Secrets For Surviving Panic Attacks

Well, it’s another Saturday. My avid blog readers might know what that means…I’m at the carwash again for my Inside-Out Wash and Hand Wax. And yes, I know I’m pretty particular about the state of my car, thank you very much, but in my professional opinion there’s no pathology there whatsoever. Anyway, I’m stuck for a minimum two hour sentence at this joint. It’s always the longest two hours of my life, and if I don’t find something to occupy my mind I might just lose it. I usuallly sit inside for the A/C, but the weather was beautiful, so I sat outside on what barely passed as a patio: two of those round concrete table jobbies with the rough curved benches encircling them, surrounded by tall but sparse hedges on three sides. I wasn’t the only one with the bright idea to sit outside- Floridians get very excited in November when the temperature dips below 75 for a second and the cooler breezes make it onshore- we flock to outdoor spaces like Aztecs worshipping the sun. I spied a concrete bench that was empty and sat down with my coffee from my fave place on US-1. There was a dude at my table on the bench across from me, and he didn’t so much as acknowledge my presence when I sat, so engrossed in his phone was he. Fine by me. As I surveyed my company, what struck me was that there were literally zero words being exchanged among the other waiters, even those that were clearly there together. It was like a freaking monestary- if the monestary was right next to a carwash with its particular “music” of Inside-Out Washes and Hand Waxes in the background. I don’t know why I still find the lack of communication, especially in the very most basic sense, to be so alarming, almost disturbing even. I know I’ve gotten into this in so many different blogs and videos, and of course in my book, but it seems like no one talks to anyone anymore. People talk more to Alexa and Siri these days than other people. Anyway, what were my fellow waiters doing while they weren’t talking? They were of course on their phones, just like everyone always is, always on freaking cell phones. I wasn’t the least bit shocked to see what looked like a ten-year-old girl buried in a phone. These days, young kids, I’m talking like age three and up, have phones to play games on, because moms can’t bear to give up their phones to allow the kids to play on them, and if the kids don’t have phones to play on, they’ll drive their moms crazy and make it impossible for the moms to be on their phones. So the obvious solution, nay, the only solution, is to get your four-year-old a phone. I wonder what Dr. Spock or Mr. Rogers or Bert and Ernie would say about the Romper Room set having phones, or even worse, needing phones. 

Anyway, as I sat on the hard and scratchy concrete bench on the “patio” surrounded by the sparse hedges, a woman entered the scene. She walked up and asked if anyone was sitting next to me, to which I said no. The way these benches are curved and situated, it makes it a little awkward to sit at one with a stranger, but she smiled and took a seat next to me. She looked about 40 or so, medium height and weight,  with jet black hair. I guessed she had more than a little Latin blood in her. She was not dressed Saturday casual like the rest of us waiters: she wore a nice black skirt suit with a bright pink blouse, and I assumed she was on her way to work. At where or doing what I had no clue, but realtor was at the top of my guess list. I noticed she wore no wedding ring, though that doesn’t really mean anything these days. She looked like a woman of means, and she was fairly attractive, but something was off. She looked kind of shocked for lack of a better term, like psyche shocked, and she nearly visibly vibrated, like she was plugged into a light socket. She was clearly very unsettled by something, or maybe several somethings, and it or they were simmering just below the surface. I could see she was accustomed to the valiant effort to keep them there, but they were clear as the day to me. Your average person on the street wouldn’t see any of this in her, but I’ve made my living watching and listening to people as they lay bare their pain and fear, and this woman had plenty of both. 

She said her name was Pilar, and that and her slight accent confirmed my previous guess that she was of Latin descent. I knew damn well that something was wrong with Pilar, something that I might be of help with, but also that I might not. My mental machinations continued. She could be in denial, and she could be offended if I offered an opinion. I mean, how many people want to be analyzed by a shrink they just met while waiting at the carwash? I decided that I would not open Pandora’s box. Not going there. I’m just going to sit here in the sun and be polite, but be surface. Mind my own business. Polite, surface. After a moment sitting at the little concrete table, she asked me how long the carwash takes. I dutifully explained that the Inside-Out Wash and Hand Wax took a bare minimum of two hours, especially on a Saturday morning, but that it was well worth the wait. At this, she blew her bangs out on a long resigned sigh. Then motioning to my cup, she asked where she could get good coffee. I gave her directions to my fave spot, which was just up the street on US-1 and told her to ask for “Bailey the Barista, the best barista in the Easta” I had given this name to a barista named Bailey at my fave place because she really is the best barista ever in the vast history of baristas. (ADD side note: what the hell did we call the people who made our coffee prior to the advent of Starbucks?) Pilar laughed and said she’d be back; right after she left, even the guy across from me stood up and said that with my glowing recommendation, he just had to go for a cup as well. How to win friends and influence people…with coffee…who knew, I mused. Maybe the next book? I filed that under ‘Later’ in the grey matter. 

I took Pilar’s absence as an opportunity to remind myself not to get involved, to not play the curious shrink role. No matter how bored to tears, how desperately in need of a distraction I became, I would be strong. I would not go there. Be polite, be surface. You may be wondering why I don’t just announce my profession and delve into stuff with people at every opportunity. First, that would mean I’d have to be ‘on’ and wearing my Dr. hat a lot when I’m at social events and such, when I’d really prefer to be chill. But it goes beyond that. Here’s the thing. Unless someone asks me straight up what I do, I don’t usually tell random people I’m a psychiatrist, because invariably I end up spending a lot of time listening to a story about someone’s Aunt Edna from Des Moines who has 53 cats and hasn’t left her home in 12 years because she’s purposely hoarded it with old newspapers, jars full of pee, and her old fossilized poopy diapers, all as an excuse to never leave, and do I think that maybe she’s depressed and can I give her a prescription for Prozac? There’s a lot of that kind of thing. Another issue that can happen is someone tells me their story, and in my opinion they may actually need help, but when I tell them they should seek that help, they get all pissed off at me. Plus, when I talk to people when I’m out and about, they don’t know that they should have no expectation of privacy because they aren’t patients and we aren’t in my office, and they may tell me some deeply private things, and it just gets messy for me that way. So, for those reasons, and a lot more, I don’t generally just announce that I’m a psychiatrist. But there is a flip side. It’s no secret that I hate to do nothing. I hate waiting for my car to have its Inside-Out Wash and Hand Wax because I have nothing to do while I wait. And remember: I hate doing nothing. So sometimes, like during my interminable wait for my car, when I’m bored out of my skull and climbing the walls, I might be less averse to telling people I’m a psychiatrist, because 100% of the time, it starts what might be an interesting conversation, one that might help pass the time until my car is ready. All I have to do is introduce myself and my profession, “Hi, I’m Dr. Mark Agresti, I’m a psychiatrist. What’s up?” and we’re off to the races. People spill their guts. Other times, I don’t use my last name or announce my profession, but I still engage in the conversation. So it’s kind of like the little cartoon with the angel on one shoulder and the devil on the other and do I dive in or mind my own business? It’s an internal tug-of-war I’m familiar with. Earlier, I had simply introduced myself to Pilar as Mark. In this case, I knew that Pilar was genuinely troubled, but if I told her that I was a psychiatrist, I wasn’t sure how she would take it; she seemed fragile to me. All the more reason for me to be polite but be surface. But on that flip side, I did have time to kill, and Pilar seemed very nice, and maybe I could help her just as another human rather than as a physician. So much for polite and surface. Maybe she wouldn’t even want to open up to me. But maybe she would. I had the feeling it could get deep on this carwash patio. Guess I’d find out. 

