dr.K's tiips

Chapter 1. Psychiatric medication

Recently I watched a National Geographic documentary: Stress – Portrait of a Killer.  In it, the brilliant Stanford neuroscientist, Robert Sapolsky, compares human stress to that of Primates and other animals.   Unsurprisingly, when humans and other animals experience stress, we all have similar increases of stress hormones in the blood. That is hardly a basis for a fascinating documentary. However, the catch is that we, humans, have the same level of stress hormones just by thinking about potential problems, as a zebra would when it flees for its life from a pride of lions.  Moreover, if the zebra (or any other animal in danger) survives the predators, the hormone levels return within 10 min to the pre-stress baseline.  Without “reflecting on what happened”, the Zebra continues grazing with the herd, unconcerned and calm. We are the only beings that are stressed by our imagination rather than a real physical danger. We tend to worry about the future, which invariably exists only in our imagination.  If you worry about your plane ride in the summer, how can you deal with it?

When the zebra identifies a danger, it runs for its life.  It can DO something about it.  We, on the other hands, are helpless against most of our worries. We can do nothing about them since they do not exist, at least not yet, not now.  Surely preparing for a predicted hurricane gives one a sense of mastery.  But how can you deal with the thought that you will never be happy again, or win the competition, or get the job, or the love, or the place, you hope for. How can you protect against a fear of flying, or failure, or of old age, or death?  We are aware of many potential problems, some real but most imaginary and totally out of our control.  Indeed, the ability to think in symbols, to imagine – exclusive to humans being – is our mixed blessing.  Among all living things, only humans have developed the ability to think about the past and imagine the future in the sophisticated form we call consciousness.  Our young cognitive apparatus  – approx. 100 thousand years old – is superimposed on an ancient emotional system (about 100 million years).  It seems as if our emotions are unable to distinguish between the concrete, reality-based present tense, and the imaginary, timeless inner mental world.  And so, our emotions react to some imaginary future danger, in the same way it does to a real, concrete and current threat to our life.

People who are constantly preoccupied with “what ifs”, and “should haves”, invariably live stressful life.  The Stress hormones (adrenalin and glucocorticoids), released in the body when we worry about something, cost a huge and increasingly devastating price to our health. These hormones are meant for use in times of danger.  They shut down many “unnecessary” systems and activate in full throttle those necessary to fight for survival.  The toll of fight and flight on the body is tremendous, and can last only a short period without inflicting damage.  In nature, whether you flee to safety or are killed is usually decided in a matter of minutes.  The mammal body was not made for extended period of mortal danger.  But when the danger exists in your mind, there is no obvious or expeditious resolution.  You can spend years worrying about issues that never get fully resolved  (are you good enough? will you develop cancer? is there life after death? etc). Additionally, you may be overbooked, overworked, overcommitted, rushing through multi tasks and racing against your own life.  Stress may become such a part of your life that you do not even notice how stressful your life is and how much unnecessary pressure you add to it.  But your body does not forget. We now understand the damage down to the sub cellular level.   I highly recommend watching the documentary mentioned above – It should serve as a wake up call for all of us.

Some stress is unavoidable.  If you care for a sick or disabled family member, struggle with a chronic illness, or deal with a loss of a loved one you would inevitably be stressed about it.    On many occasions, telling you to “take it easy” is not more than a cruel insensitive remark.  I never admonish anyone, myself included, for feeling stressed.  It is only frustrating, and adds another layer of stress – you become stressed about being stressed. But the effects of stress are so perilous, it behooves an honest discussion about the ways to reduce it.  During the next few months, I will periodically publish installments on how to reduce and limit the sources of stress in your life.  Today I will focus on the role of medications in stress reduction.  While I do not advocate medications as the first line of treatment of stress, I want to make clear my favorable approach to judicious, careful and targeted use of psychiatric medications in the treatment of chronic stress.

