Diagnosing and Treating Mental Illness
A Guide for Physicians, Interns, Nurses, Patients, and Their Families
Updated edition
By John V. Wylie, M.D.
_
Smashwords Edition
First Copyrighted 2010 by Demers Books LLC
Rights transferred to author July, 2011
Second edition Copyrighted 2012 by John Wylie
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without permission of the author.
ISBN for this Edition: 978-1-4524-2268-8
Cover photograph by John Consoli
Books Shown on the Cover
Counsels and Ideals & Selected Aphorisms
by William Osler
*
The Practice of Behavior Therapy
by Joseph Wolpe
*
Cognitive Therapy of Depression
by Aaron Beck, John Rush, Brian Shaw, Gary Emery
*
Alcoholics Anonymous Big Book
Textbook of Psychopharmacology
by Alan Schatzberg and Charles Nemeroff
*
Comprehensive Textbook of Psychiatry,
by Benjamin Sadock and Virginia Sadock
*
A Treatise on Insanity
by Phillippe Pinel
*
The Idea of Phenomenology
by Edmund Husserl
*
Basic Writings
by Sigmund Freud
*
The Origin of Species & The Descent of Man
by Charles Darwin
Reviews for first edition:
Editorial Review - Library Journal vol. 134 iss. 16 p92 (c) 10/01/2009
Wylie (clinical psychiatry, Georgetown Univ.) shares his 35-plus years of experience as a clinical psychiatrist in this new guidebook that helps diagnose common mental health conditions and offers guidelines for health-care workers for treatment or referral to mental health experts. Wylie's focus is to distinguish normal emotional problems experienced by healthy people from psychiatric conditions that should be regarded as medical sicknesses and to provide a concise compilation of modern treatments for mental illnesses.
VERDICT Offering an excellent foundation of basic knowledge on the most common mental illnesses, this will be of some value to erudite lay readers, but the succinct, highly clinical chapters are more relevant for primary health-care providers.—Dale Farris, Groves, TX
*
Reviewer: Vincent F Carr, DO, MSA, FACC, FACP(Uniformed Services University of the Health Sciences)
Description: This is a simple approach to mental illness developed by an experienced academic psychiatrist. Dr. Wylie looks back over his 35 years of practice and presents a common-sense retrospective evaluation of the changes in psychiatry during that time. It is an extraordinary book, removing the social politics and focusing on what works.
Purpose: The author offers plain language explanations and encourages primary care practitioners to accept more responsibility for the psychiatric care of patients. He makes an important differentiation, and injects his common sense, between the words "clients" and "patients," which has irritated many physicians — a nice, welcome touch.
Audience: Anyone in healthcare — medical students, residents, attendings, nurses, and paraprofessionals - can benefit from this book. It is well written and helps define which professions should be caring for which patients and how to work together.
Features: The book is divided into generalized chapters, but the division is logistical only, as the author's thought process carries the discussion along, integrating concepts very nicely among the chapters.
Assessment: This is a valuable book, grounded in common sense. Everyone in healthcare should read it. The lessons of this experienced academician are well worth the time.
For my patients
and
my brother, Bob
TABLE OF CONTENTS
1. THE NATURE OF MENTAL ILLNESS
2. WHO SHOULD TREAT MENTAL ILLNESS?
4. PATHOLOGICAL DEPRESSION: THE SHUTDOWN RESPONSE
5. PATHOLOGICAL ANGER: STRESS, FRUSTRATION & VIOLENCE
6. OBSESSIVE COMPULSIVE DISORDER (OCD)
7. POST-TRAUMATIC STRESS DISORDER (PTSD)
8. ADDICTION, COMPULSION & IMPULSE CONTROL
12. FINAL COMMENT FROM THE AUTHOR
DETAILED TABLE OF CONTENTS
PREFACE
1. THE NATURE OF MENTAL ILLNESS
2. WHO SHOULD TREAT MENTAL ILLNESS?
3. PATHOLOGICAL ANXIETY
Panic: The Nexus of Anxiety
What Panic Tells Us about Anxiety
Two Anxieties: Being Trapped and Abandoned
Physical Symptoms in Panic
Should Patients Change Their Lives or Treat the Illness
Causes of Panic: Genes vs. Childhood Upbringing
Treatment of Panic and Pathological Anxiety
Phobias
Generalized Anxiety Disorder (GAD)
Anxiety: Mental Illness or God-Given Attribute
Hysteria and Suicide
Hysterical “Overlay” in Sickness & “Underlie” in Marriage
4. PATHOLOGICAL DEPRESSION: THE SHUTDOWN RESPONSE
Atypical Depression: Separation Anxiety
Treatment of Atypical Depression
Medications in Treatment of Atypical Depression
Melancholic Depression: The Fear of Being Trapped
Treatment of Melancholic Depression
Medications in Melancholia
Electroconvulsive Treatment (ECT)
Chronicity (as in chronic)
5. PATHOLOGICAL ANGER: STRESS, FRUSTRATION & VIOLENCE
Snit Disorder and Abuse
Treatment of Snit Disorder
Borderline Personality Disorder
Treatment of Borderline Personality Disorder
6. OBSESSIVE COMPULSIVE DISORDER (OCD)
Two Components of OCD
Treatment of OCD
Medication Treatment of OCD
7. POST-TRAUMATIC STRESS DISORDER (PTSD)
8. ADDICTION, COMPULSION & IMPULSE CONTROL
Alcoholism
Detoxification
Treatment of Alcoholism
Treatment of Alcoholism with Medicines
Other Addictions
Eating Disorders
Treatment of Eating Disorders
Sexual Disorders
9. BIPOLAR DISORDER
Mixed State Bipolar Disorder
Treatment of Bipolar Disorder
10. SCHIZOPHRENIA
“Voices”
Treatment of Schizophrenia
11. DEMENTIA
12. FINAL COMMENT FROM THE AUTHOR
ABOUT THE AUTHOR
END NOTES
PREFACE
Medicine is in my bones. I am a fourth generation physician and started out as a surgeon, my father’s esteemed profession. After several years of training, I decided it was not for me. In college, I had majored in the liberal arts and felt the center of my interests were humanistic. After an interim in which I immersed myself in Freud and Jung, I made the decision to train in psychiatry. Although absorbed by the theories of Sigmund Freud, the doctor in my bones was disturbed that they mainly pertained to patients with milder psychiatric conditions. Then, with the arrival of Prozac, it seemed as if the entire edifice of psychoanalysis calved like a glacier into the biochemical soup of the brain.
