that being older makes a difference -- in general it's assumed that you're more responsible.
> The lorazepam incident happened exactly a year ago on October 31st. I had taken 3 a few days before and felt practically nothing. I got them from a kid at school. They were very powdery (white, little round pills). I didn't believe that they were real or that they would even work. So I took about 11 plus all the remaining powder and broken pieces. I didn't intend to overdose. I didn't even think they'd work. Unfortuanately for me, they did all too well. I woke up the next morning not remembering a single thing from the previous night. I went to the hospital and explained to a doctor what had happened. It was very stupid of me and I can't belive it was only a year ago. To me it seems like it was five.
Ahh, so it was an accident related to experimenting with recreational drug use. I think that doctors will be okay with that as long as you make it clear that you've learned your lesson. (What posessed you to want to try Ativan, anyway?)
> I think that I have ADD (without the hyperactivity) with an anxiety/panic disorder.
Yeah, it sort of sounds more like ADD than depression. Can you say anything about your depression symptoms, if any? Perhaps the doctor who diagnosed you with depression was misled because you seemed tired, or perhaps the depression was secondary to the anxiety and ADD.
> The Adderall may make the anxiety more intense, but it is the only thing I have responded to well. It has made my life much better even with the increase in anxiety. I take 10 mg of Dextrostat in the afternoon so that I can stay awake until I want to fall asleep (10 PM or so).
> That way I can control my sleep schedule. I take clonidine which makes it a little easier to fall asleep.Interesting combination. Does the clonidine do anything else for you?
I took Cylert (a long-acting stimulant -- it lasts all day but is milder than Ritalin or amphetamine) for a little while in college and it helped me feel alert in the day and, like the stimulants do for you, it improved my sleep, made it more regular and less fragmented.
> I have been looking around a lot for info on anxiety/panic disorders. I have high baseline and high anticipatory anxiety in between attacks. They can be brought on when any sort of attention is brought near me (not to me directly), or if I think that people are looking/talking about me. I am extremely self conscious. I also get them when I am alone worrying about things or thinking about future events. I have had them when I am with friends at work or when driving to school. I also have them sometimes when walking to a class or anticipating the end of a class. They are spontaneous it seems, but are very easily brought on when attention is brought near me.
My pdoc says that a lot of people have a mix of generalized anxiety (worrying, ruminating about the past and/or the future), social anxiety (fear of being the focus of attention, performance anxiety, extreme self-consciousness), and panic disorder (spontaneous panic attacks). I also think that situationally-predisposed panic attacks can lead to spontaneous panic attacks. I have many of the same problems that you have, BTW.
> I think that benzos are the best choice for my anxiety, but I don't think that my pdoc will consider them.
Don't be so sure. I think if you present things the right way, s/he might be willing to try benzos. Be sure that your doctor knows about the panic attacks. Emphasizing the anxiety rather than the depression might help if you feel that a benzo is right for you. Don't ask for a specific benzo. If you start taking it and don't "feel" anything, you shouldn't assume that it isn't doing anything -- take it for a little while (a few days, at least) and see if your anxiety seems to be getting better.
Also, if your pdoc wants you to try another antidepressant that you haven't tried, don't object too much. Be patient. If you insist that you need benzos, it could make you sound like a "drug seeker." (Funny expression -- aren't people who go in asking for antidepressants or antihistamines or whatever also "drug seeking?")
I think that since you've tried two SSRIs already and had problems with them, you shouldn't be expected to try another SSRI (the SSRIs besides Paxil and Prozac are Zoloft, Luvox, and Celexa). But there are other antidepressants that work differently and you may find that they help you. Don't rule antidepressants out completely.
> I don't want something that have lots of side effects or changes my personality/perceptions.
You can't predict what side effects a particular drug or class of drugs will have for you. The only things I'd say you should probably stay away from are antipsychotics (like Risperdal), SSRIs, and the other antidepressants that you've tried already (like Remeron).
> I can recall my pdoc saying something about lorazepam when I visited her after the incident. She said something like, "I never prescribe those for longer than 11 or so days. They're muscle relaxants. Very dangerous."
Benzodiazepines are not "very dangerous," although ODing on them isn't exactly a good idea! And they are perfectly good treatments for social phobia, panic disorder, and generalized anxiety -- a lot of people find them much more tolerable than antidepressants, which often make anxiety *worse* at first (SSRIs in particular).
> I think she is very close minded and stubborn in some ways.
From what you say, it sounds like she is. Maybe you should consider trying to find a different doctor. (But as I said before, don't give them the impression that you are looking for someone to prescribe benzos for you. Benzos really are quite safe, well-tolerated, and minimally addictive, but a lot of doctors still have unreasonable prejudices against them.) Do you have a GP, a regular doctor? If so, you might talk to him/her about the problems you've been having with your psychiatrist and ask for a referral.
Hope this helps. Take care.
-elizabeth
Posted by Gracie2 on November 1, 2001, at 6:34:38
In reply to Re: Best thing for panic attacks/extreme anxiety » Rakken, posted by Elizabeth on October 31, 2001, at 9:31:25
We have talked about this before but I will say again that there is nothing wrong with "doctor shopping", and even my !@#$%&! HMO allows me to switch doctors without penalty.It's so important to have a doctor you like and trust, and sometimes it's difficult to find a doctor on the same wavelength as yourself. I dropped my first pdoc because she would simply brush aside my questions as if they didn't matter, even about the medication I was taking. I found this to be very insulting.
Find a doctor (specialist, psychiatrist, GP, dentist) that listens to you, spends an adequate amount of time with you, and is not terrified of prescribing a painkiller or benzo if it is warranted. I know it's a pain in the butt to keep switching doctors with the paperwork and all, but think about how important this guy is in your life. It really is worth the trouble.
-Gracie
Posted by jojo on November 2, 2001, at 22:51:50
In reply to Doctor shopping, posted by Gracie2 on November 1, 2001, at 6:34:38
>
> We have talked about this before but I will say again that there is nothing wrong with "doctor shopping", and even my !@#$%&! HMO allows me to switch doctors without penalty.
>
> It's so important to have a doctor you like and trust, and sometimes it's difficult to find a doctor on the same wavelength as yourself. I dropped my first pdoc because she would simply brush aside my questions as if they didn't matter, even about the medication I was taking. I found this to be very insulting.
>
> Find a doctor (specialist, psychiatrist, GP, dentist) that listens to you, spends an adequate amount of time with you, and is not terrified of prescribing a painkiller or benzo if it is warranted. I know it's a pain in the butt to keep switching doctors with the paperwork and all, but think about how important this guy is in your life. It really is worth the trouble.
>
> -GracieAfter 12 years of Psychoanalysis, once going 7 days per week, and often 3 and 4 days, and having
"therapy" with 3 analysts, and a consultation with the Head of the Psychoanalyst Society, I decided to switch to a non-analytic Psychiatrist.
After my 4th year of analysis, I had asked about antidepressants, and was told it "was like taking an aspirin, it helped with the pain, but didn't cure the "real cause". I was taking 5-10 mg of Dexedrine from the lab where I worked at the time, limited to when I had to write grant applications, which the Analysts discouraged.
I am now where I might have been 25 years ago, taking Celexa and 35 mg./day of Dexedrine. Influenced by the Analysts, and trying to be a "responsible person", I was not taking enough Dexedrine, so that more than 10 mg. made me hyper and caused bruxism.
The patient lives with the consequences of his choice of physicians. By all means, shop for a doctor!
This is the end of the thread.
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