Anxiety disorders are the most common class of psychiatric disorders. Their US prevalence is about 20%. They’re also among the least recognized and least treated. We have sort of finally beaten into people’s thick skulls that depression isn’t just being sad, and you can’t just turn your frown upside down or something – but the most common response to anxiety disorders is still “Anxiety? So what, everyone gets that sometimes.”
But it’s hard to describe how disabling anxiety can be. A lot of people with nominally much worse conditions – depression, bipolar, even psychosis – will insist that they want their anxiety treated before anything else, because they can live with the rest. On the other hand, while a lot of people with psychosis have enough other problems that treating the psychosis barely puts a dent in their issues, a lot of people with anxiety would be happy and productive if they could just do something about it.
Since I’ve gotten some positive comments on my discussion of depression treatments I thought I’d go through some of the things I’ve seen used to treat anxiety. I’ll include the same disclaimer:
This will be inferior to reading official suggestions, but you will probably not read official suggestions, and you may read this. All opinions here are my own, they are not endorsed by the hospital I work at, they do not constitute medical advice, I have a known habit of being too intrigued by extremely weird experimental ideas for my own good, and you read this at your own risk. I am still a resident (new doctor) and my knowledge is still very slim compared to more experienced professionals. Overall this is more of a starting point for your own research rather than something I would expect people to have good results following exactly as written.
I’ll mostly be talking about what’s called generalized anxiety disorder, with some applicability to panic disorder. Social anxiety, specific phobias, et cetera are their own thing, as is anxiety secondary to other illnesses – but some of the advice may cross over. I’m not going to get too into diagnosis, because generalized anxiety disorder is pretty much exactly what you think it is and a lot (though not all) of this will be applicable for subclinical anxiety as well.
I. Diet And Lifestyle
You didn’t think you were going to get out of this part, did you?
Pretty much every study – epidemiological or experimental, short-term or long-term, has shown that exercise decreases anxiety. The effect seems limited to aerobic exercise like walking, running or swimming, preferably for longer than twenty minutes. Various mechanisms have been postulated including norepinephrine, endogenous opioids, and decreased inflammation.
There’s less agreement on diet. The people who hate fat says high-fat diets cause anxiety. The people who hate carbs say high-carb diets cause anxiety. The people who hate processed food say processed foods cause anxiety. The people who recommend fish oil for everything say insufficient fish oil causes anxiety. None of it seems super credible, but Mayo Clinic has some suitably bland advice.
The one very important connection – if you drink too much coffee, or any other source of caffeine, that will make you anxious. I once had a patient come to me with severe recurrent anxiety. I asked her how much coffee she drank, and she said about twenty cups per day. Suffice it to say this was not a Dr. House-caliber medical mystery.
Also needless to say: get enough sleep. Seriously. Get enough sleep.
Many people find that various breathing exercises or other sorts of mindfulness activities can be helpful in the short term and sometimes build skills useful for the long term. My hospital gives people these handouts on breathing techniques and progressive muscle relaxation. I’ve made fun of HeartMath in the past, but I only learned about them because many people find some success, probably placebo-ish, with their quick coherence technique. If you’re an overachiever and want to get really into this sort of stuff, people always say good things about yoga and especially pranayama breathing. Studies seem to back this up (1, 2, 3) though you’ve got to be careful to weed out the studies by very religious Hindus trying to prove they’ve been right all along.
Meditation has similarly positive results. Here’s a study showing that an intervention to teach patients meditation resulted in decreased anxiety with p < 0.001 even three years later. Here's a meta-analysis of 39 studies finding an effect size of about 0.6 (medium) in the general population, and an effect size of about 1.0 (large) in people with anxiety disorders. But here’s an equal and opposite review that found only “equivocal” results. As far as I can tell, most people investigating meditation think it works pretty well. The meditation techniques that seem to work best are mindfulness meditation and transcendental meditation. You can learn a little about mindfulness meditation here. In order to learn about Transcendental Meditation, send a check made out for $5000 to Maharishi Mahesh Yogi, PO Box….
II. Therapy
Cognitive-behavioral therapy works okay for anxiety just like it works okay for everything else. The Big Graph O’ Effect Sizes says that psychotherapy on average has an effect size of 0.51 in generalized anxiety, compared to medication’s 0.31. This shouldn’t be taken too seriously – the confidence intervals overlap and there’s a wide range of efficacy for different medications – but you won’t be doing any worse by going for the therapy first. Even the Cochrane Review, famous for never drawing any conclusion other than “more research is needed”, is tentatively willing to say that psychotherapy works for anxiety disorders. Their study trends towards finding that cognitive behavioral therapy works better than supportive therapy, but is unable to prove significance – apparently more research is needed.