With time to kill, I decided to be like everyone else and get on my phone to check my Facebook, or Fakebook as I like to call it. They recently refused to boost one of my posted blogs. Interestingly, it was called “Carwash Psychiatrist” and was all about a different Saturday morning conversation with a steroid-raging mountain-sized man. Fakebook refused to boost it citing inappropriate content. I call total bs on that. I thought it was really informative and interesting, if I do say so myself. It’s on my website if anybody wants to read it and decide for themselves. I re-read it again as I sat there, and still I didn’t think it was inappropriate. I wished I could figure a way to get around Fakebook to boost it. As I considered that, Pilar returned and sat down next to me with her cup of coffee. Her expression was more open than it had been. I think she was more comfortable with me because now we had this coffee connection. Somehow, sitting next to each other drinking coffee together set a mood to talk, a vibe like we were old friends catching up. Glancing at my watch, I saw that I still had an hour until my car would be ready. More than enough time for a conversation, if one arose. I had given up the mental jujitsu match and decided to be polite and open. I could feel Pilar’s dis-ease, referring to her uneasiness, not illness, though she always kept it hidden…or tried to. She looked at her watch and sort of tisked the time, saying that she hoped her car would be done soon because she had to get to work. When I asked her what she did and if she usually worked weekends, she said that she designed and sold high end kitchen cabinetry, and that no, she didn’t normally work weekends, but she was behind because she’d missed a lot of days recently because she’d been sick. This was it. This was the turning point. I could be in or out. Polite and surface or open. I know something’s going on with her, maybe there’s something I can do to help her, so I go there, unable to resist the psychiatrist in me, but at this point still unwilling to tell her there was one. So I went there, I asked her the obvious question that her answer had begged: what was wrong?

She answered, “I thought I was dying.” Okay, I’m looking directly at this woman, and while she looks troubled, she is definitely not dying. I’ve seen dying. I know dying. I decided to take the light-side approach and gave a little non-committal laugh as I said she’d have to narrow that down with some details. She began, “A month ago, I had to go to the emergency room.” I expressed surprise and asked what happened to land her in the ER. She replied, “I woke up one morning and I had this tightness in my chest. I couldn’t breathe, and my heart was racing. I was sweating buckets, and I was so uneasy, like something awful was happening. I thought for sure I was having a heart attack. I had this sensation of pins and needles in my fingers. I didn’t know if I was losing my mind or really actually dying, because I felt like I didn’t know who I was or where I was…I felt like it wasn’t real. Crazy, right?” Before she had even finished her second sentence, I knew that Pilar was describing anxiety, maybe a panic attack, so I said, “Let me take a wild guess, when you went to the ER, they took your vitals, started an IV, drew blood for labs, did a chest x-ray and an EKG and when the results came in, they told you everything was normal, that you just had anxiety.” Surprised, she said yes. When I asked if she’d had other similar episodes, she said, “You know, I have been getting these attacks in the middle of the night when I’m sleeping. When it happens, I wake up and I’m sweating, I can’t breathe, my heart’s hammering, and I feel like I’m honestly losing my mind, because I can’t calm down. I really feel like I’m dying, like I’m having a heart attack, and I’m sure I’m going to die.” When she followed up with her family doctor, he repeated the same tests that the emergency room doctor did and came up with the same conclusion of anxiety, so he gave her 2mg Xanax and told her to break them in half and take a half twice a day. She said it helped a lot, but that she had been living on them for the past 3 weeks, and she was very worried about becoming addicted, because she had read that they are very addictive. She was definitely right on that count. Xanax is very effective at treating anxiety and panic disorders, but it’s a dual edged sword at best and not good as a long term solution. Then she told me that about two weeks ago, she had another attack, and she wanted to try to avoid going to the ER if possible, but she wanted to be close in case she needed them. So she decided to drive to the ER but not go in. She parked and sat in the lot for about 90 minutes, waiting for the attack to subside, but she didn’t go in. She did that same thing twice. Then, she said that she had plans to go out with her friends about a week ago, and she had an attack in her house. She was just about to get in her car to meet them, and she had an another attack. She said that this one was the same deal: shortness of breath, sweating like crazy, feeling like she isn’t real, like she is losing her mind, like she’s having a heart attack and that she’s going to die. It seemed that this had been going on for about a month. Then she said that she was living in a constant state of fear, always scared that she was going to have an attack. And that was why she was working this weekend, because she had called out of work so many times in the past 4 weeks that she was really behind on some projects. I asked her how things stood now, and she said she had stopped all social engagements. She was pretty much confined to her house, only leaving for necessities like going to her office, grocery store, and gas station. It seemed like that was pretty much it, and she needed a Xanax just to do those few things. She was living in constant fear of having the attacks, but now that fear had expanded; now she had fear of getting in her car, fear of driving, fear of being out in public, and even fear of meeting up with her friends. She’s pretty much stuck in her home, only leaving if she absolutely must. So a month into her anxiety and panic attacks, that’s where she stood. It wasn’t good. She’d have to get help to get it under control.

Keep in mind, Pilar doesn’t know what I do, but I kind of needed to push the envelope a little. I asked what her family practice doc’s diagnosis was, and she said he had told her that it was just plain old anxiety. That didn’t jive for me; this wasn’t garden variety anxiety. When I told her that I didn’t think it was just anxiety, she kind of freaked out, eyes wide, asking if she could die from it, if she would be like this for the rest of her life, and if there was a cure for it. And only then did she finally think to ask what it was. I told her with a smile, “I think you’re going to live. I’m pretty sure you have something called panic disorder. I’ve read about it. You should see a psychiatrist, because there are ways to treat it without using addictive drugs like Xanax.” She looked relieved as she asked what panic disorder was. I explained that it’s not a physical illness, it’s a psychiatric illness with attacks exactly like she was describing, and that Xanax works, but that there were other medications for it, and that’s why she should see a psychiatrist. When she asked how I knew about all this, I told her that I had read up on it a lot because I had a sister who was diagnosed with panic disorder. I went on to say that her doctor gave her Zoloft, and that seemed to work really well for her. After two weeks on it, her attacks had basically stopped, and it wasn’t addicting at all like Xanax. When she asked if I knew what caused the attacks, I told her that I’d read that the panic attacks were the result of a false alarm going off in the brain, a suffocation alarm. You think you’re suffocating, you think you’re about to die, but you’re really not. She said she never imagined that something in her brain could cause her to feel like she was really dying, but that she was glad that it was treatable. I told her that when she got on the right medicine, the attacks should go away, just like they had for my sister. She thanked me profusely and assured me that she would see a psychiatrist. Then she lifted her coffee cup, took a big sip, and said she was so relieved. I told her that by the way, caffeine wasn’t the best idea, that my sister had to give it up because it encouraged more attacks. She said she understood, but that between waking up with attacks and taking the Xanax, she was exhausted and needed the boost, but that she would make the effort to stop the caffeine. I reiterated that she should get off the Xanax asap, that it was just a very temporary fix, and she smiled and gave me a funny salute and an “Aye aye, Captain!” 

