Anxiety, simplified

I thought it would be good to return to a more “bread and butter” informational psychiatry post for once.  Consider this a drastic reductionism of a complex field.

Following the prior post about avoiding benzodiazepines, many have asked — What else can I do to feel less anxious besides take benzodiazepines?

The short answer is other (safer) medications, and/or psychotherapy.

Like any other blog post, this isn’t a substitution for medical advice, since there can be causes of anxiety that require medical intervention, such as hyperthyroidism. Make sure you get evaluated properly before trying to chalk your anxiety up to a “mental” problem. Even after that, it’s useful to see a professional who can help you tease out what’s contributing to it and the options to change how you’re feeling.

Anxiety usually refers to a common cluster of symptoms, such as shakiness, sweating, heart racing, panic attacks, restlessness, and just an internal feeling of nervousness. These are physiological aspects of anxiety. They occur during an activation of the sympathetic nervous system, the “fight-or-flight” response.  What evolved to protect us from something life threatening (Bear attack!) now activates to things that feel life threatening.  And then there are of course the emotions that those sensations add up to (e.g. nervous, anxious, worried, etc), and the thoughts we think in response to them as well (“I’m dying,” “this will never end,” “there’s something wrong with me”).

There’s different anxiety diagnoses, from panic disorder to generalized anxiety disorder to PTSD (sorta). A simple way to lump them, though, is to ask if the anxious feelings go on throughout the day, or only in short bursts (situationally or episodically). Of course people can also feel a baseline level of anxiety all day with short bursts of worsening (such as panic attacks) as well.

So let’s talk about Jack and Jill.

Jack was born anxious. He was a nervous kid, and he grew up to be a nervous adult. People just wrote him off as “that’s the way he is,” so he never explored if he could do things to feel different. Now as an adult he’s nervous all day long and his new girlfriend is telling him this isn’t “normal.” Jack comes in for an evaluation wondering if it’s “normal” or not. I tell him that “normal” is less useful than thinking about the terms “common” and “’healthy.” Anxiety is common. It isn’t necessarily healthy.

I go on to tell Jack about how meds work for someone with anxiety all day long, which is to lower the baseline level of nervousness, like turning the volume down on it. But it means taking a medication every day. Usually this is an SSRI (prozac, zoloft, lexapro, etc), considered the first line medication by most psychiatrists for anxiety. It’s taken at a scheduled time, and gradually the anxiety comes down. It’s not an instantaneous fix, but it lasts.

Jack and I go on to discuss ways that therapy can also help him, from challenging his thoughts that there’s something wrong with him or that bad things will continue to happen, to practicing ways to relax, to learning to control feelings that feel out of control. He might even try therapy where he thinks about his family relations as a the “cause” of anxiety (though I have a little less confidence in that). Over time Jack feels like he has more space to breathe and think, as his anxiety decreases. It takes some time and patience, though.

Jill is a young working woman who has never had any problems with anxiety or depression, but has never been particularly introspective, either. She just moved to a new city and after hearing about the dangers of some areas, finds herself wracked with anxiety whenever she steps outside. She just had her first panic attack, and is especially worried about having more. Even worse she’s been tasked to do public talks for her new job, and has a lot of worry about public speaking.

If someone has anxiety only episodically and feels completely normal in between these episodes, they might be able to get by with an as-needed medication. These are medications like vistaril (hydroxyzine), or in the case of phobias something like propranolol (a beta blocker).

Jill and I sit down for a talk, and we discover that anticipation is a big part of her anxiety. She anticipates how bad things could be. As do many people with anxiety. In many ways this is about fearing what might happen, which feeds the anxiety itself. So we have a talk about therapy, and how an approach like CBT might be able to challenge this anticipation, and break the habit of anticipating every bad thing that might happen.

There are of course exceptions situations where meds should be used more cautiously. Such as situational anxiety. As in someone didn’t have anxiety, and then something in their life changes, and now they’re feeling so much “stress” that they’re feeling anxious. I have several patients who have been in jobs that they hate, are overworked, but don’t have an easy way to leave it. The demands on them are overwhelming, from the hours to the workload to quotas. They are in a situation without an escape. So they tell themselves that they’ll just deal with it until things change. They don’t change their job, they just hope things resolve on their own. This is not usually a successful strategy. Anxiety can be taxing emotionally, and can lead to burnout. So in this case I’m a bit more cautious about prescribing a medication. I believe in relieving suffering, but I’m upfront with the person that it might just lead to tolerating an intolerable situation, which removes the pressure to figure out a better lifestyle. So in that case it’s their choice, and I encourage to look deeper at all of their options and make sure they’re not staying in a terrible situation.

PTSD is its own animal, though I still think about it in the anxiety spectrum. I’ll be writing a more complete post on PTSD soon.

For every kind of anxiety, medication can help. For every kind of anxiety, therapy can help. Using both together can help all the more. It’s just a matter of finding the right balance for the individual, something in line with what they’re willing to try.  We want to be able to engage the parasympathetic system, or challenge the sympathetic from taking over and snowballing in a way that’s hard to break out of.  This of course then should include meditation, relaxation exercises, even hypnosis, since they can all help with relaxation.

I may include some easy exercises in future posts that can help.


Why I hate Xanax

A lot of people like Xanax. It’s given out like candy. People get it from their friends, from their primary care doctors, even from their psychiatrist. I hate it. I might go so far as to say it’s evil, though really it’s just bringing out the worst aspects of our nature. In my professional opinion, it’s bad for you.