Exposure therapy can also be useful for panic attacks or specific phobias. This is where they expose you to the thing you’re scared of (or deliberately initiate a panic attack) and keep doing it until you stop being scared and start being bored. According to a bunch of studies it works neither better nor worse than cognitive-behvioral therapy for most things, but my unsupported impression has always been that it’s better at least for panic disorder. Cognitive-behavioral therapy seems clearly superior for social phobia.
You can get psychotherapy from any qualified psychotherapist, a category including counselors, social workers, psychologists, and sometimes psychiatrists. Ones who use “a school” (for example, describe themselves as practicing cognitive behavioral therapy) are usually considered better than those who don’t (“Oh, I do a little of everything with every patient”). If you can’t find (or don’t want to find) a good therapist, there is preliminary evidence that a good self-help therapy workbook (“bibliotherapy”) is about as good as real therapy – including for anxiety (study, other study, yet another study).
I have no special insight into which self-help workbooks are any good, but The Cognitive Behavioral Workbook for Anxiety: A Step-By-Step Program
III. Medications
To be tried after diet and lifestyle interventions when possible.
Medication can work either instead of or in addition to therapy. There are at least seven categories of commonly used conventional anxiety medications: SSRIs, SNRIs, antihistamines, antipsychotics, anticonvulsants, benzodiazepines, and azapirones. These can be divided into mostly-acute (antihistamines and benzos) and mostly-long-term (SSRIs, SNRIs, anticonvulsants, azathioprines), with antipsychotics kind of being a tossup. Depending on whether you just need to get through the occasional panic attack or whether you’re in a chronic unremitting anxiety state, you might want one, the other, or both.
You probably know antihistamines (example: Benadryl) from the many common over-the-counter members of this class. They have some mild short-term anti-anxiety effects. Benadryl will work in a pinch if you need something without a prescription, but the most commonly used anxiolytic antihistamine is hydroxyzine (“Vistaril”, “Atarax”), which is a bit more powerful and less likely to make you fall asleep. As far as anxiolytics go it’s pretty safe as long as it doesn’t make you too sleepy. If you just need something to take the edge off the occasional anxiety attack, this works fine.
Benzodiazepines (examples: Xanax, Ativan, Valium, Klonopin) are very effective in the short-term but also very controversial. In some people they are very habit-forming and can produce a picture very similar to addiction to alcohol (which they chemically resemble). Keep in mind how bad an idea it might be to become extremely addicted to prescription pills that you may suddenly lose access to depending on how your doctor is feeling (you might expect doctors would take the difficulty of coming off these drugs into account, but you might expect a lot of things from doctors that don’t always happen). Studies suggest benzodiazepines can sometimes build tolerance, and that after a month or two of frequent use, they lose their positive effect and you need them just to feel normal. That having been said, a subset of patients – and I can’t tell at this point if it’s a majority or a minority – go on benzodiazepines, do very well, stay on them for long periods without getting dependent, and never have anxiety again. It’s kind of a crapshoot. The most generally recognized “safe” use of benzos is the occasional Xanax to deal with rare but very stressful situations (for example, flying on an airplane if you’re scared of heights). Other people say Klonopin is safer than some of the others and that it’s worth a shot as long as you realize that “Klonopin dose gradually creeping upwards” is a sign that you’re getting into a bad place and need to react immediately. Most people recommend trying other things first before you come here, but once you’ve exhausted other options these can be a powerful last resort.
SSRIs (examples: Prozac, Celexa, Lexapro, Zoloft) are the mainstay of chronic anxiety treatment just like they’re the mainstay of chronic everything-else treatment. As usual, they have real but modest effects after about a month or so, more in some people and less in others. As usual, if one SSRI doesn’t work for you, you might want to try another. These are pretty safe aside from the sexual side effects. Some people get mild withdrawals if they go off these too quickly, so don’t do that. A lot of people use both an SSRI for chronic treatment, plus either an antihistamine or benzo for “break-through” anxiety.
SNRIs (examples: Effexor, Cymbalta) are like SSRIs, but for two neurotransmitters instead of one. This is supposed to make them a little bit more effective. Maybe they are, maybe they aren’t. Fewer sexual problems than SSRIs, but worse discontinuation syndrome. They’re a good second-line chronic medication if SSRIs don’t work. Effexor is probably the best.