I have never lost my conviction that, for now and many generations to come, the most accurate descriptions of mental illness derive not from examinations of the brain but from the mouths of patients who suffer from these enigmatic sicknesses. This book consists of what my patients have told me about their illnesses and what made them feel better.
Having pondered the nature of human emotions in health and sickness from many years, I have come to the conclusion that the basic emotions of fear and anger, each exist in pairs and each are in dynamic balance. The fear of being trapped pushes us outward and the fear of separation holds us back. The rage to survive and procreate thrusts us out and the rage granted to the authority of society presses back upon us. Our astonishing abilities to think and speak depend upon the intensity of integration between these interacting emotions; each pair inveighs upon one another both internally and between each other while maintaining equilibrium.
It is the sheer volume of these emotional dynamics that, at a certain threshold, also makes them vulnerable to imbalances that cause them to spin out of control. More generally, it is the intensity of emotional reactivities amongst these balanced pairs of emotion that comprise an individual’s temperament. A temperament with specific sensitivities can then be pathologically “tuned up” in childhood by certain kinds of stress, or, perhaps, not sufficiently “toughened up” by not enough of certain other kinds of stress. I will never believe that “too much love” causes mental illness. Quite to the contrary, love constructs a sanctuary that, as I have witnessed many times, can sustain a patient through the ravages of these sicknesses whose very existence in our collective mind hides beneath the shroud of our ignorance about them.
Each individual is born with an electronic instrument pre-tuned by the mysteries that braided together its strings to be set in motion by rapidly changing new worlds of experience. Whether who we are as individuals is thrust upon us or chosen by us, mental illness is a part of who we are and how we suffer as a group. Thus, being an intrinsic part of us, we should embrace the mentally ill amongst us and regard them as deserving of our respectful care for paying the price for the soaring genius of our human family.
Chapter 1
THE NATURE OF MENTAL ILLNESS
The term “existential” has been informally adopted by the psychiatric community as an adjective to describe emotional problems experienced by individuals who are basically psychiatrically healthy. The purpose of this Guidebook is to help distinguish existential problems from psychiatric conditions — conditions that should properly be regarded as medical sicknesses — and to provide a concise guide to modern treatments for them. Of course, psychiatry has undergone a major transformation during the past half century with the development of effective medications that are now at the disposal of those primary care physicians who have the inclination to participate in the care of the mentally ill. This book is designed to assist in this participation and as a resource for physicians, nurses, therapists, and patients and their families.
The scientific understanding of the pathophysiology of mental illness lags behind the rest of medicine because of the sheer complexity of the brain. There are no biometric tests for mental illness in clinical use. The fact remains that the most reliable way to diagnose mental illness is to carefully ask the patient to describe how they feel. The Diagnostic and Statistical Manual of Mental Disorders, or DSM, consists of lists of symptoms for each condition that are heavily dependent on patients’ subjective reports of how their experience feels to them. Sigmund Freud and his followers built the entire theory of psychoanalysis on the basis of patients’ subjective reports of their emotional experiences. The study of mental function and malfunction by means of examining subjective experience is called phenomenology and, although it is a far cry from the concrete certainty of scientific knowledge, in the area of psychiatry it continues to have central relevancy.
Human emotional function is characterized by the interaction of a wide variety of emotions, some of which are in conflict with one another. In health, all these emotions are held in a dynamic balance. It is the thesis of this book that the central theater in which mental illness occurs is at the brain level within which these emotions dynamically and functionally interact. Mental illness occurs when the balance between specific emotions is disrupted. Similar to other complex disorders, the genetic vulnerability to mental illness is diffuse with many genes having small effects, and the biochemistry is a veritable jungle of cause, compensation, and effect. However, trying to understand the genetic basis and microbiology of mental illness before thoroughly understanding the “gross pathology” at the level where emotions functionally interact is like trying to understand the genetics and microbiology of diabetes before understanding the role of insulin.
During the 35 years of my practice as a clinical psychiatrist, I have attempted to assemble a phenomenological theory that specifically distinguishes the aspects of mental conditions which are pathological from those which are existential. In essence, I have tried to give a theoretical structure to the symptoms in the diagnostic manual. Over the years, I have observed how, in each illness, specific normally functioning emotions transform into mental illness, and, when the patient improves, have observed how they fit back into their prior normal function. Close attention to how patients describe the subjective effects of psychiatric medications has provided clarification as to the nature of how emotions malfunction in mental illness.
I believe that the pathological transformations undergone by normally functioning emotions are similar to fundamental mechanisms in other medical illnesses that disrupt normal function. For example, mental illness occurs in the brain. The brain is composed of electrochemical circuitry which is regulated by negative feedback controls at many levels. Indeed, the breakdown of feedback regulation from the molecular level all the way up to complex biological processes is surely one of the most fundamental pathological mechanisms in all of medicine.
The simplest examples of negative feedback regulation are hormonal systems in which the substance that stimulates the production of a hormone is inhibited by the hormone itself, such that its level is regulated. In negative feedback, one element stimulates or amplifies another element, which, in turn inhibits or dampens the first. In uncontrolled positive feedback, both elements stimulate or amplify each other. The most commonly experienced example of positive feedback is the squealing of a speaker hooked up to a microphone in a noisy room. The noise is picked up by the microphone, amplified and put out by the speaker; then picked back up by the microphone, around and around up to a squeal (feedback reverberation) until the amplifier is turned down. Most simply put, this is the model I am putting forth as the fundamental phenomenon of mental illness.
Sex is the best gross example of positive feedback. Need I spell out the details? In complex systems, there are positive feedback interactions, which tend to “rev” things up, combined with negative feedback interactions which tend to calm things down. When two people get angry with each other, they act as a positive feedback loop up to the point at which negative feedback controls fail and violence ensues. Similarly, when two people become frightened they too can form a positive feedback loop until negative feedback controls fail and they become hysterical. In mental illness, negative feedback controls on internally interacting emotions fail, releasing them into the squeal of what I will repeatedly refer to as “feedback reverberation.” I shall also express this pathology by using the image of emotions “locking up” into feedback reverberation.
