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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by zeugma on August 25, 2003, at 18:19:26
Hi everyone- I am having a real problem. I have been extremely anxious over a situation which has developed at which I KNOW should not be anxiety-provoking, in fact most people would take it as positive- but I am suffering extreme anxiety over it and a return of phobic symptoms. I ahve been diagnosed with social anxiety and I believe I also have avoidant personality disorder. I have found that in order to retain what little calm I can, I try to keep people at arm's-length as much as possible. I do not call friends unless they call first, I try to keep work relationships as distant as possible so as not to potentially become embarrassed by my colleagues' close observations of me, and I restrict my social life as much as possible, which is difficult for me, since I am a naturally gregarious person. But my fear of others and of being embarrassed is so great that I have found that my emotional stability is greater when these restictions are in place. This in itself has caused a lot of loneliness and depression, but that is better than panic (what I am feeling now).
The strange thing is I don't feel depressed. But I am experiencing a return of the symptoms of my depression. Agitation, phobia about spoiled food (I haven't been able to eat a real meal today), and extreme anxiety around others. I typically am anxious around others anyway, but my responses have gotten more severe. I can't even enjoy taking a walk anymore.
I called my pdoc about half an hour ago. He seemed pretty unfazed by all this. He told me that these were issues I should work out in CBT. I suppose what I am afraid of is that I will break down before I can see any of my therapists (I have two) or my pdoc- who told me that if I am still anxious by the time I see him again, he'll give me something on a prn basis. The problem is though that I feel I need something NOW. If this anxiety makes me lose weight, for example, the weight loss itself will add to the anxiety (I am already noticeably underweight). And it just reminds me of all the times in the past when severe social anxiety precipated a meltdown. I don't know what to do. My CBT therapist has a number for emergencies- I just saw her today though. Should I go to a hospital and tell them I am having a panic attack. I feel completely lucid, but also panicking- a strange feeling.
I take 75mg nortriptyline, 80 mg Strattera, 30 mg Buspar. Any advice would be appreciated.
Posted by zeugma on August 25, 2003, at 22:48:38
In reply to anxiety attack- advice needed, posted by zeugma on August 25, 2003, at 18:19:26
I am going to scrap the CBT for now. The exercises I am doing for that therapy, such as writing detailed analyses of anxiety-provoking situations, are themselves causing levels of anxiety that are totally unacceptable and beginning to interfere with my functioning. I am noticing some extremely disturbing symptoms returning so I am going to act now. My appetite has vanished and food-related phobias are becoming intense. I will return to CBT when *Im have an anxiolytic on hand. Until then, I choose social phobia over wasting away.
Posted by Jasmine Neroli on August 25, 2003, at 23:01:41
In reply to decision, posted by zeugma on August 25, 2003, at 22:48:38
Sounds like the right path for you right now. You need a "triage" approach, since you seem in or near an anxiety crisis. Your own GP would probably have no objection to giving you Lorazepam (Ativan)on a short term basis, I'm sure. It's very quick acting and can therefore be taken "as needed". I took it, when I was initially prescribed Celexa for anxiety/Depression and was waiting for it to "kick in" and it really helped. Don't think it works as well on a continual basis though. I'm now on Klonipin everyday, and LOVE it!
Posted by Sabina on August 25, 2003, at 23:02:27
In reply to decision, posted by zeugma on August 25, 2003, at 22:48:38
i hope it works for you.
i know you said you had phobias about spoiled food. how are you with sterile, canned nutrition drinks like Ensure? just a thought.
good luck.
Posted by zeugma on August 25, 2003, at 23:30:25
In reply to Re: decision, posted by Jasmine Neroli on August 25, 2003, at 23:01:41
> Sounds like the right path for you right now. You need a "triage" approach, since you seem in or near an anxiety crisis. Your own GP would probably have no objection to giving you Lorazepam (Ativan)on a short term basis, I'm sure. It's very quick acting and can therefore be taken "as needed". I took it, when I was initially prescribed Celexa for anxiety/Depression and was waiting for it to "kick in" and it really helped. Don't think it works as well on a continual basis though. I'm now on Klonipin everyday, and LOVE it!
I've heard nothing but good things about Klonopin. There are tons of studies that have established it as a preferred treatment for social phobia. Thanks for responding!
Posted by zeugma on August 25, 2003, at 23:36:45
In reply to Re: good luck with your decision » zeugma, posted by Sabina on August 25, 2003, at 23:02:27
> i hope it works for you.
>
> i know you said you had phobias about spoiled food. how are you with sterile, canned nutrition drinks like Ensure? just a thought.
>
> good luck.I appreciate your suggestion. I have had this problem for many years, and once when I was at a GP's office the nurse noticed I was severely underweight, and asked if I was eating three meals a day. I told her I was often too "busy" to eat (God, I hate lying!), and she suggested Ensure. I did live on it for awhile. Unfortunately it was very heavy in my stomach and aggravated the nausea I often felt (IBS). So I haven't touched it in years.
Thanks for the suggestion and for wishing me luck!