But no one wants to hear that.

Yes, it feels good when you take it. People take it for anxiety. They feel less anxious (usually) after taking it. Must be working, logic would dictate. Unfortunately this is short-sighted, in the same way that we as a collective society (and medical establishment) view pain as something to annihilate.

Xanax makes you feel good. It brings on euphoria. Heroin feels pretty good too. Feeling good from it doesn’t mean it’s good for you. In fact it is this hedonistic approach of minimizing anything uncomfortable [painful] and maximizing pleasure that leads to more problems with both pain and anxiety. I’ll discuss pain in another post, particularly the overtreatment of pain as a phenomenon which is leading to a significant number of deaths from prescription pain pill abuse and misuse. Here Xanax needs to be addressed.

“My doctor prescribed it for me, so it must be safe.”

“The FDA approved it, so it must be safe.”

In truth nothing is absolutely safe. Water will kill you if you drink enough of it. Seriously. Every medication has its potential benefits and potential drawbacks. You are not guaranteed to get either the benefits or the drawbacks. It’s really a numbers game. Do the benefits outweigh the risks? In Xanax we both overestimate the benefits and underestimate the risks. And those that prescribe it like candy have a fundamental misunderstanding of how anxiety works, in my opinion.

Over and over again I hear –
“But you have to give me Xanax. It’s the only thing that works for my Anxiety.”

Really it doesn’t. It’s giving you the illusion that it’s helping, because it seems to give temporary relief. And it does. It works really fast. It gets into your system quickly, and feels really good really fast.

And then it’s gone.

The anxiety returns. Even worse, there may be withdrawal anxiety as the medication comes out of your system, bringing up all the feelings that your body and mind are out of control. So you turn to the same thing that seemed to help, even if temporarily: more Xanax. As you take it on a regular basis, possibly with increasing amounts, your body becomes tolerant to it. Tolerant means the same amount doesn’t have the effect it used to have. So again you need more of it. If you start to worry about the possibility of anxiety (anticipatory anxiety), you can then make yourself more anxious. Then you’d need a Xanax just to prevent the possibility of something bad happening.

I wish this was a fanciful diatribe with no grounding in reality. I’ve seen hundreds of these patients in my relatively brief career, caught in exactly this cycle.

The basics
Xanax is a benzodiazepine (aka benzo). It’s a tranquilizer. The same drug “family” includes clonazepam (klonopin), diazepam (valium), lorazepam (ativan), chlordiazepoxide (librium), and others. Xanax is notorious because it has such a short half-life, meaning it lasts in your system a brief amount of time. Surely the longer acting tranquilizers must be the better approach? Perhaps. Some people do function on benzo’s. That isn’t really in debate. The question is whether they function better with them than without them, in the long-term, and if there isn’t a safer alternative. In my opinion, they’re a third or fourth line approach, at best.

Anxiety is uncomfortable, and people in our culture don’t want to be uncomfortable. At all. Ever. So logic would dictate we should try to annihilate it. If something helps a little, use it a lot.

This is the rationale that actually leads to anxiety becoming an unremitting problem. Trying to keep it in check, to hide from it, or to hold it at bay, all feeds the problem. Fear is the problem. Psychotherapy figured out the truth: the way to lessen anxiety is to face it, not avoid it.

I had a patient once who had panic attacks. I think of panic attacks as the worst kind of anxiety, so severe it can feel like a heart attack or like you’re dying. He grew up on the streets (homeless for much of his life), coming from a tough childhood. He never had anyone he could trust. He got over his panic attacks without medication, and even without therapy. He had tried Xanax and other meds, and was on the slippery slope of trying to manage the anticipation of anxiety by using more and more benzo’s.  He would think about how bad anxiety could get, and would get anxious about that, and so would end up taking benzo’s just to prevent possible anxiety.  He was getting more and more addicted.

Then one day he got fed up. He was having a panic attack, and felt the fear of dying.

He shouted at himself, while beating his chest, “just fucking do it! Just fucking die already.”

He welcomed the worst possible consequence. And immediately the panic attack went away. The fear fed the panic. When he stopped fearing it, it deflated. It was still uncomfortable, but it didn’t build up the same way. He cured himself.  He doesn’t have panic attacks anymore.

If you want a medication for anxiety, look at the whole picture.

“I only want to take something as needed.” Your anxiety is all day, though. You have brief periods of it getting worse, but the rest of the time there’s some anxiety. So really you need something that works all day. You’re falling into the fear of chemicals while still wanting some chemicals. The issue is that the ones you’re asking for perpetuate or worsen the problem, rather than improve it. It’s a lot harder to treat anxiety in someone already addicted to benzodiazepines than someone not. Thus the slippery slope of good intentions and short-term outcomes.  And I believe medical providers with our good intentions cause more iatrogenic problems with this than we do help people.

The other risks
Unlike other medications for anxiety, the risks with benzodiazepines are much higher. Primarily the risks are seizures and death. If you take too much, you could get oversedated and die. If you mix it with anything that makes you sleepy (or pain medications), you could get oversedated and die. Withdrawing off of benzodiazepines can bring about increased anxiety, but more importantly the risk of seizures. Alternative medications like SSRI’s while not perfect, have far fewer risks to them, and are thus a much safer choice.


–postscript.  Yes, I float between the 1st/2nd/3rd person.


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