The perspective that mental illness represents the release of emotions into uncontrolled hyperactivity is consistent with the science of psychiatry as it is understood so far. Functional imaging of all psychopathology reveals central aspects of neurological hyperactivity across multiple structures of the brain. The fact that vulnerability to mental illness most likely occurs diffusely at the molecular level does not preclude the probability that the primary locus of the pathology itself exists at high levels of the brain, nor does it preclude secondary effects at the molecular level which not only might contribute to the intransigence of the pathology but also perhaps provide the substrate for intervention with medications and other physical treatments. In short, I firmly believe that a “top down” understanding of mental illness should continue to illuminate a scientific understanding.
The mystery of why these illnesses have not been swept away long ago by natural selection has led some to believe that mental illness, at least during some time in the past, served adaptive social functions. As others have suggested, it is possible that some of the genes implicated in mental illness are adaptive in combination with one set of genes but cause mental illness with another set; but I (along with all my patients) am adamant that mental illness, like cancer or any other sickness serves no function for the patient whatsoever and is the enemy of health.
Besides providing a theoretical framework by means of which psychiatric conditions can be differentiated from existential problems, the Guidebook gives a concise compendium of modern treatments for the former. Multiple balances are struck in the presentation of medication treatments, stating general principles whenever possible. Part of the purpose of laying out a comprehensive outline of these treatments is to help the primary care physician make a more informed decision as to the level of complexity at which he or she refers a patient to a psychiatrist or psychotherapist. Effective psychotherapy treatments are described for each condition along with a general sense of how the relationship between the psychotherapist and psychiatrist (or internist) is coordinated.
Finally, I want to convey to any students who might read this book the sense of the excitement I have found in the practice of psychiatry. Since I have been in the field, medication and psychotherapeutic treatments have developed to the point that, with persistence, these painful conditions almost always improve. At the same time, the very nature of these illnesses remains a stubborn mystery. In the daily course of treating patients, the burden of responsibility for this suffering is constantly leavened by the realization that each patient offers another opportunity to view a tantalizing mystery from a slightly different angle. If you are a person with a humanistic bent who also enjoys speculating about mysteries, this is the field for you.
Chapters 1, 3, 4, and 12 give the reader a general understanding of what mental illness is and how it is treated. The section on Panic in Chapter 3 is particularly important, because many general principles and medication issues are covered. The other chapters can be read individually as needed.
Chapter 2
WHO SHOULD TREAT MENTAL ILLNESS?
As stated earlier, a principal aim of this book is to sharpen the reader’s ability to distinguish the patient with mental illness from people who are suffering from life’s inevitable difficulties that lie waiting for us all. I shall return to this crucial distinction repeatedly in many contexts. I feel it is appropriate to use the word “counseling” when referring patients for existential problems, and “treatment” for mental illness. One ought constantly to keep one’s “ear to the ground” in search of effective, mental health counselors, particularly those willing to deal with marriages and families. As will be explained, marriages and families, as well as being the source of many existential problems, can also be an inextricable part of mental illness. My experience is that excellent counselors can come from a wide variety of backgrounds including psychology, social work, and the clergy. Many of these counselors have properly clarified the distinction in question by referring to their clients, reserving the word “patient” for those with mental illness.
Traditionally the roles of psychiatrist and therapist were carried out by a single person, but increasingly, these roles are split. It is important to understand that effective psychotherapies have been developed for mental illness and that these treatments have earned practitioners with backgrounds in clinical psychology and social work an indispensable role in treating the mentally ill. Simultaneously, the efficacy of psychiatric medication has also placed psychiatric treatment within reach of the primary care physician. It is the goal of this Guidebook to encourage primary care physicians to participate in the treatment of the mentally ill and one foundation of that participation is to have a firm grasp on the roles of the psychiatrist, the primary physician, and the psychotherapist in modern practice.
In my frequent collaboration with psychotherapists, I have found it not of utmost importance to declare who is in charge with ultimate authority, which is of interest principally to lawyers in assessing blame. In modern practice, it is more and more common for a psychotherapist to see the patient most frequently, say once a week, and a psychiatrist to be in a specialist, consultant role, seeing the patient only as frequently as demanded by the activity of the symptoms. Because of the length and flux of these professional relationships, the need for communication varies frequently and is usually carried on by phone rather than by formal letters.
Primary care physicians are by far in the best position to make referrals to specialists simply because they can see and hear the results of treatment when the patients come back for their regular checkups. Not only should these physicians have a ready list of psychiatrists and therapists who have various subspecialty training and interests, but they also need to refine the list as to kinds of patient personalities various mental health care providers are particularly adept at treating. On the other hand, both psychiatrists and psychotherapists should also sift through their counterparts with whom they work effectively in order to make a subsequent, secondary referral. Indeed, conversations between primary care physicians and trusted mental health care providers as to whom would be effective for a given patient are always appropriate.
If you are an internist who enjoys helping psychiatric patients as I do, I feel you should go ahead and conduct the medical end of psychiatric treatment, preferably with a therapist also seeing the patient. I certainly have enjoyed the collegial role of “curbside” consultant to many of my physician friends and was always happy to either formally consult or take over the treatment for a while if things were not working out. To those physicians particularly interested in treating psychiatric patients, I strongly recommend the excellent comprehensive text on the subject, Psychiatry for Primary Physicians published by the American Medical Association Press.
The psychiatrist has specific expertise and retains authority in the area of diagnosing mental illness. However, the stigma still attached to mental illness also adheres to the psychiatrist. It will not infrequently be encountered in the form of resistance to a recommended referral. The response to this resistance should be firm. The experience of seeing a psychiatrist should be no different from that of consulting any other medical specialist. The qualities are the same: kindliness, the ability to listen, the flexibility to entertain more than one diagnosis, and to know when to seek further consultation, especially if treatments are not working.