Azapirones (example: BuSpar) is, unusually, a rare drug which is specifically targeted at anxiety, rather than a being a repurposed antidepressant or something. BuSpar is very safe, not at all addictive, and rarely works. Every so often somebody comes out with a very cheerful study saying something like “Buspar just as effective as benzodiazepines if given correctly!” and everybody laughs hysterically and goes back to never thinking about it.
Anticonvulsants (examples: Depakote, Neurontin, Tegretol, Lyrica) are seizure medications that sometimes sort of work for anxiety. Most of them have strong side effects and limited utility. The exception is Lyrica (pregabalin), which is pretty new but has shown excellent safety and efficacy in studies. It doesn’t have an FDA indication for anxiety and it’s pretty expensive, so you might have a hard time getting it, but it is at least a well-kept secret.
Atypical antipsychotics (examples: Seroquel, Zyprexa, Abilify, Geodon) are, as always, overused. Most of them either make you gain lots of weight, put you at increased risk for heart rhythm problems, make you feel terrible, put you at risk of permanent movement disorders, or all of the above. They do often treat anxiety, sometimes very well, and psychiatrists like them because they’re good all-purpose no-nonsense drugs with big advertising budgets, but unless you’re also psychotic consider trying some other things first before you try these.
An article in Journal of Psychopharmacology tries to compare the efficacy of all of these classes of drugs and gets the following effect sizes (bigger number = bigger effect):
Pregabalin: 0.5
Antihistamine: 0.45
SNRI: 0.42
Benzo: 0.38
SSRI: 0.36
Azapirone: 0.17
Alternative medicine: -0.31
(remember, other studies suggest psychotherapy is around 0.5)
I heavily challenge the claim that antihistamines are more effect than (or anywhere near as effective as) benzos. I don’t know the confidence intervals on these numbers, so I would suggest reading it as “Everything is about equally effective, except azapirones which aren’t as good”. Their “alternative medicine” category was mostly kava and homeopathy, and I have no idea why it came out negative (kava’s pretty good, and homeopathy shouldn’t separate from 0).
There are also some less commonly used drugs that might help people who don’t respond to any of these.
As usual, MAOIs are very effective, moderately dangerous, and super hard to get. They seem to work especially well for panic disorder and social anxiety.
Clonidine is a medication usually used to control blood pressure. It’s somewhat effective against anxiety and some people think it should be used more. But it can cause you to become too sedated (abnormally low heart rate) and in some people it makes anxiety worse for some reason.
Beta-blockers (example: propranalol) are another blood pressure medication. It is especially effective against somatic symptoms of anxiety – racing heartbeat, shaking, et cetera – and sometimes getting rid of those can make the anxiety go away entirely. It’s most famous for its use against performance anxiety: about a third of musicians use them in concerts, and I’ve heard similar rumors about public speakers, actors, et cetera. I used to think this was a little-known piece of trivia, but whenever I bring it up to doctors (“Hey, did you know some people use beta-blockers for performance anxiety”) the usual response is “Oh, yeah, I prescribe myself some of that when I have to give a presentation at grand rounds.” They don’t seem quite as good for longer-term anxiety disorders, though some people have had good results with them.
I once saw an excellent psychiatrist whom I deeply respect try everything on a patient with severe treatment-resistant anxiety with no results whatsoever until finally he came to Thorazine. This treated the patient’s anxiety pretty well, at the cost of provoking quite a bit of anxiety in the doctor.
Without meaning to give medical advice, and with the caveat that you should ask your doctor for their opinion – one good pharmacological treatment algorithm for anxiety disorders is:
If you just have occasional outbursts that bother you, take occasional doses of hydroxyzine.
If you have a longer-term problem, start with an SSRI. If that doesn’t work, either try more SSRIs and SNRIs, or go to Lyrica. You might as well be on BuSpar somewhere in the process too. If none of that works, choose your poison (or have it chosen for you) among MAOIs, benzos, clonidine, or antipsychotics.
IV. Alternative Treatments
To be used out of curiosity or desperation only – you have other options and these are not guaranteed safe or effective.
Massage therapy, acupuncture, aromatherapy, and everything else in the category of “unnecessarily medicalized relaxing thing” all perform very well as long as you don’t look too hard for a suitable control group. Yes, these are probably placebo, but they’re very effective placebos and if they both work I would rather take a placebo than an antipsychotic.