We have complex love/hate relationship with psychiatric medications. They are the most prescribed in the world and perhaps the most controversial.  Even those who suffer from chronic psychiatric conditions are made to feel guilty for taking them.   I agree that many people are prescribed medications unnecessarily, in psychiatry and otherwise.  But in my practice, I usually encounter the opposite:  people who could benefit tremendously from medications and are reluctant to take it.   Some fear their brain or personality would change, some see it as admission of weakness and defeat, as we are expected to “get out of it” on our own.  I will soon address those biases.  But first, what kind of psychiatric medications are helpful in chronic stress, what do they do, and who should consider them? In my opinion (and this is the community standard) two groups of psychiatric medications are well suited to the treatment of chronic stress:  The anti anxiety drugs (in particular benzodiazepines e.g., Valium, Ativan and Klonopin) and the SSRI’s (such as Zoloft, Paxil and Prozac).  While the former group is not recommended for long-term use due to its habit-forming properties, the SSRI’s can be safely taken for prolonged periods.

Let us consider each group separately although they do have some overlapping effects:

The anxiolytics:  In many ways, anxiety is the psychological equivalent of physical pain.  With its myriad symptoms, both physical (e.g., palpitation, dizziness, dry mouth, tremulousness etc.) and mental (difficulties in concentration, fear and dread sensations, being “spaced out”, etc) anxiety can be very debilitating and painful.  It is important to distinguish anxiety from stress:  Stress is the low-grade physical and emotional tension that many feel on a regular basis.  While many of the anxiety and stress symptoms are similar in their origin (a heightened activity of the sympathetic nervous system) stress is more subtle and diffused.  The symptoms of stress (such as changes in blood pressure, indigestion and fatigue) are insidious and cause a gradual “wear and tear” rather than the paralyzing picture of anxiety. Most of us get so used to living with stress as to make it almost unnoticeable.  Anxiety on the other hand, is usually acute, in response to something concrete, and tends to disrupt one’s normal course of life.

Anti anxiety medications are very effective, have a rapid onset and wash out of the body relatively quickly.  They are recommended as adjunct to treatment of psychiatric conditions most of which have anxiety as part of the symptom picture. But even at the absence of any psychiatric disorder, when anxiety appears in response to some life’s adversity, anti anxiety medications are effective and safe.  The decision to take anxiolytics for random anxiety is not medical but rather a philosophical one:  It is akin to treatment of random headaches.  Some people refuse to take medications against headache: while a questionable practice (recent scientific evidence demonstrates health benefit from treating headaches with analgesics) it is really up to them to decide.  Most headaches are benign, short lived and if one chooses to suffer rather than take a Tylenol, it is his/her own decision. Similarly, if a person chooses not to take an anxiolytic and is willing to tolerate the anxiety, there is nothing wrong with it. Perhaps the only difference between the treatment of headaches and anxiety is that medications against headaches are over the counter, while medications against anxiety require prescription.  It is a good thing: unscrupulous and unsupervised intake of anxiolytics can quickly get out of control and may lead to addiction.  Yet, the administration of anxiolytics under a supervision of a psychiatrist, is safe, and can help a person get through a difficult period in life in an easier, more manageable way.

In summary, anxiolytics belong to the group of psychiatric medication that need not be restricted to psychiatric disorders.  They have a role – much like analgesics – in helping reduce pain and suffering, provided they are monitored and supervised by a psychiatrist or a knowledgeable family practitioner.  Once an absence of any underlying medical condition (e.g., thyroid hormone dysfunction) is established, there is no downside to using them.  In fact, when one considers the physical and mental deleterious effects of anxiety and the great personal suffering, it makes sense to use them more liberally.

What about SSRI’s?

The use of anxiolytics should not be that controversial since they provide a quick relief from a painful condition.  SSRI’s, on the other hand present a much more complicated decision when prescribed at the absence of a diagnosable psychiatric disorder. While I believe they have a clear beneficial role, I appreciate the controversy and would concede that those opposed to it (especially to the wide unsupervised use) have a valid point.