Furthermore, the psychiatrist, now more securely back in the role of physician, has reclaimed the power to confer the status of patienthood with all its ancient rights and privileges. I generally like to have the patient bring the spouse or a family member to the first visit mainly to corroborate the history after meeting alone with the patient. After a diagnosis of mental illness has been made, when possible and appropriate, I have made it a practice to talk to the family about granting the same, full privileges of being deemed a patient as would be given those suffering from physical sicknesses. There is a respectful care associated with the designation of being a patient that addresses the isolation inherent in all illness. My patients have often spoken to me about the loneliness of mental illness. As my physician father used to say: “There should be no shame in sickness.”
Chapter 3
PATHOLOGICAL ANXIETY
Anxiety is the most common psychiatric condition. Once in a while I will run into someone who doesn’t understand the concept of anxiety. Anxiety is fear that something bad has happened or is going to happen. For most people, anxiety is a robustly healthy emotion which motivates us to live cautious, prudent, hardworking lives. As I have told my patients over the years, “Most people get up and go to work each day not because they want to, but because they are afraid of the consequences if they don’t.” Because anxiety is such an emotional staple of normal life, defining a boundary beyond which it becomes a disorder is all the more challenging.
The phenomenon of Panic shall be presented first because it is the prototypical example of the primary pathological process shared by all mental illness as presented in the introduction: the failure of negative feedback controls resulting in runaway feedback reverberation. In Panic, specific anxieties increase in intensity up to a threshold beyond which they degenerate into feedback reverberation in which the constituent emotions are locked into a high-pitched emotional runaway circuitry. Panic lurks as the potential pathological culmination of all other anxiety conditions and, thus, provides a unifying context for a general discussion of the nature and treatments of anxiety, particularly a detailed description of medication therapies.
Following the lengthy discussion of Panic, two other anxiety conditions, Phobias and Generalized Anxiety Disorder, will be briefly discussed along with the treatment considerations unique to them. This section is followed by a very personal philosophical discussion about existential anxiety. The Chapter ends with a discussion of hysteria including advice about what to do if someone is threatening to commit suicide. Obsessive Compulsive Disorder and Post-Traumatic Stress Disorder are also anxiety disorders, but shall be presented later in the book, because their distinctive natures places them outside the broad theme of Chapters 3 and 4 demonstrating the relationship between anxiety and depression.
*
PANIC: THE NEXUS OF ANXIETY
Think of being in an airplane that suddenly loses altitude. A rush of adrenalin surges up from your stomach into your chest and throat as you clutch your chair and attempt to hold onto, really, yourself. Now imagine that same experience happening “out of the blue” — such as when you are sleeping or walking down the street. The first thought is that some internal catastrophe has occurred, such as a heart attack or stroke. Even after having suffered many panic episodes, it is difficult not to believe while it is happening that something catastrophic and fatal has happened or is about to.
The escalation of anxiety into panic serves as a general, overall example of how normal emotional function transforms into emotional illness. Every one of us will panic if the circumstances are extreme enough, but whatever function panic may serve in those rare cases would be happily forfeited by the legions of patients who are relentlessly seized by this emotional inferno for no apparent reason. Often the initial episode of panic is in reaction to a confluence of stresses in a young person’s life, but that initial experience is so shatteringly traumatic that the passage of time becomes saturated with the dread of its impending repetition. In a cruel and vicious cycle the anxious anticipation of the recurrence of panic brings it on all the more intensely.
What Panic Tells Us About Anxiety
Because of its pure intensity, the experience of panic must be examined closely in order to clarify the nature of its ingredients of anxiety, which are normally concealed by their blending into the flowing mixture of normal emotional life. In mental illness, the constituents of interacting emotions, “pop themselves out” and, despite their shrill distortion, reveal the basic aspects of their composition. A basic duality in the human mind clearly emerges in firsthand descriptions of the exquisite suffering of panic: “I become anxious, and then I become anxious about being anxious.” One half of the person makes the other half anxious in an escalating spiral. Within panic the two fundamental human anxieties are pitted against one another.
Two Anxieties: Being Trapped and Abandoned
The most basic human fear is that of being trapped or even suffocated. I often refer patients to the image of a “rat in a trap” preoccupied by escape. Surely, one reason that the nation was so gripped by the 9/11 attacks on the World Trade Center was that everyone could instinctively relate to the specific horror of being trapped. People who are prone to panic do not like hot, humid weather. “It feels like a hot blanket covering me up.” The fear of being trapped goes well beyond a physical circumstance but is a fundamental emotional component to one’s social circumstances. Humans can feel trapped by their jobs, their economic or social status, and let’s not leave out families and marriages. Poor humans! We have to constantly balance our fear of being trapped with our other major fear.
The next most basic fear in humans is separation anxiety. Once an attachment has been established, particularly a family or romantic bond, the emotional rupture of that connection produces anxiety. Who among you cannot recall from your childhood a circumstance or two when you were seized with anxiety in response to the departure of a parent or some other person with whom you had established a close attachment? People who are prone to anxiety problems in general are especially sensitive to separation such that, often mere physical separation, for example a child or a spouse going on a trip produces excessive anxiety. Separation anxiety can also be manifested in response to physical circumstances, such as traveling even if everyone is going with you. If you are afraid of spiders, it is much worse to see one in your room alone than outside when you are with a friend.
Whereas, in normal functioning, these two anxieties balance and weave together the avoidance of life’s many traps with the maintenance of family bonds and friendships, in the illness of panic they suddenly coil together and rise up like a serpent.
Physical Symptoms in Panic
One discovers the true nature of panic only after following many patients with this disorder over long periods of time. Initially, the experience of panic triggers physical symptoms, such as rapid heart rate and the feeling of suffocation causing compensatory over breathing, which, in turn, can cause numbness and tingling. Often, the patient focuses on these symptoms thinking some dire physical illness, such as a heart attack or a stroke, has stricken her and she is about to die. The normal trusting relationship with one’s body, including gut reliance that changes in the basic rhythm of heart rate and breathing reflect either physical exertion or some real danger in one’s environment is fundamentally disrupted. Patients are reassured by initial visits to a physician or emergency room, after the prompt resolution of the panic symptoms with a dose of a benzodiazepine tranquilizer. As treatment progresses, and the physical symptoms abate, patients often first realize that the root panic experience is separate from those physical symptoms that had initially appeared to cause it but had actually just exacerbated it.