Inositol and l-theanine are both found in small quantities in the diet (inositol in some vegetables, theanine in tea) and supplementing them has been inconsistently found to help with anxiety. Inositol had some preliminary evidence for effectiveness in panic disorder, but a more recent meta-analysis was unimpressive. I can only say that I have some anecdotal evidence of extremely positive reactions to inositol, but we all know what they say about anecdotal evidence. Keep in mind that the dose used in studies is way larger than the dose anyone will give you – usually corresponding to about 20 of those 500 mg inositol pills a day. This makes it expensive and inconvenient, and most people just compromise by taking so little inositol it shouldn’t possibly be able to have any effect. L-theanine also has a lot of small studies in support, although there’s some question on whether it works on its own or whether it just has useful synergistic effects with caffeine. Sun-theanine is generally considered the most effective form, and recommended dose is about 100 – 400 mg. Both these supplements are afaik very safe and a good option for people who want to test things that might or might not work but have minimal risk. Magnesium should also be in here somewhere.
GABA is the main inhibitory neurotransmitter in the nervous system, and a lot of these other interventions are attempts to convince the brain to release more GABA or potentiate the GABA that’s already released. Can we just cut out the middleman and ingest GABA pills directly? The supplement industry would like you to think so, and you can certainly buy them anywhere supplements are sold, but it’s generally believed that orally ingested GABA can’t cross the blood-brain barrier. The Russians have developed a modified version of GABA that doesn’t have this problem; called picamilon, it seems to be a pretty popular anxiety treatment on the other side of the Pharmacological Iron Curtain. It’s pretty easy to get as a non-prescription supplement here in the West. There are very few studies on it, the ones that exist are in Russian, and I have nothing to go on but a couple of anecdotal reports, most of which are positive (though I personally noticed no effects). But the mechanism of action is plausible, and the long history of successful Russian use at least suggests it probably won’t kill you immediately. Most common dosage seems to be about 100 – 300 mg.
The nootropics/supplement/nutraceutical community also suggest ashwagandha and bacopa for anxiety; various low-quality studies support the use of both (ashwagandha meta-analysis, bacopa study 1, bacopa study 2, bacopa study 3). Bacopa may take several months of frequent use before it starts working; I tried it briefly and had to stop because of gastrointestinal side effects, which are pretty common. There’s also some worry around heavy metal contamination. Swanson’s and Nootropic Depot’s are two that have third-party testing showing they’re uncontaminated.
Kava is a traditional drink from various Pacific islands with anxiolytic properties. Multiple meta-analyses including a Cochrane review find it to be an effective anxiety treatment, but its safety is in question after reports of several cases of liver failure caused by the plant. This may be yet another case of people exaggerating freakishly rare side effects; the risk has been estimated at less than one in a million doses (though remember that if you take it daily for ten years, that number bcomes 1/300). Others suggest a rate as low as one in a hundred million but this assumes zero underreporting; others challenge this assumption. Possibly it is only poorly prepared kava causes liver problems; for traditionally prepared kava, look for preparations that specify they are made from root/rhizome material only. The American Academy of Family Physicians recommends that:
Physicians who supervise patients taking kava for the treatment of GAD should take care to avoid the following: (1) high dosages (more than 300 mg per day); (2) combining kava with hepatoactive agents; (3) using non-root preparations; and (4) exposure for longer than 24 weeks. Use of WS1490 standardized kava extract is also recommended. If these safety precautions are followed, kava can be appropriate therapy for selected patients diagnosed with GAD
Don’t take kava if you have any liver problems, if you’re on any medications that might interact with it, or if you plan on drinking alcohol at the same time. Consider talking about it with your doctor first and getting plans to check liver enzymes regularly.
Selank is an experimental Russian anti-anxiety medication going through their version of clinical trials. It’s a bit high-maintenance – you have to keep it refrigerated or else it decays, and the only two functional means of administration are injection or nasal spray – but anecdotal evidence is extraordinarily positive. No side effects have been found thus far, but needless to say by the time you get to “injecting experimental Russian medications into yourself” we have left the point where we can entirely guarantee this is a good idea. Ceretropic sells a nasal spray version, which is probably more convenient than having to inject it.
Phenibut is another Russian anti-anxiety medication. It is potentially addictive and dangerous. I do not want to actively recommend against it, because it can be very useful if used infrequently and carefully. Discussing exactly how to use it infrequently and carefully is beyond the scope of this article. Please do not use this unless you have looked into it carefully and understand the risks and benefits.