First, why do I support (and use) SSRI’s for people without a defined psychiatric disorder?  For one simple reason:  They are a great aid to psychotherapy.  Historically, SSRI’s were developed as antidepressants.  With time, their anti-obsession and anti-anxiety properties were discovered and put to good use in those who suffer from OCD (Obsessive Compulsive Disorder) and panic disorder.  They were also found useful in PTSD, eating disorders and social anxiety among others.  But they have another, related attribute that I find extremely compelling in my everyday practice:  They make it possible for you to “Take a vacation from yourself”.

What does “vacation from yourself” mean?  Can you truly take a vacation from your own self?

Obviously not!  Most psychiatric treatment is based on the fact, that you are forever “stuck” with yourself.  But you can take a metaphoric vacation from one aspect of your existence, namely, the intrusive chatter in your brain.  We all experience intrusive chatter: think about a time in your life when you were preoccupied by thoughts you did not want to have.  Remember the night before the big exam?  You may have said to yourself, “I’d better get a good night sleep and not think about it”.  And yet, no matter how hard you try to distract yourself from thinking about the exam, you still find yourself at 3am, exhausted, unable to sleep, and totally consumed by anxious thoughts.  Chronic stress sufferers have an “intrusive chatter” most of the time even without a specific trigger.  The intrusive content might be self-deprecating, self-defeating, self-loathing or merely pessimistic, in short all types of negative and unhelpful thoughts.  While the underlying mechanism is probably the same for constant chatter and obsessional thinking of OCD (that is why SSRI’s are helpful in both) there are substantial differences:  OCD thoughts are very fixed, concrete and are usually perceived as irrational by the sufferer.  In “constant chatter” the thoughts are poorly formed, fleeting and without any real sense of irrationality.  The thoughts might be “I cannot do it” or “I need to lose weight” or something similar. While not illogical, they are unhelpful, distracting and often very discouraging.  Constant chatter does not amount to the strong interference and prominence of intrusive thoughts as in OCD.  Rather, constant chatter is like white noise:  it is always in the background and increases in inverse proportion to the level of distraction around you:  The quieter your environment the more intrusive it becomes.  And so constant chatter is at its peak when you are trying to rest, sleep, read, or concentrate on any type of mental activity.

One of the activities most disrupted by constant chatter is psychotherapy.  By design, most of the psychotherapeutic “work” is done internally. As you concentrate on issues you would like to change while trying to focus on your inner world, the constant chatter intensifies and disrupts your connection with yourself.  The annoying, repetitive and negative thoughts that flutter in your mind prevent you from attending to your feelings, since you cannot affect any distance from yourself.   That is when SSRI’s come in handy:  They are invariably able to stop the constant inner chatter.  Once effective (and it can take months before it takes effect) you find yourself, perhaps for the first time in your life, being able to sit and think about nothing in particular and better yet, turn off at will the annoying intrusive thoughts that reverberate unwanted in your mind. Taking a vacation from yourself does not mean (as many people believe) taking a vacation from your feelings.  Many consider SSRI’s a “feel good” medication, believing it is meant to numb emotional response to everyday life.  Nothing can be further from the truth:  SSRI’s enables those who suffer from constant chatter, to choose whether they want to think about something or not.  I like to describe the mechanism the SSRI’s, in a nonscientific terms, as a movable padding – positioned between one’s thoughts and feelings.  Moved into position, it creates some buffer between the anxious thoughts and the anxious emotions.  The chronically stressed person can, at long last, block a mental concern from igniting a vicious cycle of a cognitive/emotional storm. Conversely, the same mechanism prevents an anxious pang from exploding into a cascade of concerns.

In summary, SSRI’s and anxiolytics should definitely be considered as an effective way to prevent our imagination from igniting an unnecessary stress reaction. There are other proven techniques to decrease and control stress in our life. I will cover them over the next few months.  Ideally, our stress reaction should return to the role nature intended; to sharpens our mind and reflexes in the presence of a real present danger or concern.  By “abusing” that rapid intervention system for petty or imaginary concerns, we deplete our emotional resources and reserves. We must learn how to stop our futile, self-destructive struggle with our imaginary demons.

I cannot think of a better Spring cleaning plan.