Should Patients Change Their Lives or Treat the Illness?
The basic answer to this question is to treat the illness. Panic Disorder can be precipitated by a single event, in which case the section on Post-Traumatic Stress Disorder (PTSD) should be read in Chapter 7. Most often the initial episode of panic is in the context of an ongoing circumstance, such as a job or a relationship, in which the patient feels more and more trapped but afraid to leave. Think about how broad a swath that situation is in life, particularly in the younger years.
In panic, the fear of being trapped triggers the fear of separation in the vicious feedback reverberation cycle characteristic of all mental illness. Perhaps the initial episode is an indication that the current circumstance is, indeed, beyond the tolerance of the patient’s sensitivities, and, therefore consideration should be given as to extraction from it. Great care must be exercised in making such a decision however, because, very rapidly, the patient’s view becomes distorted such that the confining nature of any commitment creates anxiety and the possibility of further episodes of panic.
The stock and trade of those in mental health care, ever growing with experience, is a sense of the kinds of basic life experience that are fundamentally and “existentially” upsetting. A careful calculation should be made in which the shadow cast by the reality of the circumstance is weighed against the patient’s heightened sensitivities to it. Whether or not the decision is made to leave the ongoing circumstance, the panic symptoms must be treated directly as an illness.
Causes of Panic: Genes vs. Childhood Upbringing
Yes, I recommend giving medication “up front” for panic. Inevitably, this advice begs the question as to whether this means that the condition is a “chemical imbalance.” I respond by informing patients that all the unique emotional reactions that combine to comprise their particular temperament ultimately have physical and chemical roots. I point out to them that in a spectrum of emotional dispositions in the population, they are on the more anxious and sensitive side. Most of these patients have figured that out by themselves already, and I confirm that these qualities are not pathological in and of themselves.
Asked whether the condition is “all genetic,” I respond that all mental illness is roughly 50 percent genetic and 50 percent environment. I ruefully add that we have not made much progress in understanding the actual nature of the interaction between genes and childhood experiences, except that it is much more complicated than we used to think. I ask whether any of the patient’s relatives are “high strung,” reassuring them that they “come by this honestly” when they tell me that, indeed, some are.
There are two simple examples of how genes and childhood experience could theoretically interact. A genetically anxious parent could respond to their genetically anxious child by either over protection or pushing too hard, in either case possibly making the anxiety problem worse. I find that knowledge of this sort never helps to control the active symptoms of panic and sometimes compromises the needed support of key family members by the implication that they are responsible for the problem. Quite to the contrary, I try not to fail to reassure the patient and the family that panic is not a result of faulty child rearing or even abuse, which leaves a far more complex footprint primarily manifested by disruptions in abilities to carry on close relationships. If the patient and the family are interested in speculating about the interaction between “constitutional” anxiety and the childhood culture of the patient, that is best done later by a therapist perhaps with an eye towards altering responses to excessive anxiety in the patient’s own children.
Treatment of Panic and Pathological Anxiety
With wry humor, I have repeatedly told my patients with Panic that the best treatment for anxiety is to not be anxious. What I mean by this is that getting on top of a panic disorder is a “confidence game.” When panic strikes several times, the patient is placed in the anxious position of anticipating “when the other shoe will drop” which, in the cruel signature of mental illness, brings on the condition even more. So, if by “hook or crook” (drugs) the panic can be controlled for a period of weeks or months, the patient’s anticipation that it will reoccur at any given moment will naturally decrease, bringing with it a return of confidence which then collapses this particular vicious cycle and replaces it with a healthy one. Treatment in psychiatry is often slow, and one of its most active ingredients is persistence. Patients under psychiatric treatment must become scientists and continually measure their own symptom episodes in 3 basic ways: frequency, intensity, and duration. How often does it occur, how bad was it, and how long did it last. Is it getting better, worse, or staying the same.
1. Insight Oriented Psychotherapy
Until 30 years ago, all psychiatric patients were treated with Insight Oriented Psychotherapy. These treatments use Freudian concepts to help patients develop insight into the manner in which repressed childhood feelings continue to influence their adult emotional life in adverse ways.
Many patients have told me that they have benefitted from the self-knowledge resulting from this procedure which had added depth and meaning to their emotional lives. In order for this psychotherapy to be effective, it needs to be administered in hour long sessions at least once a week, over several years. Because of this intensive use of medical resource for a single patient, this type of therapy has progressively been squeezed economically. For the illnesses described in this Guidebook, I feel that Insight Oriented Psychotherapy continues to be the primary treatment modality in the two conditions in which lack of insight are a major feature: persistent hysteria (described at the end of this chapter) and Borderline Personality Disorder (described in Chapter 5). It shall be mentioned below that Generalized Anxiety Disorder is another condition for which this treatment should be considered. Otherwise, Insight Oriented Psychotherapy seems to be most effective for emotional problems, which are below the threshold of illness as defined in this book, but it can be helpful in consolidating gains in some after these illnesses have been treated. I have never discouraged my patients from pursuing this form of treatment, but have warned them that I have seen long term, intensive psychotherapy become a “hiding place” in which commitments in one’s real life are compromised. I generally feel that relationship problems should be treated conjointly in psychotherapy with the spouse and/or family involved.
In response to the need for more “targeted,” results-oriented treatments for specific conditions emphasized in this guidebook that do meet the criteria for illness, several other modalities have proven to be effective.
2. Cognitive Therapy
Cognitive therapy is a relatively new psychological treatment in which patients’ attitudes or “belief systems” about themselves are the focus of treatment. In cognitive therapy, entrenched faulty beliefs, such as “everyone thinks I am a loser” are challenged as to their accuracy. These kinds of faulty belief systems can increase anxiety to thresholds which release panic and therapeutically altering them can help prevent its recurrence.
