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Hi –

Here is what is probably the most controversial article from my book “Freedom From Agoraphobia.” In it, I am disagreeing with a lot of mainstream thinking in Psychiatry today. So, please don’t think that this is what you will hear if you go to the average psychiatrist. The message: you are NOT stuck with having to take medications all your life in order to not have panic attacks! In fact, you really don’t have to take medications at all! You may if you want – and this article will tell you all about them – but they are far from being the only way out. So, if you have been convinced that panic attacks are a physical disease and need a physical agent to correct them, get ready for something new.

Since I am an M.D., I cannot express my point of view without being concerned about liability. So please note this disclaimer before reading further: Any medical information in this article is not intended as a substitute for informed medical advice and you should not take any action before consulting with a qualified health care professional.

I hope you will enjoy and learn from this article.

Mark Eisenstadt, M.D.

Article Eight Medications Or Is There Better Living Through Chemistry?

Medications are an increasingly-popular way that people deal with their problems these days. It seems that everybody is in favor of them. We are in an age when medical research is constantly making new discoveries about various functions of the brain and brain chemicals. There are many Psychiatrists who believe that physical and chemical processes going on in the brain will eventually go far towards explaining the causes of emotional problems. Consequently, it makes sense to them to use physical means (medications) to correct those problems.

Also, medications are an easy fix (when they work). You simply take the pills as directed. You don’t have to change your lifestyle or your way of handling situations. And the side effects you have to put up with are becoming less and less onerous as new, higher-tech medications are being developed.

Naturally, the drug companies doing the developing want you to use their medications to deal with your problems. It is such big business that people who follow the stock market usually know all about new drugs under development long before the physicians who will be doing the prescribing have even heard of them. This is also why the drug companies in recent years have begun to direct their advertising at the general public. Even on primetime TV (in the U.S at least), we are assailed by ads asking whether we have this, that and the other symptoms, telling us we might well have depression, sinus trouble or ugly toenails and advising us to ask our doctors about prescribing this or that drug.

Lastly, the insurance companies want us to use medications to deal with our problems. They cost the company a whole lot less than seeing a therapist. So the insurance industry encourages them by limiting coverage for therapy while paying more of the cost of medications.

So why shouldn’t you just take that pill and be done with it? Well, maybe you should. But here are some things worth considering before you toss these articles in the circular file and start looking for someone with a prescription pad:

First, taking that pill may well not mean that you are done with it. To be approved for treatment of panic attacks, there has to be research showing that the drug is statistically significantly more effective than a placebo (sugar pill). It doesn’t have to work in everybody – no drug does. Nor does it have to get rid of all your panic attacks when it does work – it just has to lessen them significantly. So, if you decide to go with medications as at least part of your program, you should be aware that they may not work completely and that you may have to try a number of them to find the one that gives you the most effect.

Second, another reason the pill may not leave you done with the problem is that the panic attacks often come back after you stop taking the medication. In certain research projects, the panic attacks did not return in some people (for as long as the study lasted). But even in those studies, many other people had to stay on the medication for life if they wanted the effect to remain.

This makes sense to me because the medication has not changed the cause of the panic attacks (traps). So, if the medication is simply blocking the effect of the trap (panic attacks), naturally that effect will return as soon as the block is removed. If, however, the individual got out of her trap while taking the medication, then of course the panic attacks will not return after stopping it. (Until the next trap.)

This situation of medications not curing a problem is common throughout medicine and psychiatry. Recommending that a medication be taken for life is frequently done for Depression, Bipolar Disorder, Schizophrenia, ADHD, some Anxiety Disorders and many

more. Naturally. Despite all the research, books and excitement going on about “the biological basis of psychiatric disorders,” the field of medicine is a long, long way from defining a clear biological cause for even one of these conditions. Much less finding a drug that will correct that cause. Much less finding a drug that will correct that cause and leave it corrected.

When I was in medical school, one of my professors made this point by challenging us to name three conditions that could be cured (meaning the root cause corrected) other than by antibiotics or surgery. (Nowadays, I suppose one could add antiviral and antifungal medications as well.) We couldn’t. And that was his point. Possibly gene-based medicine will change this situation but we are running into a lot of complications there, too.