Posted by jay on August 26, 2003, at 0:10:47
In reply to anxiety attack- advice needed, posted by zeugma on August 25, 2003, at 18:19:26
> Hi everyone- I am having a real problem. I have been extremely anxious over a situation which has developed at which I KNOW should not be anxiety-provoking, in fact most people would take it as positive- but I am suffering extreme anxiety over it and a return of phobic symptoms. I ahve been diagnosed with social anxiety and I believe I also have avoidant personality disorder. I have found that in order to retain what little calm I can, I try to keep people at arm's-length as much as possible. I do not call friends unless they call first, I try to keep work relationships as distant as possible so as not to potentially become embarrassed by my colleagues' close observations of me, and I restrict my social life as much as possible, which is difficult for me, since I am a naturally gregarious person. But my fear of others and of being embarrassed is so great that I have found that my emotional stability is greater when these restictions are in place. This in itself has caused a lot of loneliness and depression, but that is better than panic (what I am feeling now).
>
> The strange thing is I don't feel depressed. But I am experiencing a return of the symptoms of my depression. Agitation, phobia about spoiled food (I haven't been able to eat a real meal today), and extreme anxiety around others. I typically am anxious around others anyway, but my responses have gotten more severe. I can't even enjoy taking a walk anymore.
>
> I called my pdoc about half an hour ago. He seemed pretty unfazed by all this. He told me that these were issues I should work out in CBT. I suppose what I am afraid of is that I will break down before I can see any of my therapists (I have two) or my pdoc- who told me that if I am still anxious by the time I see him again, he'll give me something on a prn basis. The problem is though that I feel I need something NOW. If this anxiety makes me lose weight, for example, the weight loss itself will add to the anxiety (I am already noticeably underweight). And it just reminds me of all the times in the past when severe social anxiety precipated a meltdown. I don't know what to do. My CBT therapist has a number for emergencies- I just saw her today though. Should I go to a hospital and tell them I am having a panic attack. I feel completely lucid, but also panicking- a strange feeling.
>
> I take 75mg nortriptyline, 80 mg Strattera, 30 mg Buspar. Any advice would be appreciated.
>
>Hi...I know you already made your decision. But your two meds, the Nortrip and Strat combined could be inducing some intense norepinephrine activity, which you likely don't need. I am not saying dump them and try an ssri, which I imagine you have, but maybe the addition of a serotogenic med, and a med for GABA-related anxiety (like a daily benzo and/or Neurontin). I was on a high dose of Effexor (strong norepinephrine activity at high doses) for years, and suffered anxiety I thought I wouldn't live through, and a clinician doing an evaluation of my meds pointed to some research showing that over-doing norepinephrine based medication in very anxious people sometimes leads to problems. I've moved onto a balance of high dose serotegenic and low dose norepinephrine based meds, and higher benzo dose (and may be starting Neurontin again..).
I recall a similar feeling between nortrip and effexor (at the high dose I was taking.) For years on the med I had almost daily panic attacks, and had to resort to constant benzo use.
Now this is just *me*...but some may apply in your situation too. I kinda don't see why we have to wait to get a panic attack to take a benzo. If we can head it all off, or lower occurance, that sounds like a good choice. To me..IMHO....
But, best wishes and luck with whatever road you try.
Sincerely,
Jay
Posted by zeugma on August 26, 2003, at 1:09:51
In reply to Re: anxiety attack- advice needed » zeugma, posted by jay on August 26, 2003, at 0:10:47
Thanks, Jay, for that thoughtful reply. You obviously have experience with anxiety and the way different meds can affect it. Yes, I have tried SSRI's. The experiences on them (and Wellbutrin) were so severe that I swore off meds for over ten years. nortrip and Strat are the only AD-type meds I have ever been able to tolerate. It's very, very hard for me to say what effect the two are having on my anxiety. My pdoc- beset by wishful thinking, perhaps- has been asking me what effect my cocktail of drugs has been having on my anxiety. I told him none. That is not quite true. I experience the anxiety differently- instead of becoming anxious for no reason that I can discern, I register each cause of anxiety with crystal clarity- lucid panic, if you like. The Strat in particular does this. Odd?
Anyway, about noradrenergic meds- they seem to wake me up. 75 mg nortrip did not wake me fully, not at all. With the full dose of Strat I feel about as awake as other people- an effect I only got after weeks on the full dose. I conclude from this that my ADHD seems to need all the norepinephrine it can get. Which is why I'm reluctant to ramp down either drug. I would only do it (at this point) as washout for an MAOI. but it seems more sensible, doesn't it, to just add Klonopin? Like you say, it seems irrational to let panic attacks happen before treating the anxiety. I can only attribute this to my pdoc's unwillingness to treat this aspect of my disorder.