Cognitive therapy has become an important adjunctive tool with proven effectiveness, particularly in the treatment of the full spectrum of depression including those deemed illnesses, as shall be discussed. But it is of vital importance that the patient maintains the correct belief that the panic phenomenon, itself, is a true illness that has torn itself away from pre-existing belief systems whether or not they were faulty. Panic is attributable to the breakdown of emotional regulation at a more fundamental psychological level than belief. Once mental illness has been diagnosed, it is a grave error to imply to patients that they are “doing it to themselves,” because this false belief can lead to stigmatic attitudes toward mental illness typified by the exhortation to “snap out of it.”
3. Behavioral (Desensitization) Therapy
The other main adjunctive psychological treatment is desensitization, which falls under the rubric of Behavioral Therapy. The therapeutic effect of desensitization on anxiety has been proven so many times that it approaches the status of a therapeutic Law. That Law states that, over the long run, if the patient is anxious in response to some identifiable object or situation, such as being in a grocery store, avoiding the store makes the anxiety worse, while exposing oneself to it in measured steps makes it worse at first, but, with persistent exposure, makes it better.
If you are afraid of bridges, first think about bridges, then go watch them from a distance, then slowly creep out onto one and sit out there, not for a couple of minutes, but for a couple of hours. But again, it is important to realize that, like cognitive therapy, desensitization is a treatment for anxiety, not panic. In carefully managing the pace of exposure to the anxiety-provoking circumstance, it is important to remain well below the panic level, which, if exceeded, sets back the treatment. As shall be discussed, Behavioral Therapy is the primary treatment modality for all phobias and Obsessive Compulsive Disorder. Although the root panic phenomenon is not treatable through desensitization, the anxieties which precipitate it in the first place, as well as those secondarily caused by it, can be.
For example, in Panic, the “insult to injury” increased anxiety caused by the above-mentioned physical symptoms of “air hunger” and rapid pulse can be helped by desensitizing the patient to them. In a calm, secure situation the patient is instructed to over-breathe in order to reproduce the symptoms of numbness and tingling, or to exercise to increase the pulse, then stop and try to relax in the face of these experiences.
Commonly patients with Panic Disorder have panic level responses to being “trapped” in specific closed-in spaces (claustrophobia) such as elevators, subways, airplanes, crowded theaters, etc. Alternatively or additionally, panic can be released by being out and separated from home. Once the panic phenomenon is under control with medications, the therapeutic agenda of nudging the patient into attempting to gradually increase exposure to these environments must immediately commence. Because the fundamental dynamic in all pathological anxiety disorders is becoming “anxious about being anxious,” I have often given these patients the curious advice to, “Pick a tolerable level of anxiety, and try to desensitize yourself to becoming anxious in response to that baseline level.” I don’t really think that this actually works, but the advice serves to illustrate the dual nature of their condition.
4. Self-Relaxation, Biofeedback, Meditation, and Yoga
I have tried to emphasize to all of my patients with anxiety disorders the importance of establishing a routine whereby, several times per day, they take at least 10 minutes during which they attempt to relax. The secret of relaxing is that it takes mental effort and concentration. Concentrate on your breathing: slow it down and control it. Then concentrate on relaxing the jaw, neck and shoulder muscles (visualize a coat hanger with the hook being your jaw muscles, twisted perpendicular to the hanger, which is the back of your neck and your shoulder muscles).
Like any physical discipline program, it helps to have a trainer. Relaxation therapists, who, sadly, are a dying breed, use biofeedback machines. Electrodes are adhered to the patient’s forehead with wires attached to a machine which transduces the level of muscle tension to a display on a TV monitor. Patients obtain immediate feedback on whether their efforts at relaxing are successful and thus can more quickly learn how to do it. I certainly encourage any of the Eastern forms of meditation and particularly the daily practice of yoga for patients with anxiety conditions. It is important to understand that the benefits from these regular activities are not immediate and results should not be expected for at least 6 weeks. The benefits from these modalities may not be decisive without other psychiatric treatment, but they are absolutely reliable if the patient persists in practicing them over the course of months and years.
5. Medications in the Treatment of Panic and Pathological Anxiety
Again, the best treatment for panic is to block the panic decisively for a period of not days, not years, but months. Two classes of drugs are approved for the treatment of panic: benzodiazepine tranquilizers and the Serotonin Reuptake Inhibitors (SSRI’s) antidepressants. Please allow me to digress into a mini-tirade: Valium (available as diazepam), Prozac (available as fluoxetine), Thorazine (available as chlorpromazine) and lithium were all prototypes of their particular class, and all have “hit the media” in their day resulting in all being tarnished by the stigma of mental illness. You would casually comment that you are on an antibiotic, but to tell someone you are taking one of these “bad boys” is an entirely different matter. Nevertheless, these have been extraordinarily important medicines. Before Valium, the barbiturate sleeping pills, such as Seconal, were the only tranquillizing medications available, which could and frequently did cause death in even mild overdose, especially with alcohol. Benzodiazepines (Valium derivatives) can be fatal in huge overdose in conjunction with alcohol, but rarely benzodiazepines alone. Although both barbiturates and benzodiazepines are addictive, a sudden cessation of barbiturates is much more lethal. Stopping barbiturates can precipitate Status Epilepticus (a constant epileptic seizure). Seizures are also a threat when benzodiazepines are suddenly stopped, but much less of a threat.
All treatment interventions have up and down sides. The up side of benzodiazepine tranquilizers is that they work both reliably and quickly (within 15-45 minutes) to suppress not only the panic, but also the “anticipatory” anxiety that one is about to have a panic attack. Reliability is the main benefit. Once panic disordered patients take a tranquilizer, they know that the “cavalry will soon appear over the hill.” It is a general rule with all psychiatric drugs, except in dire emergencies, that patients should begin a course of drugs with small doses, usually one half of the minimum available dose, obtained by simply cutting the pill in half. Understandably, anxiety patients tend to be anxious about any alteration of their mental status, which is already unbearably altered. The first dose is taken in the evening, early enough for the patient to get a sense of what the response is before going to sleep. The art of taking tranquilizers consists of slowly increasing the dose up to strike an appropriate balance between the continuance of anxiety if the dose is too small and sedation if it is too high.