Generally, medications only work as long as we take them. Lipid-lowering drugs improve cholesterol as long as we take them. Diuretics, antacids, analgesics and nose drops all work only as long as we take them.

Meanwhile, non-medication treatments for the milder emotional disorders have often been shown to be at least as effective as medications and more long-lasting. There have been studies with this result on phobias, depression, obsessive-compulsive disorder and even insomnia.

The third reason you may not want to put all your eggs in the medication basket is side effects. Even though the drug companies are always working to take the market away from each other by finding drugs with fewer side effects, and even though they are making progress, all medications do have side effects. Just as the strength of the desired effect of a drug (fewer panic attacks) varies from one person to another, so do the side effects. An agoraphobic friend may have no problem taking a particular medication but when you take it, your sex life goes down the drain. (This is a common side effect of Prozac-like drugs.) Whenever we take any medication, we have to weigh the positives and negatives. Sometimes the choice is clear-cut. Other times, the benefits may not be so pronounced and the side effects may be considerable.

Fourth, no growth happens from taking a medication. Like most other therapists, I have found that problems such as Agoraphobia are signals that there is some growing to be done. By doing this growing, the agoraphobic will not only achieve relief from panic attacks, but she will also attain a richer and happier life. I have known many ex-agoraphobics who regard their Agoraphobia as the best thing that ever happened to them because in seeking the answer to it, they found far better lives than they would ever have had otherwise. Of course! Is there any comparison between Sylvia taking a medication to stop her panic attacks and Sylvia recognizing and breaking out of her unhappy lifestyle to stop them?

The bottom line for me is that medications for Agoraphobia are O.K. if you want to use them while you are working your program. (Kind of like using the nicotine patch while you are stopping smoking.) But your Agoraphobia is telling you that your life can be and needs to be improved. And if you miss out on this, then for my money, you’ve made a poor bargain.

Some people will say that they’ve been told they have to take medications because their Agoraphobia means they have…

The Infamous Chemical Imbalance!!

- a term that has cost me a lot of time straightening out the misimpressions it creates. Here’s how it came about: Somewhere back in the dim recesses of early therapy, people got to feeling criticized and put down for having emotional problems. All sorts of stigma developed as though it was the patients’ fault. (Also, mothers were getting blamed a lot.) To say people were “mental” or “crazy” was a way to sneer at them. Generally, if you suffered from a physical illness, this did not happen to you. People did not sneer if you had pneumonia. (Although there was some of this, too – like calling a crippled person “a gimp.”)

As medications for mental conditions began to be developed, some well-meaning doctors began telling their patients that they shouldn’t feel embarrassed about their problems because they had “a chemical imbalance.” The usual comparison was to the fact that having diabetes means you have too little insulin and you wouldn’t feel guilty about that, right?

I think they had two reasons for saying this: First, they wanted to relieve the guilt and stigma, which would not only make patients feel better, but would make it easier to work out their problems. Second, they figured that something chemical had to be going on if a chemical (the medication) changed other chemicals which changed the symptoms.

So far, so good. There are chemical things going on and it is not your fault that you have your problems – you certainly did not choose them. Furthermore, feeling guilty about your problems only gets in the way of solving them.

Unfortunately, as the term “chemical imbalance” spread, it took on meanings that are not true. One of these is that your condition is a chemical imbalance. In other words, that your problem is that you have too much or too little of a particular chemical. This is not a strange thing to understand from being told: “You have a chemical imbalance.” But it is not true!! We don’t know that you have too much or too little of a particular chemical. In fact, diabetes is one of the very few conditions where we thought we do know that. (And actually, we are finding that diabetes is also a lot more complicated.)

Although you may have been told that you have a chemical imbalance, no chemical has been identified as being the cause of Agoraphobia. (Yes, some drugs that affect Serotonin sometimes help in Agoraphobia. But so do some drugs that don’t affect Serotonin. And sometimes one Serotonin-affecting drug does not help while another does. So we certainly cannot say that Serotonin is the cause of Agoraphobia. And the same holds true for any other chemical you care to name.)