We continued to talk, and she said that she was glad she had sat down next to me. I kind of felt badly about my little white lies, not telling Pilar that I was a psychiatrist while telling her that I knew about anxiety and panic disorder because I’d read up on it when my sister had been diagnosed with it. The next thing I knew, I heard two last names called, mine being one. The other actually turned out to be Pilar’s. We stood up simultaneously, laughed, and then shook hands as she thanked me again. I told her no problem and to be well. And that’s how it was left. As I got into my freshly Inside-Out Washed and Hand Waxed car, I assuaged the bit of guilt I felt by reminding myself that there is risk in telling people you’re a psychiatrist these days. I didn’t tell Pilar. Maybe I should have, I don’t know. I think I helped her despite holding back the truth, and I felt good about that. I was sure that she would see a psychiatrist and make the effort to stop the Xanax. How weird would it be if she actually came to me, to my office to see me? It could happen. If it did, she might be angry. I’d have to cross that bridge when and if I came to it.

Pilar’s panic disorder is not at all uncommon, unfortunately. By some estimates, approximately two million adults in the United States suffer with panic disorder each year. There are two types of panic disorder: with agoraphobic features and without. Agoraphobia is defined as an extreme or irrational fear of entering open or crowded places, of leaving one’s own home, or of being in places from which escape is difficult. Most people with panic disorder start off without agoraphobia, but if the condition persists without adequate treatment, it can progress to include agoraphobia, where people find it almost impossible to leave their homes. It can be very debilitating, but it doesn’t have to be. Emma Stone, Amanda Seyfried, Sarah Silverman, Oprah Winfrey, John Mayer, Kristen Bell, and Caitlyn Jenner… What do these people have in common? They’re just a few of the many notable people that have panic disorder. That just goes to show that having a psychiatric illness like panic disorder isn’t the end of the world, and it doesn’t have to hold you back. You just need to make the choice to seek appropriate treatment if you suspect that you have it or have been told that you have it. Don’t make the mistake of ignoring it with the hope that it’ll just go away, because it won’t…it’ll only progress.

For more “psych stories,” check out my book, Tales from the Couch, available on Amazon.com.

How To Get People To Like you In Ten Minutes

Through the years I’ve had lots of patients ask me how to interact with people and how to be social, the mechanics of it, so I want to give some rules of the road, social skills 101 if you will. First, let’s talk about why social skills are important. Social skills are the foundation for positive relationships with other people: friends, partners, co-workers, bosses, neighbors, on and on. Social skills allow you to connect with other people on a level that is important in life, a level that allows you to have more in-depth relationships with others rather than meaningless surface relationships that have no benefit to anyone. Once you understand the value of having good social skills, you need to want them for yourself and commit to working on them, because that may mean doing new things that may be uncomfortable at first.  So, how would you start to improve social skills? Well, socialization is an interaction, so you need at least one other person to socialize with. So  the first step is to put yourself among other people. Basically, you have to suit up and show up to socialize. You might feel wierd or shy at first, but don’t let anxiety stop you. If you’re not around other people to socialize with, you’re obviously not going to improve your social skills. So take a breath and dive in.

Step number two, put down the electronics. If you’ve put yourself in a social situation, you may be tempted to fiddle with your phone to avoid the awkwardness of just standing there, but when you’re around people, turn the phone off.  You shouldn’t be disrupted, you can’t be distracted, and you can’t be checking email, messages, notifications, etc. Those things will get you to exactly nowhere. When you’re distracted, you won’t pay proper attention to the social setting you’re in, and since that’s kind of the whole point, put it away and keep it there.

So you’re in a room with plenty of folks to socialize with, your phone is tucked away, so what’s next? Well, if you want to interact with people, socialize with people, you have to look like it. You can’t put yourself in a corner with your arms crossed and a disinterested look on your face. Step three is to demonstrate an open, friendly posture. You need to be inviting to others who may want to talk to you. Put on a friendly face – you’ll be surprised at how many people approach you when you look approachable. 

As they say, the eyes are the entries to the mind. Step four is to always maintain good eye contact. This is hugely important when conversing, but fleeting eye contact also comes in handy when you’re just circulating in a room or looking for someone to strike up a conversation with. Eyes can entirely change a facial expression and easily convey mood and interest. Without eye contact, there is limited communication, and social skills are compromised without appropriate eye contact. Eye contact is so integral to communication that some people say they can tell if someone they’re talking to is being honest or lying by their eye contact, or the lack thereof. 

To communicate well, you must pay attention to your equipment…your speech. So step five is remember your speech: the tone, the pitch, the volume, the tempo, the accent. Right or wrong, people will judge and label you by your voice. A man’s voice that’s too loud is a turnoff, he comes off as a blowhard. A woman’s voice that’s too soft is annoying because people have to try too hard to hear her, and people may say she’s a sexpot, a la Marilyn Monroe. If she speaks at too high a pitch, she’s a bimbo. To some, a southern accent means you’re dumb and a northern accent means you’re a hustler. Speaking too slowly or too fast is annoying, too monotone and you’ll put people to sleep. On the flip side, a singer or actor with perfect pitch or an especially unusual or dulcet tone can build a legacy based just on their voice, a voice that will be instantly recognized for all time. When it comes to the way you speak, be aware and make alterations to be distinct and easily understood. Remember voice inflection, because monotone is a tune-out and turnoff. Speech should be like a story, with highs and lows, ups and downs to hold people’s interest.

After reading step five above, you might think that developing good social skills hinges on everything you say, but that leaves out a key factor…listening. Step six on the path to developing good social skills is to be a good listener. Just listen. Eazy peazy lemon squeazy. Now, if you’ve ever in your entire life enjoyed speaking to someone who clearly wasn’t listening to anything you said, raise your hand. Any takers? Anyone? I thought not. It is annoying AF when it’s so obvious that someone’s not listening to you speak. And you don’t want to be annoying AF, do you? I thought not. Social skills aren’t just about what comes out of a person’s mouth, so listen. 

A great way to deal with nerves that may accompany you when you put yourself in a social situation and talk to people is to find commonality, so this is step seven. When you first meet someone, a sense of commonality is a great way to establish a quick rapport with them. Commonality is something you share. It could be something as simple as going to the same school, a shared interest in sports, same places where you’ve lived or hobbies in common. Step seven is to find commonality with someone; something simple to break the ice and establish a conversation. 