If the frequency of panic level anxiety is low enough, or in patients who have discontinued all medication after successful treatment, an acceptable option is to take tranquilizers only occasionally. The patient might only take an appropriate dose in anticipation of entering into a situation, such as flying, that has triggered panic or anxiety in the past. Furthermore, once it crosses the person’s “radar screen” that anxiety is being triggered and starting to escalate into panic, the earlier the patient takes the medicine, the better: “Cut it off at the pass!” Often, just the comfort of knowing that the pill is tucked in the patient’s wallet or purse and “it’s there if I need it” is sufficient. The mantra I give my patients when thinking about psychiatric medicines in general in order to inoculate them against stigmatic attitudes is that they are a “tool, not a crutch.” Nevertheless, addiction is a very real problem with tranquilizers.
Let there be no doubt that benzodiazepine tranquilizers can be addicting, and this should be understood by all who take them. Some of the tranquilizers are inherently more addictive than others, but all have addictive potential if taken more frequently than several times a week for longer than a month or so. Physical withdrawal after long-standing dependence on tranquilizers can be, in the words of several of my patients who have gone through it, “a bitch.” Not only does the anxiety come back, but it is accompanied by muscular spasm and insomnia.
The secret of getting off benzodiazepine tranquilizers is to do it very, very slowly and methodically. My patients get very good at cutting up pills into halves and quarters. I tell them, “Get out your jeweler’s lens.” If a patient is on a high dose, often they can make larger reductions at the beginning of the program, but then need to slow down later. I point out that reducing a 5 mg dose to 4 mg is only a 20 percent reduction, whereas reducing a 2 mg dose by the same 1 mg is a 50 percent reduction. Sometimes, to emphasize the point that the slower the reduction the better, I tell patients that it can take half the time that they have been on a tranquilizer to get off of it. Usually patients want to go faster and I relent to their impatience, but the point has been made and received.
Now, after having said all that, I also emphasize that, in addition to physical dependency and consequent withdrawal, there is one other component to addiction. This is the idea of drug abuse. Benzodiazepines can be abused because some people enjoy their effects as a “high.” In general, patients with anxiety disorders do not abuse drugs, because they are “high enough” with their anxiety. As I have often put it, anxiety patients are not trying to “get off” (high), they are trying to get “back on” (feel back to normal). Just as physical addiction to narcotics is not as severe when patients are taking them properly for unbearable pain, tranquilizers taken for unbearable anxiety or panic do not produce the same level of addiction as they might to an abuser.
Xanax (available as: alprazolam) is by far the most addicting of the benzodiazepine group. This is due both to the fact that it is inherently more potent than most of the others, but more because it has a shorter half-life, which is the time a drug takes to reduce to half of its peak blood level. More relevant to patients, is the clinical half-life of a drug, which is simply the time elapsed as reported by the patient between when it starts and then stops having an effect. The clinical half-life of alprazolam is about 4 to 5 hours, after which the resurgence of anxiety reminds the patient that he or she needs to take another pill in order to feel calm. It is not a good mentality to establish a pattern of having to take a pill because you can feel the effects of the last one wearing off. That has the “earmarks” of addiction. A long-acting formulation of Xanax partially solves this “roller coaster” problem by slowly releasing the medication over a longer period of time, but you are still stuck with the same short half life drug which drops off just as quickly if you miss a twice daily dose. On the other hand, alprazolam is probably the most powerful anti-anxiety, anti-panic drug, so it could be used in the short term for very severe, intractable cases. Otherwise, I feel it is well to keep alprazolam doses in an addiction-comfort-zone neighborhood of 1/4 mg several times a day. Nevertheless, in some cases, a short half-life drug may be helpful.
Ativan (available as lorazepam), in my opinion, is the mildest of the benzodiazepine tranquilizers. Although its half-life is about as short as alprazolam, it is not nearly as powerful a drug, and therefore not as addicting. A short half-life drug can be a distinct advantage, particularly in the elderly, because the level of the drug does not build up in the system over time. Because it is metabolized outside of the liver, it is “cleaner” in that there are fewer interactions with other medications, with the obvious exception of alcohol. (“If you’ve taken a tranquilizer, you’ve already had a drink!”) Nevertheless, in doses of 2 mg or higher, lorazepam’s short half life means that the patient must be vigilant about situations in which he or she might suddenly stop taking it, such as forgetting to take it on a trip, or during an unexpected hospitalization. But, all and all, lorazepam is one of my preferred choices of tranquilizers, particularly for the elderly.
Clonazepam is my favorite choice for pathological anxiety conditions in general. But first, the bad news. Some years ago, I consulted on two elderly patients in the hospital who were virtually unresponsive and both looked as if they had had a stroke. However, their common problem turned out to be long-standing doses of clonazepam which had simply “caught up with them” and conked them out. Both of these patients woke up and were fine after reducing the dose. But other than this dose-build-up problem, I generally prefer clonazepam in the treatment of anxiety. It is well tolerated by patients because it is potent and has a half-life that is long enough to enable patients to take it only 2 times a day without the up and down “roller coaster” effect of having to urgently take the next dose because the last one is wearing off. The clinical half-life is about 8-10 hours so that the ups and downs of both the onset and withdrawal of a given dose are hardly perceptible and thus minimizes the addictive potential. As I shall repeat in the section on addiction, a substance is addictive in direct relation to its speed of onset. That is why the “quick hit” of nicotine in cigarette smoking is so addictive. Still, after taking even 1 mg of clonazepam per day for long periods of time, the patient needs to be withdrawn slowly. Incidentally, it is standard practice to shift over to clonazepam from an equivalent dose of a shorter half-life tranquilizer and then initiate withdrawal due to greater ease and margin of safety. Like all psychiatric medication, I start with a small dose and then build it up to hit the happy medium between anxiety and sedation, as mentioned above.
For some reason, in medicine, the first drug that is discovered in a general class usually “hangs in there” through all the subsequent minor alterations of the chemical compound that produce “improved” copy-cat drugs and maintains some role in treatment. Valium (available as diazepam) is no exception. Unique amongst all benzodiazepines, diazepam has a direct muscle relaxant property, so it is used for muscle spasms, such as in the back. But this same property is a negative characteristic for chronic administration, because, after taking it for a while, it makes one feel like a “wet noodle-jelly fish” and tends to depress patients. It also is more easily abused because, although it has a long half-life, it is absorbed very rapidly into the brain, and, therefore, is quickly perceptible in as short as 10-15 minutes after ingestion as a sudden feeling of relaxation.