So being told that you have a chemical imbalance should not be taken to mean that it is anywhere near to being established that Agoraphobia is a condition of wrong amounts of certain chemicals. Some people may suspect this but the evidence for their suspicion is highly debatable. Not to mention the fact that panic attacks go away when people get out of their traps or when they stop working their way into them by means of catastrophic thinking.

Another false idea derived from the chemical imbalance notion is that since the problem is a chemical one (supposedly), it requires a chemical (medication) to fix it. The logic here is that only chemicals can affect chemicals. Wrong again! What happens when you sneak up on someone and yell “Boo!!”? Their hair stands up, their hearts pound, they get a host of other unpleasant startle symptoms and they promise themselves to get you back. In other words, by completely non-chemical means, you have changed the amount of adrenaline in their bodies. No chemical was needed to affect their chemicals. Another example: what happens when you are terrified and having a panic attack in some enclosed place and you therefore leave? You calm down, right? So, if your panic attack was a chemical phenomenon, you have again changed it through entirely non-chemical means. Conclusion: it does not require a chemical to affect our body chemistry. Obviously. You can sit perfectly still in a chair and rev yourself up or calm yourself down just by what you think about. (We do it all the time – it’s called watching TV.) So someone has told you that Agoraphobia is a chemical condition and therefore requires a chemical to change it? Give me a break!

I hope this straightens out some of the misconceptions people get from the term “chemical imbalance.” Overall, it seems to have been more misleading than it was helpful. Now, let’s consider which medications are available and what they can do. (In the U.K., brand names may be different than in the U.S. but the generic names are the same.):

Anti-anxiety Medications (“Anxiolytics”)

Benzodiazepines

Pronounced “ben-zoe-die-ay-zeh-peens” if you are wondering. They are also called “benzo’s” for short. This is a family of drugs that is familiar to most everybody even if you haven’t heard their name before. Common examples of these medications are Valium, Librium, Ativan, Xanax, Restoril, Halcion, Dalmane and Serax. (These are their brand names. Except for Librium, their generic names all end in “pam” such as diazepam (Valium), lorazepam (Ativan) and temazepam (Restoril).) If you’ve been treated at all for anxiety, you’ve probably tried at least one of these. If so, you have doubtless experienced their usual characteristics.

These are as follows:

They calm you down within about 30min. to 2 hours. This depends upon which one you are taking and how sensitive you are to its effects. But they calm you down from Anticipatory Anxiety, not from a panic attack. For most people, taking a benzo during a panic attack does little more than make them feel really calm or knocked out after the panic attack is over. About the only exception to this is if you go to an emergency room and get the benzo by injection and in a large enough dose to put an enraged logger to sleep. Literally.

Benzo’s used to be prescribed just about like candy. They relieved stressed people and were believed to usually have no serious side effects. This medication La-La Land came to a crashing end with various suits for damages and the publication of books such as Barbara Gordon’s “I’m Dancing As Fast As I Can,” describing the nightmarish consequences of the authors’ overuse of benzo’s. In other words, it was discovered that they weren’t so benign after all.

For one thing, people who take them on a regular basis often develop tolerance. This is the phenomenon of a drug losing its effect unless you take larger and larger doses. Just like habitual drinkers tolerate much more alcohol before getting the effect they want as compared with non-drinkers who feel ready to pass out after only two or three. The body has gotten used to the drug.

What usually goes hand-in-hand with tolerance is withdrawal. The body has made adjustments to compensate for the habitual presence of the drug. When the drug is not taken, the body that was ready to receive it is essentially “left hanging.” This is drug withdrawal. And it does not feel good. In fact, many of the symptoms of withdrawal are the same as what you took these drugs for in the first place. Queasiness, anxiety and agitation are just a few. So if the drug has stopped working because of tolerance, you can’t just quit taking the ineffective stuff or you will get the additional anxiety caused by withdrawal on top of your original anxiety! End result: you’re worse off than you were to begin with.

If you’ve been through this lovely scenario, you know that the only way out is to slowly taper down off the benzo. That way, you get the withdrawal symptoms in smaller doses but for a longer time than if you just stopped taking it. And meanwhile, you have to handle your original anxiety in some other way.