Once you’ve begun a conversation with someone and you want to further it, you need to go beyond just commonalities. You need to relate to the person on a deeper level. How do you do that? Through step eight, empathy. Empathy is the ability to relate to someone by putting yourself in their position in order to understand them better. If someone has a dying parent, has just lost their job, if someone is lonely, has ended a relationship, didn’t get a promotion, or experiences anything that elicits an emotional response, being empathetic is the ultimate understanding of their pain, their sorrow, or their disappointment. Step eight in improving social skills is the ability to put yourself in someone else’s shoes in order to have genuine empathy for that person. A key word here is genuine. As a general rule, good social skills are genuine. Lip service is not part of good social skills.

Step nine is a pretty simple concept, though not so much in practice. Respect. In order to learn good social skills (and have anyone to practice them on) you must respect what other people say. I did not say agree. You can completely disagree with their opinion, but step nine is that you must respect their right to have it and include it in the conversation.  

While in theory you have the right to say anything you want in your social circle, you should watch what you say. Step ten is to consider the content of your conversation. There are certain things that shouldn’t be brought up in some situations. As they say, religion and politics are big no no’s for sure. Gossiping is also on the no list, because it’s really toxic to a conversation and leaves people scratching their heads. If you’re talking about Mary to Connie, Connie’s bound to wonder what you say about her when you’re speaking to Shelly. So it’s best to just not talk about people. But I think it was First Lady Dolly Madison who said “If you don’t have anything nice to say, sit next to me” Some people do like gossip, the jucier the better. But you have to be prepared to pay the piper. A conversation can be like a minefield, with certain subjects as the mines. You have to navigate through the whole conversation without blowing yourself to smithereens.  

In order to have appropriate social skills, you must consider the non-conversational parts of social interaction. If you’re so drunk that you can’t speak or no one can understand what you’re saying, obviously you can’t use good social skills. Same goes for drugs. If you take a Xanax to calm your nerves before the company mixer, you will not have appropriate social skills. You may not think people can tell, but you’d be wrong. Step eleven is  about intoxicants like alcohol, marijuana, benzodiazepines, and Adderall… they all make you act weird and affect your social interactions, and people pick it up right away. They may not know what drug you’re on, but they’ll know you’re on something for sure, because your social interactions will be inappropriate. Rule eleven: you cannot interact appropriately when using drugs or alcohol, so cut both out if you want to have good social skills.

If you follow these steps, you’ll definitely learn better social skills. And a breath mint wouldn’t hurt. Like with anything else, practice makes perfect when it comes to social graces. Be positive, open, honest, empathetic, clear, respectful and sober, and you’ll never be at a loss for people to talk to. You’ll navigate the waters of conversation deftly with give and take, and all included will come out feeling positive about the interaction.

Marianne asks “how can I get off klonopin’’

A woman named Marianne messaged me wanting to know how to get off of Klonopin, which is a benzodiazepine, or benzo for short. She has been taking them regularly for more than twenty years, which is a very long time to be on a benzo. That will certainly complicate things. Before I go into how to stop taking benzos, I want to tell you what they are and what they do. 

What are they?

Benzos are medications designed to treat anxiety, panic disorders, seizures, muscle tension, and insomnia. Some of the most commonly prescribed benzos include: Xanax (alprazolam), Klonopin (clonazepam),Valium (diazepam), Restoril (temazepam),
Librium (chlordiazepoxide), and Ativan (lorazepam). A 2013 survey found that Xanax and its generic form alprazolam is one of the most prescribed psychiatric drugs in the United States, with approximately 50 million prescriptions written that year. Unfortunately, this class of drug is also highly abused. Another 2013 survey found that 1.7 million Americans aged 12 and older were considered current abusers of tranquilizer medications like benzos. When abused, benzos produce a high in addition to the calm and relaxed sensations individuals feel when they take them. 

How do they work?

Benzos increase the levels of a chemical in the brain called GABA. Meaningless trivia: GABA stands for gamma amino-butyric acid. GABA works as a kind of naturally occurring tranquilizer, and it calms down the nerve firings related to stress and the stress reaction. Benzos also work to enhance levels of dopamine in the brain. Dopamine is the feel good chemical, the chemical messenger involved in reward and pleasure in the brain. In simple terms, benzos slow down nerve activity in the brain and central nervous system, which decreases stress and its physical and emotional side effects.  

Why can using them be problematic?

Benzos have multiple side effects that are both physical and psychological in nature, and these can cause harm with both short-term  and extended usage. Some potential short-term side effects of benzos include, but are not limited to: drowsiness, mental confusion, trouble concentrating, short-term memory loss, blurred vision, slurred speech, lack of motor control, slow breathing, and muscle weakness. Long-term use of benzos also causes all of the above, but can also cause changes to the brain as well as mental health symptoms like mood swings, hallucinations, and depression. Fortunately, some of the changes made by benzos to the different regions of the brain after prolonged use may be reversible after being free from benzos for an extended period of time. On the scarier flip side of that coin, benzos may in fact predispose you to memory and cognitive disorders like dementia and Alzheimer’s. They’re many studies currently focusing on these predispositions. A recent study published by the British Medical Journal (BMJ) found a definitive link between benzo usage and Alzheimer’s disease. People taking benzos for more than six months had an 84% higher risk of developing Alzheimer’s dementia, versus those who didn’t take benzos. Long-acting benzos like Valium were more likely to increase these risks than shorter-acting benzos like Ativan or Xanax. Further, they found that these changes may not be reversible, and that the risk increased with age. Speaking of age, there are increased concerns in the elderly population when it comes to benzo usage. Benzos are increasingly being prescribed to the elderly population, many of which are used long-term, which increases the potential for cognitive and memory deficits. As people age, metabolism slows down. Since benzos are stored in fat cells, they remain active in an older person’s body for longer than in a younger person’s body, which increases the drug effects and risks due to the higher drug concentrations, like falls and car accidents. For all of these reasons, benzos should be used with caution in the elderly population. 

A big problem with taking benzos for an extended period is tolerance and dependency. Benzos are widely considered to be highly addictive. Remember that benzos work by increasing GABA and dopamine in the central nervous system, calming and pleasing the brain, giving it the feel goods. After even just a few weeks of taking benzos regularly, the brain may learn to expect the regular dose of benzos and stop working to produce these feel good chemicals on its own without them. Your brain figures, “why do the work if it’s done for me?” You really can’t blame the brain for that! It has become dependent on the benzo. But as you continue to use benzos, you develop higher and higher tolerance, meaning that it takes more and more of the drug to produce the regular desired effect. This tolerance and dependence stuff really ticks off your brain. It’s screaming “why aren’t these pills working anymore?!” The answer is that it has become dependent and tolerant, so it needs more. Just to prove its point, it makes you feel anxious, restless, and irritable as it screams “gimme gimme more more more!!!” The problem is that the body is metabolizing the benzo more quickly, essentially causing withdrawl symptoms, and a higher dose is needed. The longer you’re on a benzo, the more you’ll need. It’s a vicious cycle and it’s sometimes tough to manage clinically. 