Overall, the best evidence seems to be for l-theanine (especially if you drink coffee) and bacopa (especially if you’re willing to wait months for any effect), with picamilon also worth your time to try and Selank as an option for the very adventurous.
V. Conclusions
No treatment stands out as extremely effective, and the best route to dealing with anxiety probably depends on many factors like your amount of free time, your motivation, your access to medical care, and your willingness to put up with side effects. After you’ve fixed lifestyle issues, I think any of “self-help workbook”, “start SSRIs”, or “try l-theanine” are good first options. On the other hand, benzodiazepines, antipsychotics, and kava are all options I would hold off on until you’ve tried a couple of other things.
Like with the depression post, the most important conclusion you can take from this is that you have lots of options. Please don’t let people give you an SSRI and then give up. Work with your doctor. Anxiety actually has a pretty good prognosis if people work on it, but it can be a difficult and frustrating process. Just remember: there are lots of options.
PS: Relevant Onion
How much is enough sleep?
About 8 hours is enough for me, but I find that I also need to keep the schedule consistent. I’d always shift later and later, then sleep a ton on the weekend to try to catch up, and end up always feeling either sluggish or sleep deprived. The sleep deprived state is bad for anxiety because it reduces the number of spoons I have for combating the anxiety.
So now I set multiple alarms on my phone to make sure I’m always waking up at the same time each day all week long.
I find boredom really dangerous for anxiety, and it also makes it harder to sleep. So getting lots of mental and physical exercise during the day made a huge difference for me in being able to sleep at night and get through the days without constantly ruminating about the anxiety.
Having mental stimulation also helps me sleep: my best cure for insomnia is to find a good brain teaser on Futility Closet and try to solve it in my head while I’m trying to get to sleep.
Fairly confident this varies a lot from person to person, maybe anywhere from 6 to 10 hours. Thing to try to find out: go to sleep when you’re tired (and do other good sleep stuff; I like melatonin, f.lux, and taking a hot shower), and wake up without an alarm, in darkness (say with a sleep mask).
I also have two random tests for diagnosing whether I haven’t had enough sleep that I don’t expect to generalize to other people, which are 1) do pushups (it’s noticeably harder if I haven’t slept enough) and 2) singing (voice quality is noticeably worse if I haven’t slept enough). Together with waking up without an alarm I learned that I need somewhere between 9 and 10 hours to feel fully awake, which is an hour more than I would’ve guessed.
In my experience:
sleep enough so that the constant low-level hum of pain goes away. For me, that’s usually 7.5-8 hours. But it’s the feeling that matters.
Some research shows that lack of sleep dulls cognitive performance (maybe other types?) even when the subject feels 100%. Subjective assessment may not get you all the way there.
Enough that you wake without an alarm. This is less obvious than it sounds. Anecdote alert:
I used to be chronically sleep deprived and insomiac. I had a revelation a year or so ago when someone on LW mentioned that they got up without an alarm; at the time, the concept of being able to wake naturally without inevitably being late for everything was alien to me. My reference point was weekends, when I would forego the alarm and not wake until nearly noon — obviously unacceptable when you work a 9-5 job.
It turns out that’s not normal. I believed I was naturally nocturnal; I was wrong. Once I was getting enough sleep regularly (as opposed to borrowing time most days and “catching up on sleep” on the weekends) it was actually fairly easy to sleep in the evening and wake in the morning. I managed that by forcing myself to sleep with melatonin (to deal with my evening insomnia) and moving my work schedule an hour later. After a few months I stabilized around 8-9 hours of sleep a night, stopped needing the melatonin, and now typically wake before my alarm goes off, no special measures required.
(obviously none of this will help if you have really serious insomnia or a genuine nocturnal circadian rhythm. But in my case, bizzarely, the insomnia went away when the sleep dep did)
This, but with a caveat. If someone already has an anxiety disorder, adding “Oh God Oh God I didn’t set the alarm now I’m going to oversleep and loose my job”, might not be entirely helpful.
Err, yes. I should have noted that I do still set an alarm as a just-in-case measure. But if it’s a 100% requirement to wake you up, you’re doing it wrong.
Yeah, this.
99% of the time I wake up before my alarm goes off, but I still set it, because I’m too generally anxious about missing work to take the chance.
I set a “backup” alarm that ideally never goes off. With regular sleep, I’ll wake up normally 15-30 minutes before the alarm. If I don’t, the alarm allows me enough time to hurry and still be ready for work on time.