In addition to these addictive qualities of benzos, there are some further prices to pay for the good feelings they give. They interfere with memory and learning. And there have been studies showing two to six times the rate of motor vehicle accidents in older people who were taking them than in those who weren’t. This was sharply illustrated for me one time when I was the passenger while my mother (who insisted that her doctor give her Valium) was driving. She turned from a side road onto a highway with one lane going in each direction. But she turned into the oncoming lane! I did not say anything at first, thinking that she would immediately correct the mistake. But she continued to blithely drive down the wrong side of the road without an inkling that anything was wrong until I finally had to tell her about it (or have a panic attack). For me, the most disturbing part of the incident was her telling me afterwards that she hadn’t the slightest sensation of being drugged or affected by the Valium in any way! This impaired judgment as to your mental state means that you can’t tell that you do not have your normal abilities. And this means that you won’t take the steps necessary to compensate such as having someone else drive. This is certainly the most dangerous aspect of this kind of situation.

So do benzos have any value for the agoraphobic? Yes. But not as medications to be taken regularly. They are fine when used once in a while – for instance to help you get through some particularly difficult situation. Like that visit from your sister with her spoiled kids and snobby husband.

Taking an Ativan before they get to your house might be an excellent idea. It could really help you let it roll off your back when 3-year-old Dennis The Menace pees down your heating register. You can even take another Ativan a few hours later if the visit is dragging on. But do not let yourself find a reason to take one tomorrow.

Can’t stop catastrophizing about that lunch date with the Begonia Club? O.K., cool out with a Valium that morning. It will last well through the afternoon and beyond. PTA meeting the next day? Uh uh. Save the Valium for then if you prefer, but do not take it two days in a row.

The same goes for using benzodiazepine sleeping meds like Dalmane, Restoril or Halcion. Occasional use in times of particular stress won’t do you any harm (as long as you do not drive). But taking one each night may quickly stop helping while making it even harder to sleep than it was in the first place.

Incidentally, the main difference among these is how long they stay in your body. Dalmane (flurazepam) remains up to days, Restoril (temazepam) for about one half to one day and Halcion (triazolam) for a few hours. I usually prefer temazepam because it will get most people through the night while not dragging on into the next day and beyond. I stay away from very short-acting benzo’s like Halcion and Xanax (alprazolam) because they seem to let you down so quickly that you are having problems (and sometimes withdrawal) within hours of taking them.

The really best and most effective place for benzo’s is in your purse or pocket. Seriously. The greatest benefit they confer is the knowledge that you have a way of lowering your anxiety if things get too rough. In my experience, they have done far more good for more people this way than they do by taking them. And you can see why:

Their pharmacological effect (what they do) is to reduce Anticipatory Anxiety. They do not halt an on-going panic attack. To say it another way, they reduce Catastrophic Thinking. Well, what does it do to say to yourself: “Things can’t get too bad because I can always turn to this little bottle right here in my bag if I need to.”?… Right! You have just done some Cognitive Therapy (see Article 9) and reduced your Catastrophic Thinking. Putting it another way, you have just gotten the same result from knowing you have the benzo, as you would have gotten from taking one!!

So I do usually prescribe a benzo for most patients. And people do occasionally use them. But they mostly tell me that what’s really important is knowing that they have it – for just in case.

[What you have just read is one instance of my differing from “mainstream” Psychiatry. The makers of some benzo’s have placed groups of Panic Disorder patients on continuous daily use and have shown a decrease in panic attacks. (No surprise since they reduce Anticipatory Anxiety which causes most panic attacks.) They have thus obtained approval to advertise their drug as being indicated for the treatment of panic attacks. For the reasons above, I think this is a very poor way of going about treating panic attacks but it is an officially-legitimate treatment.]

Buspirone (Buspar)

Buspar is a horse of another color. It is a non-benzodiazepine antianxiety agent. It does not have the associated tolerance and withdrawal of benzos. Unfortunately, in my opinion at least, it also does not have their effectiveness. Unlike benzos, it will not have an effect from taking a single dose. You must take it twice daily for at least a week for it to work. The proponents of Buspar claim that its gradual effect (unlike a benzo that you take and feel within 30 – 120 minutes) is what causes people to not really notice its effectiveness. They say that people who have not been spoiled by benzos like it fine. Or, they say that the dose was too low. I say: “Would you guys like to come explain that to so many of my patients who tried Buspar and return complaining that it doesn’t work?” If it is prescribed for you, it is worth giving it a try (assuming you are looking for an ongoing antianxiety medication). If you are one of the people for whom it works, great.