The most severe form of physical harm caused by benzos is overdose. This occurs when a person takes too much of the drug at once and overloads the brain and body. The Centers for Disease Control and Prevention (CDC) cites drug overdose as the number one cause of injury death in the United States. A 2013 survey reported that nearly 7,000 people died from a benzo overdose in that year. Since benzos are tranquilizers and sedatives, they depress the central nervous system, lowering heart rate, core body temperature, blood pressure, and respiration. Generally, in the case of an overdose, these vital life functions simply get too low.  

When combining other drugs with benzos, obviously the risk of overdose or other negative outcome increases exponentially. But mixing benzos with alcohol is a special case, deserving of a strong warning as it is life-threatening. BENZOS + ALCOHOL = DEAD. One of the most common and successful unintentional and intentional suicide acts in my patient population is mixing benzos with alcohol. The combo is lethal, plain and simple. The body actually forgets to breathe. People pass out and just never wake up. If you’re reading this and you take benzos with alcohol and you’re thinking that you don’t know what the big deal is, you do it all the time and have never had a problem, then my response to you is that you’re living on borrowed time, and I strongly suggest you stop one of the two, the booze or the benzos, take your pick. 

What about withdrawl from benzos?

Benzo withdrawal can be notoriously difficult. It is actually about the hardest group of drugs to get off of. The level of difficulty is based on what benzo you’ve been taking, how much you’ve been taking, and how long you’ve been taking it. Obviously, if you’ve been on benzos for 25 years, it’s not going to be a walk in the park. To be honest, it’s going to be a rough road. Sorry Marianne. But it can be done. The first and most important thing is that you should never just stop benzos on your own, as it can be very dangerous and can include long or multiple grand mal seizures. Withdrawal from benzos should be done slowly through medical detox with a professional. It is best done with an addiction specialist like myself, because a specialist has the most current knowledge and experience. This is the safest way to purge the drugs from the brain and body while decreasing and managing withdrawal symptoms and drug cravings. As for the symptoms of withdrawl, these can include mood swings, short-term memory loss, seizure, nausea, vomiting, diarrhea, depression, suppressed appetite, hallucinations, and cognitive difficulties. Stopping benzos after dependency may also lead to a rebound effect. This is a sort of overexcitement of the nerves that have been suppressed for so long by the benzos, and symptoms can include an elevated heart rate, blood pressure, and body temperature. There may also be a return of the issues that lead you to take the benzos in the first place, insomnia, anxiety, and panic symptoms, and they can possibly be even worse than before. 

I’m sure that just about everyone currently taking benzos is thinking “I’m NEVER stopping!” right about now. It is not easy to do, but there is a way to manage all of this, to come off of the benzo and deal with all of the physical and cognitive aspects of withdrawl. I do it everyday. I set up a tapering schedule to lessen the specific benzo dosage over time, sometimes over a period of months. I will also often add or switch to a long acting benzo, which can be very helpful. I use several drugs to deal with the withdrawl symptoms: clonidine for tremor and high blood pressure, neurontin for pain and to help prevent seizures, anti-psychotic like seroquel for sleep, and an anti-depressant for depression, thank you Captain Obvious. The drug regimen varies from patient to patient. I also utilize psychotherapy to help work out the psychological kinks associated with withdrawl and rebound effect symptoms. Another trick I strongly recommend to many of my patients, not just those withdrawing from alcohol or any drugs, is transcranial magnetic stimulation or TMS. This is a non-invasive procedure done in the office that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and anxiety, and I’ve found that it seems to calm the nerves and offer relief to some people in withdrawl. Electrodes are placed on the forehead and behind the ears and painless stimuli are passed into certain regions of the brain for 40 minutes in each daily session for about a month. Many patients say it’s the best 40 minutes of their day.

I’d like to wish Marianne good luck. Please feel free to call me at the office at 561-842-9950 if you have any questions. 

To everyone else: If you can avoid ever having to take benzos, I strongly suggest that you do. If you’re currently taking them, give some serious thought to finding an alternative medication. I can help with that. For more information and stories about benzos, other drugs, and the process of medical detox, check out my book Tales from the Couch on Amazon.com.

How To Manage Stress

Rather than just introducing you to today’s topic, I want to play a little game of ‘Who am I?’ I’ll give you ten clues and let’s see if you can guess who I am. And no looking down below and cheating!

1. Everyone has me, either intermittently or constantly.

2. I am an unwelcome guest.

3. Some people deal with me better than others do.

4. I keep lots of people up at night.

5. I make some people physically ill.

6. I can shrink your brain. 

7. Some people take drugs to deal with me.

8. I can make some people binge, purge, or starve themselves.

9. I can cause a whole host of medical problems.

10. I have a good side, but nobody ever gives me credit for it!

Last clue: 

I am defined as “a physical, mental, or emotional factor that causes bodily or mental tension.”

So who am I? 

I am STRESS! 

I see so many stressed out people every day that I thought I’d do a little educational primer on stress.

Stress is a normal psychological and physical reaction to life’s everyday demands. A small amount of stress can be good. Positive stress is officially called eustress, and it can motivate you to perform well. But multiple challenges throughout the day such as sitting in traffic, meeting deadlines, managing children, and paying bills can push you beyond your ability to cope.

What’s going on in your brain when you feel stress? Your brain comes hard-wired with an alarm system for your protection. When your brain perceives a threat or a stressor, it signals your body to release a burst of hormones, especially cortisol, that increase your heart rate and raise your blood pressure. This is part of the fight or flight mechanism. But once the threat or stressor is gone, your body is meant to return to a normal, relaxed state. Unfortunately,some people’s alarm systems rarely shut off, causing chronic stress. When chronic stress is experienced, the body makes more cortisol than it has a chance to release. This has been shown to kill brain cells and even reduce the size of the brain. Chronic stress has a shrinking effect on the prefrontal cortex, the area of the brain responsible for memory and learning. So it’s very important to find effective ways to deal with stress. Stress management gives you a range of tools to reset your brain’s alarm system. Without managing stress, your body might always be on high alert, and over time, this can lead to serious health problems and contribute to mental disorders such as anxiety, depression and post-traumatic stress disorder. So don’t wait until stress damages your health, relationships, or quality of life…start practicing some stress management techniques. 

To help combat the negative effects of stress and anxiety, here are five tips to help manage stress in your daily life…

1. Follow a Regular Sleep Routine
It may seem like simple advice, but often the simplest advice is the best advice. Following a regular sleep routine can help you decompress, recharge, and rejuvenate your body and mind after a stressful day. Try going to bed at the same time every night and aim for 7 to 8 hours of sleep. Resist the urge to stay up late watching TV. In fact, avoid screen time altogether before bed, including tablets and smart phones. Studies have proven that reading on a backlit device before bed interrupts the body’s natural process of falling asleep. These devices also impact how sleepy and alert you are the following day.

2. Use Exercise to Combat Stress
Exercising regularly can have an enormous impact on how your body deals with stress, and it is one of the most recommended ways doctors instruct patients to reduce stress. The endorphins released while exercising can help improve your overall health, reduce stress levels, regulate sleep pattern, and improve mood. The key to exercising is to choose something that you truly enjoy. Whether it’s going for a walk, taking an exercise class at the gym, going for a swim, or lifting weights, exercise keeps us healthy. Make sure to mix up your exercise routine to prevent boredom and stay motivated. 