Sleep is definitely important for me, and getting more sleep helps me not be anxious. I have, however, read, that the “more sleep is good” line we always get may not apply in every case: specifically, with unipolar depression of the sort which keeps you in bed all day, more sleep supposedly can worsen the depression, and less sleep can alleviate it.
This seems right to me, since not getting enough sleep starts to make me kind of manic, which is bad for me, since anxiety and insomnia are bigger problems for me than depression, but I could see it might help if your problem is the opposite of mania, i. e. unipolar depression.
Sleep deprivation has been put forward as a therapy for some kinds of depression, in fact: http://www.ncbi.nlm.nih.gov/pubmed/19029872
http://www.nature.com/scitable/blog/mind-read/an_unconventional_release_from_depression
http://www.chicagochronotherapy.com/waketherapy.html
So melatonin worked for you? Because I:
1. Take at least an hour to fall asleep at night.
2. Wake up once in the middle of the night.
3. Wake up before my alarm every morning.
4. Am tired all day until about the time I get home from work, at which point I perk up and become energetic, making it difficult to get to bed early.
It’s not ideal.
What dose are you using?
I’ve had a number of problems with getting to sleep at night and waking up in the morning, and have found melatonin extremely effective for treating it. Like, the first night I took melatonin I woke up on my own, without an alarm, feeling rested, at 8AM. Which I don’t think has ever happened before.
I’m taking 0.5mg/day at ~10-11PM
1) Recommended: Nancy Kress’s socio-SF series Sleepless, starting with Beggars in Spain, about people who, genetically, lack a requirement for sleep.
2) Apparently, the “natural” human condition is “go to sleep when it gets dark, sleep for 4-5 hours, wake up, stare at the wet wild woods for an hour or so, then go back to sleep for 2-4 hours until it gets grey in the sky” – aka Segmented sleep.
So there is likely no more a set ideal than there is a set ideal amount of food to eat or water to drink – you should get what you need.
Benadryl? Huh.
Basically a source of diphenhydramine. I haven’t had Benadryl as such, there was a time when I had a bottle of old-school drowsy-formula cough syrup, and I had some, went out to the pub for a couple of pints, came back, read the label, read “not to be consumed with alcohol”, and ended up feeling very drowsy indeed for several hours afterwards. Later on when my GAD started to spring up, I ended up using it to help me get to sleep at night as an occasional thing when the thoughts were racing too much that night. When I ran out, I did a bit of research and found out that diphenydramine is also the active ingredient in Nytol, a popular brand of sleeping pills. So I got some of that. So, diphenydramine, it’s the same stuff whether sold as sleeping pills or cough medicine or allergy medicine or whatever, and has the same effects.
I’ve heard that long-term consumption isn’t advised; I think I heard either it can be addictive or you build up a tolerance or something. But as a thing to have on hand for occasional relief when it all gets too much, it’s pretty good.
In my experience it’s especially useful in getting to sleep when feeling anxious and angry about vexatious things people have written on the internet. (When discussion of an issue is causing you to take pharmaceuticals to recover, can you say that the mental health troubles you are having count as nauseam, as in ad nauseam?)
My dad had been taking benadryl for sleep for years until I recently got him to try switching to melatonin. The reason was I read (on SSC, I believe) about a study showing increased risk of dementia with prolonged anticholinergic use. Not sure how reliable that study was, but it seems plausible that it might not be good to continually suppress your cholinergic pathways.
“I’ve heard that long-term consumption isn’t advised; I think I heard either it can be addictive or you build up a tolerance or something.”
Associated with dementia, too: http://www.ncbi.nlm.nih.gov/pubmed/25621434
I’ve never found Benadryl makes me sleepy, though this may be because (a) I’ve taken it infrequently for anti-histamine effect (b) the new versions are probably the anti-drowsy kind (c) I seem to have weird reactions to medications, e.g. all the ones which warn “This’ll probably make you sleepy” never do.
Anecdotal experience based on very bad bouts of panic attacks a couple of years back:
A lot of people with nominally much worse conditions – depression, bipolar, even psychosis – will insist that they want their anxiety treated before anything else, because they can live with the rest.
(1) Yes. Depression is horrible, but it’s mostly a low-grade, everyday horrible gray sludge (unless interspersed with bouts of “I think really on balance I should kill myself”). It’s nothing like the existential dread, claw-your-own-face-off, I’M GOING TO DIE I’M GOING TO DIE shock that comes out of nowhere. I have no idea what triggered off these anxiety fits, they usually happened around 2-4 a.m. in the morning, and they were terrible. Only lasted about an hour or two, but really bad hour or two to get through.