Antidepressants

Although benzos do not prevent panic attacks except indirectly by decreasing Anticipatory Anxiety, there are medications that do. These are the antidepressants. They could equally well be called “anti-panics” but were first known for their effects on depression - hence their name. In my experience, they often don’t cause panic attacks to cease altogether. But most antidepressants significantly reduce the number of panic attacks people have. Thus, they are the mainstay of medications prescribed for panic attacks.

There are many types of antidepressants. Some of the earliest were the Monoamine Oxidase Inhibitors (MAOI’s) and the tricyclic antidepressants (TCA’s). Both groups have many more side effects than the newer antidepressants such as Prozac and those that followed.

You can easily tell whether you have been prescribed a MAOI because there are dietary restrictions for people who take them. Namely, you cannot have fermented foods such as wines, cheeses and aged meats. Since no other antidepressants entail such restrictions, MAOI’s are rarely used anymore. In the late 70’s, the makers of these drugs sponsored much research to show that they are effective for panic attacks. In later years, the relevance of the research has been called into question. Nardil (phenelzine) and Parnate (tranylcypromine) are the main surviving members of this group.

Most people have heard of one TCA or another. These include Elavil (amitriptyline), Tofranil (imipramine), Pamelor (nortriptyline), Norpramin (desipramine) and others. They are quite effective and remain in common use for a variety of conditions. Including panic attacks. They have in common a set of side effects that, in certain cases, can be quite hard to tolerate. These are dry mouth, temporarily blurred vision for fine print, constipation, difficulty urinating and sleepiness. Many other medications have these same side effects. If you are already taking one, adding a TCA may be just too much for you. On the other hand, one person may get a side effect quite strongly while another hardly experiences it at all. If you are one of the many people who can put up with the side effects, these may be great medications for you. Especially because they are all available as generics and therefore cost very little.

Prozac (fluoxetine) ushered in a new era of antidepressants (do you hear the triumphal music playing as I say this?). The first group of these was known as “SSRI’s” (Selective Serotonin Reuptake Inhibitors). In addition to Prozac, there are Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram) and Lexapro (escitalopram). In the U.K and Europe, there are a few others and some of these ones go by different names. They have many fewer side effects while still possessing the virtue of preventing panic attacks. In fact, the only common side effects are indigestion if not taken with food, decreased sexual desire and performance (which can often be overcome) and sometimes weight gain.

The SSRI’s are quite similar to each other. The main exception to this in my experience is that Paxil is often more sedating than the others. This makes it one of my first choices for Panic Disorder since it helps people sleep and, possibly, be calmer throughout the day. Despite their similarity, if one SSRI does not work, another may still do the trick. So it is worthwhile trying a second or even a third. (Remember the discussion of “The infamous chemical imbalance?”)

Lately, there has been concern over whether these drugs can increase suicidal thinking and behavior – especially in children.

Other antidepressants also prevent panic attacks. Some can show convincing research to support this. Effexor (venlafaxine) and Serzone (nefazodone) are two such and you are not being used as a guinea pig if your doctor prescribes them for you.

Anticonvulsants (Doesn’t that sound terrible?)

These are medications that were originally developed to control seizures. (No, as far as we know, panic attacks are not some kind of seizure.) In the early 90’s, it was discovered that many of the anticonvulsants are quite effective mood stabilizers as well. This means that they level out the highs and lows experienced by people who have Bipolar Disorder (formerly called “Manic-Depressive Disorder”). In fact, they are often helpful for leveling out unstable moods from many causes. Don’t get the idea that they make your mood flat – they usually just decrease the size of the swings.