3. Learn How to Meditate
One of the simplest ways to help alleviate stress is to practice deep breathing and meditation. There’s no secret to this, and you don’t have to chant and burn incense or any of that. It’s just about finding a quiet space without distractions. It only takes a few minutes every day, either before bed or first thing in the morning. Breathe in through your nose, letting your abdomen expand. Hold your breath for a count of three, then breathe out slowly through your mouth. Repeat this three times. Focus on your breathing and your heart beat to prevent thinking about everything that you need to do. If doing it in the morning allows stressful thoughts of the upcoming day to intrude, try it at night. Deep breathing is especially important when your stress levels are high. Aim for meditating for at least 15 to 20 minutes, but if you’re feeling pressured during the day, a quick 5-minute meditation session can help you chill out.

4. Take Care of Your Skin
It may not seem like skin care and stress prevention are linked, but they are. Have you ever noticed that your skin is more prone to break out when you’re stressed out? How many times have you gotten up for work all stressed out about a presentation and looked in the mirror only to see a big zit on your nose? For crying out loud…why the heck is that?!!? How does your skin know you have a big presentation? Well, stress causes a chemical response that makes your skin more sensitive. And as we discussed, your body produces more cortisol when stressed, which causes your sebaceous glands to produce more oil. More oil means oily skin that is prone to acne. So it’s important not to neglect your skin care routine, especially when you’re stressed out. This goes for both guys and girls. You may be exhausted at night and want to go straight to bed, but taking an extra few minutes to wash your face and remove daily dirt and any facial products or makeup you’ve worn during the day will make a world of difference. And if you’re prone to oily or dry skin, always choose skin care products that are specifically designed for your skin type. Your skin will thank you for it by surprising you with big red zits less often. 

5. Ask For Help When You Need it
Asking for help may not always be easy, but when you need a shoulder to cry on or someone to listen, it can help put things into perspective.  Seeking support from family and friends or a professional isn’t a sign of weakness. In fact, it takes courage to admit you need help. Many patients that I see for the first time have been needlessly suffering for so long. I feel terrible for them. There is no reason not to seek help for any ailment affecting your health, especially your mental health. Patients who wait until they start to develop multiple physical and psychiatric issues before seeking help have a much harder time recovering than those who seek help sooner. Remember that friends and family are great support, but if you develop any signs of anxiety or depression or other mental health issues, get help from a licensed mental health professional immediately. In my experience, some patients may need medication, but some do not, they find relief through simple talk therapy with me. It’s very much an individualized assessment. While not a replacement for professional help, you can also look for online support groups for stress management. You’re not the only person who’s ever dealt with a specific stressful situation, so why not discover how other people managed their stress and overcame a potentially frustrating situation.

Hopefully after reading this you have a better understanding of what stress is, how it can impact your physical and mental health, and what you can do to start dealing with it effectively to minimize its role in your life. If you feel you need help, call my office for an appointment. I can help you. For more mental health topics and stories, check out my book Tales from the Couch, available on Amazon.com or for purchase in my Palm Beach office. 

How To Sleep Better At Night

Slumber, shuteye, repose, siesta, snooze…Sometimes we have a love-hate relationship with it…we love it when it’s good and curse it when it’s bad, but we all need it. Whatever you call it, one complaint I hear from patients day in and day out is that they have difficulty sleeping. It’s so prevalent that I want to discuss how to  get better sleep. In my 30 years of practice, I’ve compiled a list of 14 things in no specific order that you can do that should have you snoozing at night night in no time. 

Rule 1: Bright light during the day.  Your body has to have bright light during the day; sunshine is best, but even sitting in a bright room, like by a window, is helpful. Bright light tells your brain that it is day time, time to be awake. Darkness or the absence of bright light tells the brain it is night time, time to sleep. If you’re in a dark room all day, you probably won’t sleep well at night. So remember, in the day time, bright light is right. 

Rule 2: Limit blue light. What is blue light? Blue light is what is emitted from your computer, laptop, and smartphone. The more blue light you are exposed to, especially at night, the more disruption you’ll have in sleep, as it disrupts circadian rhythm. Lots of people climb into bed with their cell phone or iPad, and that’s the worst thing to do. You should avoid looking at bright screens beginning two to three hours before bed. There are apps you can install on your phone that filter out the blue light. There’s also something called “F. Lux” that you can put on your computer or iPad which will block out the blue light. You never hear about it, but blue light exposure, especially at night, is a major factor in hindering sleep. 

Rule 3: Captain Obvious here with a newsflash. Caffeine will keep you up at night. Don’t think you’re going to have coffee or tea after dinner or before bed and expect to sleep. And if you’re drinking sodas, coffee, or iced tea all day, it’ll still disrupt your sleep. I tell patients to limit caffeine consumption to under 250 – 300mg a day. As a guide, an 8oz cup of coffee has about 100mg caffeine, the same amount of tea has 24mg, a 12oz can of soda has 34mg, and those gnarly energy shots have 200mg of caffeine! I strongly advise against consuming caffeine after lunch if you plan on a bedtime between 10pm and midnight.  

Rule 4: No naps! Boo! Hiss! Why is it that as kids, just the word nap sent us into a tizzy tantrum, but as adults we love naps? If anyone has an answer, please let me know. Anyway, as satisfying as it is, napping disrupts your sleep-wake cycle, temporarily resetting it to where you’re not likely to be able to go to bed between 10pm and midnight. Bummer. 

Rule 5: Melatonin. I recommend 2 to 4mg of melatonin at bedtime; it really seems to help a lot of my patients. I do find that some patients get daytime hangover from it though, so you’ll have to see where you fall on that one. But it’s definitely worth a shot if you’re suffering from insomnia. 

Rule 6: Get up at the same time every day, and go to bed at the same time every day. Yeah, it’s kind of a drag not sleeping in on weekends, but a sleep routine can make a big difference in your relationship with Mr. Sandman. You can’t regulate when you’ll fall asleep, but you can regulate when you wake up. So set your alarm and get up at the same time every day, no matter how tired you are. Don’t nap and go to sleep between 10pm and midnight, and you should fall asleep. If sleep still eludes you, stick to the same plan, and you should surely sleep the second night. You can’t decide when you’ll fall asleep at night, but you can regulate your sleep-wake cycle by deciding when you wake up. Stick to setting your alarm for the same time every day, and hopefully your brain will get the idea. 

Rule 7: I recommend taking a glycine or magnesium supplement at night as well as L-theanine and lavender. They don’t make lavender teas, pillow sprays, lotions, and sachets for nothing. I have heard from people that swear by lavender as part of their wind down routine before bed. You can find these supplements on Amazon.com. Shameless plug: handily enough, you can also find my book, Tales from the Couch for sale there too. Check it out. 