(2) Diet, exercise and sleep. *hollow laughter* Going by those recommendations, rainwater and moss seem to be the only safe thing to consume. I wasn’t eating much differently back then from how I ate either before or since, so I don’t think that diet had a triggering effect (I’m not really a coffee drinker, so it wasn’t caffeine-induced anxiety).
Exercise I have never found to have this magical beneficial effect. I can’t drive, so I have to walk or take public transport everywhere. This twenty minutes or more of walking – I’ve often done that in a day getting to and from work. Never got this “Oh, I feel so much better now” feeling – exercise makes me tired, hot, sweaty and (if it’s very vigorous and I’ve been inactive before) it gives me stiff aching muscles, but not this sense of calm and improved mood.
Sleep – the trouble with trying to get to sleep when you’re having an anxiety fit is the whole clawing-your-face-off, I’M GOING TO DIE I’M GOING TO DIE, heart racing, breathlessness, existential dread sensation. Does not make for the relaxed body and mind you need to nod off.
(3) Breathing exercises – actually are helpful, at least with getting the breathlessness under control and forcing yourself to concentrate on them – I won’t say “calms you down” but does help discipline the mind. At least if you don’t feel you’re suffocating, that’s one less thing to be anxious about.
(4) What did work for me was Xanax – 0.5 mg as needed for a strictly limited time; worked by zonking me out. I probably still was having the anxiety fit but since I was knocked out asleep I didn’t know about it. Was very reluctant to go on it and took it sparingly because I was worried about the possibility of getting addicted (psychologically if not physiologically) because it would be easy to get anxious about getting anxious and then take a tablet ‘just in case’ and there you go, instant addiction. But they did work and I’m grateful.
Haven’t had any panic attacks or anxiety fits since then, very glad to be over them, have no idea what triggered them in the first place and it’s really, really hard to explain exactly how awful a feeling it is when you’re experiencing it, because when you try to put it into words what can you say? “Baseless dread for no reason about nothing in particular”? That doesn’t sound so bad, but wait until you experience it!
Totally with you on the diet/exercise thing. I’m convinced that the exercise industry has successfully indoctrinated the entire human race with the world’s most successful placebo.
I’ve made plenty of changes on these things in my life and never noticed any impact on the general “how are you feeling” scale whatsoever, yet all of my friends swear by it. Seems bizarre to me.
I’ve had the endorphin high from exercise precisely twice, within about four weeks; both times it was wonderful, but repeating the same routine the next week didn’t produce the high, and after a year or so of reasonably regular exercise I’ve not had the high again.
So I believe it exists but I don’t know what causes it and it’s clearly not reliable.
Like religious euphoria, which I’ve had exactly once, triggered by Liverpool’s enormous Anglican cathedral, but which did not recur on a second visit to the same cathedral.
Matt M, I really think it’s down to brain chemistry. A lot of people get the nice burst of endorphins and feel all “Mmm, this is pleasant” while an unfortunate minority like us don’t get those rewards for
pressing the buttonspounding on the treadmills or what have you 🙂I’ve heard all the “Oh, but you have to do it for an extended period and keep it up for a good while so it becomes a habit and as it gets easier, your body will like it”. When I committed to an hour a day every day of a routine, I did find gradual improvement in fitness and muscle tone (not so much corresponding weight loss, and I don’t mean on the scales, I mean ‘are my clothes getting looser’). I did not find (a) I was getting lovely fuzzy feelings of “I like this! I want to do more of it!” after exercise (b) it did not become easier, in fact, as I went on, I was clock-watching to see when I’d have to do my hour and trying to find any excuse to skip it and I had to force myself “No, stick to EVERY DAY and A WHOLE HOUR”.
Some people (me) are just naturally lazy, I suppose 🙂
Right. When I say I saw no effect, I don’t mean that 100% literally. After months of running and lifting things, I did notice that running and lifting things became SLIGHTLY easier for me, and the process of running and lifting things became SLIGHTLY less unpleasant than it was previously.
But none of this translated into any difference whatsoever in how I felt during the 99% of my life when I wasn’t actively engaged in running or lifting things.
At this stage, I’m convinced if you turned up at a hospital with your head hanging on by a thread, the first thing you’d be recommended is “Diet and exercise!” 🙂
It seems to be the universal panacea, and maybe it is, but why then do we need a pharmaceutical industry if everything will be made better by eating right and taking more exercise?