These, too, have been tried for panic attacks. And there have been good results. Two of the better-studied ones are valproic acid (Depakote or Depakene) and gabapentin (Neurontin). Again, these are legitimate medications for your doctor to prescribe (although not usually as the first medications tried). Valproic acid blood levels are usually measured during treatment. Also, your doctor should keep an eye on how your liver, pancreas and clotting ability are doing. There is a strong warning against using it during pregnancy. Gabapentin appears to have a better side effect profile in general. Some recent research is showing good results in treating Generalized Anxiety Disorder. This is a condition in which one experiences the kind of anxiety you have when you are going through Anticipatory Anxiety. If Gabapentin continues to prove effective for Anticipatory Anxiety, it will be a boon to agoraphobics. This is because there would be an alternative to benzo’s that does not produce tolerance and withdrawal! So far, the only drugs that do this are antihistamines like hydroxyzine (Vistaril), which are not all that effective and have unpleasant side effects – namely, they dry you out and make you sleepy.

A number of other anticonvulsants are on the market. However, I would not be likely to prescribe them until there is more proof of their effectiveness.

A Final Word (about medications)

As previously mentioned, stay low and go slow. Agoraphobics are usually very sensitive to the effects and side effects of medications. Over and over, I have seen physicians prescribe a normal dose of an antidepressant only to have its side effects blow the agoraphobic out of the water. Unless you are willing to risk a really unpleasant experience, you should ask your doctor to start you on a very low dose and increase it very gradually. This often spells the difference between finding a medication and dose that suits you and never wanting to come near that awful stuff again.

Of course, this would have its up side, too. Because if you do not rely on medications, then you can turn more of your attention to what comes next – solutions that do not go away if you stop taking a pill…

Assignment: Once again, I am including one of the assignments because it is so important for you to know about it. Here it is:

Whole Body Relaxation

There are many relaxation methods out there. Here’s one you will encounter under many different names that is tried and true:

You tense a set of muscles, hold them tense until you really want to let them go, take a deep breath in and then simultaneously let the breath all the way out, let the muscles go loose and say the word “relax” to yourself. Easy.

Try it now with the muscles of your forearm. Rest your arm on a table, make a loose fist, bend the fist backwards towards your elbow hard, hold it until those forearm muscles are yelling for help, take a deep breath and all together: Let the breath out, release the forearm tension by moving your fist back to normal position and say the word “relax” as you do it. Doesn’t that forearm feel good and relaxed?

Now, you simply do this with your entire body – muscle group by muscle group. You may wish to experiment with different ways of tensing each muscle group. Here are some suggestions that you can do sitting, standing or (best) lying down:

We will start at the feet and work our way up the entire body. Tense your feet by bending your toes under (hold, then breathe in and release breath and toes while saying “relax”). Tense your ankles and the muscles at the back of the calves by pulling your toes up towards your knees (hold, breathe in, release breath and feet while saying “relax”). Tense the muscles in the front of the calves by pointing the feet down like a ballet dancer (hold, breathe in, release and “relax”). Tense the thigh muscles by straightening your legs and attempting to bend your knees backwards (hold, breathe, relax). Squeeze the buttocks together (hold, breathe, relax). Suck your belly all the way in (hold, etc.). Extend the lower back by pushing your pelvis forward (hold, etc.). Tense the chest by pulling your shoulders back and squeezing your shoulder blades together. Tense your upper back by pushing your shoulders forward and towards each other. Tense your hands by clenching them into tight fists. Tense your forearms as before. Tense your triceps by making your arms as straight as possible as though to bend your elbows the opposite way from normal. Tense your biceps in the approved “make a muscle” manner. Tense your neck by shrugging while bending your head back. Tense the muscles on the sides of your neck by bending your head first to one side and then to the other (Be careful not to hurt yourself!). (Each time still holding, breathing and relaxing). Tense the muscles of your face by widening your eyes, raising your eyebrows, sticking out your tongue downwards as far as it will go and open your mouth wide. You can end by lying on your back with your arms extended above your head and your toes pointed down. Stretch your body to make it as long as possible. Then do a final hold, breathe in and let it all go while breathing out and saying, “relax” to your whole body.

Lastly, take an inventory of your entire body. Is there any tension remaining anywhere? If so, tense the appropriate muscle group, hold, breathe and release it again. Any tension anywhere else? No? Well, voila! You are relaxed!

Practice Whole Body Relaxation at least twice a day so that you build up your skill with it.

You will hear more about using this in next month’s article. Until then, I continue to send you best wishes for your progress in overcoming panic attacks. It really can be done!

Mark Eisenstadt, M.D.

You can find article nine Here

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