Rule 8: This is the Mac Daddy, numero uno, absolute, not-to-be-broken rule. Alcohol. If you consume alcohol before sleep, you will not sleep. Why? As the body metabolizes the alcohol, it goes into a withdrawl-like reaction and disrupts sleep. I know what you’re thinking. You’re thinking that a little nightcap helps you sleep. Wrong. Some people will tell you differently, but trust me…alcohol and sleep do not play well together. 

Rule 9: A comfortable bedroom. Your bedroom should be an oasis of calm serenity. There should be no office or desk in the bedroom. It should be uncluttered. Anything not conducive to sleep should be out. Make sure it’s dark and quiet at bedtime. The weight of multiple blankets can help sleep. You can even purchase weighted blankets expressly for this purpose. The weight is comforting and relaxing to the body. 

Rule 10: This sort of goes hand in hand with #9 above. Try a low temperature in the bedroom. I personally make sure my bedroom is at 70 degrees. The blankets from rule number 9 come into play here too. There’s something very comforting about burrowing under fluffy blankets to go to sleep. I mean, they’re called comforters for a good reason. 

Rule 10: No eating late at night. People seem to mostly make terrible food choices at night, all in the name of snacks…chips, candies, baked goods. Sugary foods are especially bad. When you eat, the body goes into digestive mode, not sleep mode; it is very interfering to sleep. Sugars especially are no bueno. Evening or night snacking is one of the worst things you can do If you want to sleep.  

Rule 11: Relax and clear your mind. There’s an older pop song that has a lyric, Free your mind and the rest will follow. It’s true. We all have problems and stresses throughout the day, and they seem to pop up when your head hits the pillow. You have to come to some resolution on how you’re going to handle the problems in your life and put them to bed so that you can put the rest of you to bed.  

Rule 12: Spend money on a comfortable quality mattress. You’re going to spend a third of your life in your bed. Just suck it up and spend the money on the mattress. Don’t cheap out. Another place to spend money is on good linens. Few things are as inviting as a comfortable mattress covered in minimum 1,000 thread count all-cotton sheets. If you’ve never had nice linens, try them.You can pick them up on a white sale or online. You can thank me later. 

Rule 13: No exercising late at night.  When you exercise late at night, you raise blood pressure and heart rate, which will hype up the body, which is the antithesis of what you want when it’s time to sleep.  

Rule 14: No liquids prior to sleeping. No rocket science here. If you put liquids in, you’re going to need to get liquids out. In other words, you’re going to have to get up in the middle of the night to pee. And you’re probably going to stub your toe. Not good. 

This is my handy dandy guide on the do’s and don’ts when it comes to sleep. Anything is better than counting sheep. I don’t know who came up with that, but I would like to inform them that I have never in 30 years heard of it working. I’ve never before wanted people to fall asleep as a result of reading something I wrote, so this is a first! I hope you’ve learned some things here that will put you out like a light.

Warning Signs Of Bipolar

As a psychiatrist practicing in Palm Beach Florida, I come across a lot of bipolar patients.  What are the warning signs of bipolar disorder? How can you recognize if someone you love or even yourself has bipolar disorder? You can’t get through an hour television program without at least 2 commercials for bipolar medications, so I thought it would be a good idea to talk about it. 

First, what is bipolar? Bipolar disorder is a mental health disorder more commonly found in women that can cause dramatic changes in mood and energy levels. The term bipolar refers to the two poles of the disorder, the extremes of mood. Those two extremes of mood are mania and depression. The symptoms of bipolar can affect a person’s daily life severely as their mood can range from feelings of elation and high energy to depression. There are two types of bipolar, type 1 and type 2. Type 1 is more serious and disruptive than type 2, which can also be called hypomania. 

Bipolar is sort of the Jekyl and Hyde of psychiatric disorders, with cycling of mania and depression. Manic episodes and depressive episodes have very specific signs and symptoms associated with them.

When someone is manic, they do not just feel very happy. They feel euphoric. Key features of mania include, but are not limited to:

– irritability 

– having a lot of energy
– feeling able to achieve anything
– having difficulty sleeping
– using rapid speech that jumps between topics.
– inability to follow through with ideas or tasks

– feeling agitated, jumpy, or wired
– engaging in risky behaviors, such as reckless sex, spending a lot of money, dangerous driving, or unwise consumption of alcohol and other substances
– believing that they are more important than others or have important connections
– exhibiting anger, aggression, or violence if others challenge their views or behavior
– in severe cases, mania can involve psychosis, with hallucinations that can cause them to see, hear, or feel things that are not there.

People in a manic state may also  have delusions and distorted thinking that cause them to believe that certain things are true when they are not. While I have many patients that get delusions of grandeur, I have one patient that comes to mind. Her name is Felicia. Felicia is a 32-year-old receptionist. She was diagnosed with bipolar type 1 when she was 25, which happens to be the typical age of diagnosis. Felicia is on two medications for her bipolar with mixed results. She still cycles occasionally to a manic state. Sometimes that’s a clue that she may not be compliant with her meds. Like many bipolar people, Felicia loves loves loves her manic state. When Felicia is manic, she is on top of the world. Her house is pristinely clean, the meals she makes for her family are total gourmet, and her appearance is perfect. Sounds great, right? You may be thinking ‘Where’s the downside, Dr. A?’ Well, in this manic state, Felicia absolutely positively believes that she is descended from “the true” royalty. She believes that the father of the current Queen of England, the previous King George VI, actually stole the monarchy and the crown from her father. As a result, she believes that she should be the rightful current monarch. In reality, her father is a semi-retired urban planner living just outside of Topeka Kansas. Regardless, when Felicia is super manic, she will relay this story with a voice full of indignation and a perfectly straight face. She will tell anyone this story, so people think she’s totally nuts. 

A person in a manic state may not realize that their behavior is unusual, but others may notice a change in behavior. Some people may see the person’s outlook as eccentric or sociable and fun-loving, while others may find it unusual or bizarre. The individual may not realize that they are acting inappropriately or be aware of the potential consequences of their behavior. In some cases, they may need help in staying safe when they are completely out of touch with reality. Bipolar type 1 patients can be some of the most dangerous patients in my practice, as they can be violent, prone to rage and acting out on that rage. They are chaotic. If you have an untreated or ineffectively treated bipolar 1 person in the household, you will know. One big problem is that patients enjoy the manic state of their disorder. They feel such increased energy and euphoria that they are prone to stop taking their meds. Once that happens, all hell breaks loose. 

But eventually, that mania will cycle into deep depression with all of the symptoms that go with it, and may end with suicidal thoughts or acts. Key features of depressive episodes may include, but are not limited to:

– feeling down or sad
– having very little energy
– having trouble sleeping or sleeping a lot more than usual
– thinking of death or suicide
– forgetting things
– feeling tired
– losing enjoyment in daily activities
– having a flatness of emotion that may show in the person’s facial expression
– In very severe cases, a person may experience psychosis or a catatonic depression, in which they are unable to move, talk, or take any action.