Posted by zeugma on August 26, 2003, at 7:02:12
In reply to Re: anxiety attack- advice needed, posted by zeugma on August 26, 2003, at 1:09:51
Something else occurs to me as I think about this. My depression is a 'dreamlike' state. I have a hard time feeling alert- no doubt the comorbid ADHD. When I started on nortriptyline last year I DID feel intense anxiety. I also felt I needed a stimulant of some kind and suggested Provigil. My pdoc said no- on the grounds that it would cause more anxiety! So obviously he's been aware that I DO have severe anxiety. But it strikes me as ironic that while he didn't seem to think the anxiety was worth treating on its own, it WAS sufficient reason to withold treatments of another serious condition! It just doesn't make sense. I feel like he has taken advantage of my trust in him.
It also occurs to me that the one med I've taken for anxiety (Buspar) ineffective as it is- was my idea, he'd given me samples of offhandedly at our first session. Last DEcember I saw the drug was about to expire and did a little net research on it, about whether there would be a dangerous interaction with nortriptyline. I was planning to take it whether he wanted me to or not, provided it was safe to do so. But also, cooperative patient that I am, I wanted to let him know about my plan. He was dismissive about the Buspar- "It won't hurt you, at least"- now, somebody explain why he was only willing to let me try a med he considered ineffectual for anxiety (implying that he didn't think the anxiety was a real issue)- but, on the other hand, rejected possible treatments for my inattention on the grounds that it could exacerbate my anxiety! It doesn't make sense at all. Is anxiety such a stigmatized condition, or the meds that are appropriate to treat it so unspeakable that they are to be absolutely avoided until a panic attack hits? I am not only feeling panic, but also a return of the most disturbing depressive symptoms? My trust in him is shattered and I am going to find another pdoc as soon as possible.
Posted by Jasmine Neroli on August 26, 2003, at 22:09:57
In reply to pdoc puzzle re: anxiety, posted by zeugma on August 26, 2003, at 7:02:12
I hear ya! It seems to me that some doctors ( my own included) only ever view anxiety as part of another diagnosis, and a minor one at that. E.G. Depression, causing some symptoms of anxiety. or OCD causing anxiety. I have always felt that anxiety is my dominant disorder and depression often follows as stressors increase/not properly medicated. Sometime ago, on this board, someone posted a thread about Docs being highly influenced (or too extremenly comfortable) by the SSRI's and their manufacturers. Whereas "old fashioned" benzodiazepines are out of favour or worrisome. This might be the case for your doc.
Definitely shop around for a new doc, if you've lost trust in yours. After all, you would find a new mechanic in a hurry, if you didn't trust him!
Good luck!
Posted by Viridis on August 26, 2003, at 23:53:56
In reply to pdoc puzzle re: anxiety, posted by zeugma on August 26, 2003, at 7:02:12
I like JN's mechanic analogy. It seems that in every profession, there's a relatively small proportion of practitioners who are really good, and then there's simply the comfort factor -- who you can talk with and get satisying answers and results. We've just been through this with a home remodeling project. I've learned that when it comes to flooring, tiling, etc., there's only a small fraction of "professionals" I'd trust to both do a good job and interact with me enough to get a real sense of what I want/need.
So, it's no surprise that pdocs are like this too. I've seen quite a few, and finally found someone I can trust, who understands me and has good instincts about meds, without being locked into an SSRI mentality etc. The frustrating thing is that it takes trial and error, which is especially hard when you're suffering from a crippling disorder. But it really is worth the time, effort, and cost to find a good pdoc that you "click" with. And always keep in mind that they are working for you (or, even better, with you), so if the services they provide aren't satisfactory, move on. This is what you'd do in seeking any other type of professional, and when it comes to your mental health, this is one of the most important decisions you can make.
You will find relief -- it may just take a while. Best of luck!
Posted by zeugma on August 27, 2003, at 10:03:45
In reply to Re: pdoc puzzle re: anxiety » zeugma, posted by Viridis on August 26, 2003, at 23:53:56
The worst problem I am having with my anxiety is thhat I am even questioning if it is real. I.e. this pdoc that I have trusted tells me CBT will solve my anxiety disorder, and then I freak out and get all kinds of crazy symptoms... Also a problem is that AvPD people have a really hard time telling others the truth about how they feel because they are so preoccupied with thoughts like. "Will this person take this seriously? Will it sound like I'm exaggerating? Will it seem like I'm manipulating him to get what I want?" THis last one is what really scares me because there can be a grain of truth to it with respect to drugs of 'abuse.' Ironically, this means I DO have to be become extremely strategic (that I do have to manipulate the situation somewhat) in order to handle this situation right. I feel like when I will see him I will be so upset that whatever I say will be tinged with hysteria and that he might conclude that I'm either putting on a show, or secretly an addict craving a legal high.
In truth I would much rather NOT have to discuss my medication issues with him. I would have l;iked to have stabilized my meds and been able to cut down on the number of times I had to see him (he's expensive and doesn't accept my insurance). The idea about CBT was that it was in lieu of a new med. I suppose the biggest problem is that I feel I am so much more informed about the nature and treatments for social phobia by now than he is, and yet he's the one writing the prescriptions. I have asked my CB therapist for a referral to a pdoc specializing in anxiety in case I will need a 'second opinion.' After all people don't hesitate to do that if they are going to have a heart operation, and my head is just as important as my heart :-)
This is the end of the thread.
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