However, this initial “spike” effect also makes it an ideal “fire extinguisher” to quickly extinguish a panic attack in its early take-off stage. My advice in prescribing it is something like the following: “If you are out in the middle of nowhere, just put it in your mouth and chew it up and then know you will be fine in 15 minutes (but not while driving).” Before using this medication, I have patients “test drive” several doses in non-stressful situations, when they are going to be at home for the rest of the day so they can familiarize themselves to how a given dose effects them. I do not want patients to have any uncertainty about what a drug is going to do in a “commando” panic circumstance. I have many patients walking around with a few vintage, crumbling diazepam tablets in their wallets. If I see them, I remind them that, unlike wine, medications usually don’t get better with age so I write them a fresh prescription for 5 tablets to last them another couple of years.
Prozac (available as fluoxetine), which was introduced in 1988, is by far the most important medication in psychiatry since I began training in 1972. Patients who, sometimes for decades, had been dutifully pouring out their hearts on psychoanalysts’ couches (which continue to be the object of stigmatic ridicule in cartoons) suddenly felt “normal” after starting Prozac. Shortly thereafter, Paxil (available as paroxetine) and Zoloft (available as sertlaline) followed, and then Celexa (available as citalopram), Lexapro (generic: escitalopram), and Effexor XR (avalablie as venlafaxin XR ) The long-acting XR form (extended release) is preferred. Not so well known is that, several years after Prozac was approved by the FDA for the treatment of depression, it was demonstrated that these drugs were just as effective for anxiety and panic. Wellbutrin SR (available as bupropion SR ), an antidepressant with very different biochemical effects, was also approved by the FDA for depression about the same time as Prozac but does not have these benefits in anxiety/panic conditions. The long-acting SR form (sustained release) is preferred.
As implied in the name, the central effect of the SSRI’s is to increase the amount of serotonin in synapses widely distributed in the brain. I have come to feel, again through talking to my patients over the years, that the effect of raising the level of brain serotonin is primarily to reduce anxiety, which then, as I will discuss later, secondarily improves depression. My patients have repeatedly told me that the SSRI drugs simply decrease the intensity of their emotional reactions to stressful situations at the time they are occurring. “I had been stressed out by my boss who’s a yeller, and losing my temper with my kids. He is still yelling, and they are still misbehaving, but it is all simply not getting to me as much.”
Patients with pathological anxiety are high strung, sensitive, and generally “emotional” (a characteristic which I generally like.) I tell my patients that emotional sensitivity is the “ticket of admission” to get into my office. No insensitive people are allowed in here. In the population out there, there is a bell curve with respect to how emotionally reactive people are to the events of their lives. Some people, found on the left side of the curve, do not react that much. Most people who experience panic can be found on the hyper-reacting right side of the curve. It seems to me that the basic constitutional vulnerability to mental illness in general is high emotional reactivity. The best single adjective that I have come up with to describe the effect of the Prozac-type serotonin drugs is “buffer”: they should be referred to as “emotional buffers” rather than antidepressants.
There are two reasons why it is difficult to ascertain whether antidepressants are working. First of all, it takes a while before the therapeutic effect “kicks in”: up to 2 or even 3 weeks. I call this the “Alan Greenspan factor.” As Chairman of the Federal Reserve Board, he used to raise the interest rates, and no one knew what impact it was going to have on the economy for many months. In the case of antidepressants, it is weeks not months. Occasionally, it works in several days and, rarely, immediately, like the tranquilizers. I tell my patients that, like the rest of life, the bad stuff (side effects) happen “up front” and you have to wait for the good stuff. Most common are temporary side effects such as a little bit of jitteriness or gastrointestinal “queasiness” which go way in several days. Like all psychiatric medicines (I am a stickler about this), they should be started at the lowest dose available (if it is a capsule, have the patient open it up and dump of it out and put it back together) for several days until the patient is confident that any side effects are tolerable.
The second reason it is difficult to tell whether SSRI medications are working is that, when they do work, nothing “positive” is happening. They do not make you feel good; they make you feel less bad. Patients often are surprised to discover, almost as an “after-thought,” that, when in a situation that is normally very stressful, they find that the level of stress is significantly reduced. Droves of my patients have described the effect as feeling “back to normal,” or even, “I feel normal for the first time,” or “Now I know what normal is.” That these drugs are mind-restoring, rather than mind-altering is the reason these medications have no addiction potential, one of their principal virtues.
Antidepressants, like all treatments in medicine, have their down sides. First of all, patients are compelled to take a pill every single day, not just when the anxiety crops up. So if a patient has a panic/anxiety problem that occurs only once a month or less, he or she is better off taking tranquilizers only when the problem occurs, or even better, in advance of a situation that the patient anticipates will bring on an anxiety attack. Although antidepressants are not addictive and no one is selling them on the streets to get high, if one remains on them in some cases longer than 3-4 months or, for almost everyone, for over a year (which is often recommended), a person must take at least a month, preferably several, to wean off of them. It is not medically dangerous to stop them abruptly, but so-called “discontinuation” effects can be extremely uncomfortable for some patients. As in the case when beginning the medication, physical side effects of withdrawal precede any relapse of psychiatric symptoms. These withdrawal reactions are most often dizziness, sometimes described as “head rushes,” or more generalized flu-like symptoms which may necessitate extremely gradual tapering off of the medication over several months. Similar to the tranquilizers, short half-life antidepressants, such as Paxil (available as paroxetine) and Effexor XR (available as venlafaxin XR), can be more difficult to get off than the others and this is one reason not to use either as first choices.
The most complained-about side effect of antidepressants is that they do the same thing to patients’ sex lives as they do to their emotional life. They make most people less reactive sexually, most commonly making it more difficult to reach an orgasm, but also decreasing the sex drive itself (libido). Lack of sexual motivation can be tough on some relationships but also, occasionally, good for others. Another “class effect” of the SSRI antidepressant drugs is that they can cause weight gain, particularly in patients who struggle with their weight prior to taking the medication. Weight gain can be counteracted by diet and exercise, but it commonly adds one more degree of difficulty.