Bipolar type 2, also called hypomania, is a disorder which is sort of like type 1-light. It features episodes of depression and hypomania. Symptoms of hypomania are similar to those of mania, but the behaviors are less extreme, and people can often function well in their daily life. But if a person does not address the signs of hypomania, it can progress into the more severe form of the condition at a later time. I see type 2 patients more often in my practice, and I see them as generally being much calmer than type 1 patients. They do not get as violent, do not hear voices, do not have hallucinations, and are not disorganized in their speech or behavior. However, they are usually irritable. They talk quickly. They have trouble sleeping. They have trouble concentrating. They have trouble getting things done. They have relationship issues. They have trouble sleeping. These periods of hypomania can last anywhere between minutes to days to weeks.

So what can be done for a patient suffering from bipolar disorder, whether type 1 or 2? There are multiple drugs which can be used to balance the patient. I find my go-to drug would be lamotrigine, as it is minimal in its side effect profile, is mood stabilizing, does not put on weight, does not make you drowsy, and does not have many drug interactions. There are other drugs which can be used,  oxcarbazepine and divalproex, which are antiseizure mood stabilizers. These have some effectiveness and have various side effect profiles. In some cases, antipsychotic drugs like lurasidone are useful. Many times I put patients on at least two drugs, one to treat mania and one to treat depression. I can prescribe all the drugs in the world, but they won’t do any good if patients are non-compliant in taking them. So the biggest and most important key feature in treating bipolar is having a relationship with the patient and making sure they are compliant with medicine, because the manic state is so enjoyable to them that they may choose non-compliance. That’s really the biggest barrier to treatment. I always explain to my manic patients that while they may like the mania, they will have to pay the piper, because guess what? Next they’ll be hopelessly depressed and unable to get out of bed.

In my practice, I see many female patients with mood disorders. The way I approach treatment is to find the best tolerated drug. This may not be the best drug on the market, but may be the best drug for that patient because it is better tolerated and has a better side effect profile for that patient. If the drugs cause weight gain, make them drowsy, or cause sexual dysfunction, they won’t take them. And who would blame them? So I work very hard to explore all available pharmaceutical treatment options for each patient as an individual. The goal is to have a drug regimen which is the least invasive in that person’s life and to combine that with psychotherapy. Because bipolar disorder is a lifelong disease, treatment should also be lifelong. If you suspect that you have bipolar or a loved one has bipolar, contact a physician for referral to a mental health professional like myself. For more information, check out my book, Tales from the Couch, available on Amazon.com. 

Post-traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a severe anxiety disorder that can develop after exposure to any event that results in-psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one’s own or someone else’s physical, sexual, or psychological integrity, overwhelming the individual’s ability to cope. As an effect of psychological trauma, PTSD is less frequent and more enduring than the more commonly seen acute stress response. Diagnostic symptoms for PTSD include re-experiencing the original trauma(s) through flashbacks or nightmares, avoidance of stimuli associated with the trauma, and increasedarousal – such as difficulty falling or staying asleep, anger, and hypervigilance. Formal diagnostic criteria (both DSM-IV-TR and ICD-10) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.

Agoraphobia (Without History of Panic Disorder)

Agoraphobia Without a History of Panic Disorder is an anxiety disorder characterized by extreme fear of experiencing panic symptoms, of panic attacks.

Agoraphobia typically develops as a result of having panic disorder. In a small minority of cases, however, agoraphobia can develop by itself without being triggered by the onset of panic attacks. Historically, there has been debate over whether Agoraphobia Without Panic genuinely existed, or whether it was simply a manifestation of other disorders such as Panic Disorder, General anxiety disorder, Avoidant personality disorder and Social Phobia. Said one researcher: “out of 41 agoraphobics seen (at a clinic) during a period of 1 year, only 1 fit the diagnosis of agoraphobia without panic attacks, and even this particular classification was questionable…Do not expect to see too many agoraphobics without panic” (Barlow & Waddell, 1985) . In spite of this earlier skepticism, current thinking is that Agoraphobia Without Panic Disorder is indeed a valid, unique illness which has gone largely unnoticed, since its sufferers are far less likely to seek clinical treatment.

Agoraphobia

Not to be confused with agraphobia, agoraphobia is a condition where the sufferer becomes anxious in environments that are unfamiliar or where he or she perceives that they have little control. Triggers for this anxiety may include wide open spaces, crowds (social anxiety), or traveling (even short distances). Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a panic attack and appearing distraught in public. This is also sometimes called ‘social agoraphobia’ which may be a type of social anxiety disorder also sometimes called “social phobia”.

Not all agoraphobia is social in nature, however. Some agoraphobics have a fear of open spaces. Agoraphobia is also a defined as “a fear, sometimes terrifying, by those who have experienced one or more panic attacks”. In these cases, the sufferer is fearful of a particular place because they have experienced a panic attack at the same location in a previous time. Fearing the onset of another panic attack, the sufferer is fearful or even avoids the location. Some refuse to leave their home even in medical emergencies because the fear of being outside of their comfort area is too great.

The sufferer can sometimes go to great lengths to avoid the locations where they have experienced the onset of a panic attack. Agoraphobia, as described in this manner, is actually a symptom professionals check for when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post traumatic stress disorder can also cause agoraphobia, basically any irrational fear that keeps one from going outside can cause the syndrome.

It is not uncommon for agoraphobics to also suffer from temporary separation anxiety disorder when certain other individuals of the household depart from the residence temporarily, such as a parent or spouse, or when the agoraphobic is left home alone. Such temporary conditions can result in an increase in anxiety or a panic attack.

Another common associative disorder of agoraphobia is necrophobia, the fear of death. The anxiety level of agoraphobics often increases when dwelling upon the idea of eventually dying, which they consciously or unconsciously associate with being the ultimate separation from their mortal emotional comfort and safety zones and loved ones, even for those who may otherwise spiritually believe in some form of divine afterlife existence.

Gender differences

Agoraphobia occurs about twice as commonly among women as it does in men. The gender difference may be attributable to several factors: social-cultural traditions that encourage, or permit, the greater expression of avoidant coping strategies by women (including dependent and helpless behaviors); women perhaps being more likely to seek help and therefore be diagnosed; men being more likely to abuse alcohol in reaction to anxiety and be diagnosed as an alcoholic. Research has not yet produced a single clear explanation for the gender difference in agoraphobia.

Causes and contributing factors

Although the exact causes of agoraphobia are currently unknown, some clinicians who have treated or attempted to treat agoraphobia offer plausible hypotheses. The condition has been linked to the presence of other anxiety disorders, a stressful environment or substance abuse. Chronic use of tranquilizers and sleeping pills such as benzodiazepines has been linked to onset of agoraphobia. In 10 patients who had developed agoraphobia during benzodiazepine dependence, symptoms abated within the first year of assisted withdrawal.

Research has uncovered a linkage between agoraphobia and difficulties with spatial orientation. Individuals without agoraphobia are able to maintain balance by combining information from their vestibular system, their visual system and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse (as in wide open spaces) or overwhelming (as in crowds). Likewise, they may be confused by sloping or irregular surfaces. In a virtual reality study, agoraphobics showed impaired processing of changing audiovisual data in comparison with healthy subjects.