Presumably because it’s far easier to get people to take a pill than it is to get them to exercise and/or change their diet. It would still be a benefit on net even if the pills are less effective. An intervention that nobody actually uses helps no one.
I have a daily running habit, I consider it a pleasant activity, though it can sometimes be hard to get started. Wouldn’t say I’ve had “runner’s high” too frequently but occasionally you’re gliding along at a fair clip and nothing hurts and everything seems quite nice, that might qualify.
One thing about the human body and exercise, it only ever becomes “easy” when you’ve redefined “hard”, if you do ten reps, then the 8th rep will be hard, it only becomes easy when you’re doing 20 reps and now it’s the 18th that is “hard”. Running 10km becomes easy when you’ve done 20km runs, if you’re doing 10km runs and never going beyond then the 9th km will continue being the definition of “hard”. The body is conservative in that way.
In my experience this feeling means you’ve got a strong tail wind and therefore when you eventually head home you’ll be running into a strong head wind.
I solved the problem of forcing myself to exercise by using it as a procrastination method. I wait until I need to do something I enjoy less than exercise, and I go to the gym to put it off. This happens on a weekdaily basis, not because I hate my job, but because I don’t actually mind exercise that much. Occasionally, I’ll even let myself skip a really boring and pointless meeting to work out. It has the added benefits of being socially justifiable — more so than “I skipped your meeting to go to Starbucks,” at least — and keeping me off Lync for 45 minutes.
I bet they’re in cahoots with Big Rest And Fluids.
Hahaha. I love the idea of “big rest” and “big fluids,” because I do think these things are a bit overemphasized, along with “big fish oil.”
Not that “sleep more” and “drink more water” aren’t good recommendations for most people, but I think it can go too far, with people thinking you need to drink a gallon of water a day even if you don’t feel thirsty, etc.
Aha, I knew it was all Big Pharma conspiracy! All anyone ever needs for any ailment whatsoever is to eat oily fish twice a week at least, drink plenty of water, cut out starchy foods and processed fats, take plenty of vigorous exercise to get your heart rate up and get a good six to eight hours sleep a night!
Obviously the pharmaceutical companies are suppressing the studies proving this will enable us all to live to be 150 years old while looking and feeling like we’re in our 20s so they can continue to peddle their worthless pills to us 🙂
*actually laughs out loud*
@Onyomi, and also anyone else who sees it similarly. A serious response to a very funny topic.
I think that these advices seem so heavily overemphasized to some of us because we are much more responsive to that advice than others would be. I know I am, and this community tends to have a high number of people who take things like that seriously, so I feel okay guessing that you also are.
The level of emphasis on those is probably so high right now because people who are averagely-responsive to advice like that would still be underhydrated and underrested if it were not.
I have some pretty overwhelming evidence that for myself, exercise helps with depression and anxiety, more effective than some medications. I’m pretty sure I’m not alone, either.
While some exercise can produce an immediate high, or burn off some adrenaline from anxiety, that’s not the point. It’s long-term improvement in energy levels and mood. Maybe it’s neurotransmitters, maybe it’s hormones, maybe it’s increased oxygen flow, maybe it’s increased metabolism, maybe it’s self-confidence from a sexy physique, but there’s definitely something uplifting about having a physically fit body.
(Incidentally, if you really dislike the exercise you’re doing, try something else. There’s tons of ways to get vigorous exercise and likely something will work for you. Depending on your genetics, different types of exercise will be a better fit. I don’t like distance running, but I love weightlifting, and am naturally better at it. When people think of “exercise” they tend to think of running, but running is just one component of many in fitness.)
FWIW… I never noticed any particular benefits to my mental health from exercise, until I tried lifting weights. It was like magic. I think there’s something about strength training in particular, for me.
But obviously your brain chemistry may vary.
It didn’t have a noticeable effect on my mental health until I became depressed. Now, that effect is noticeable by exercise, on a bike for at least 15m/day, correlating with at least working on *some* projects instead of *no* projects.
I’m still not who I used to be, but I don’t think it’s a placebo. Also, I sleep easier *if* I got more like 30-40 minutes of it in. It has to be more than walking-level stuff, though.
Exercise helped with depression for me, but I think I’ve gotten actual euphoria from it… once or twice, ever? If that. The effect looked like nothing was happening for about three weeks, then I was really cheerful for a week, then my happiness set-level seemed to go from “constantly gloomy” to “moderately positive” and has stayed there for the better part of a decade as long as I keep up with the cardio. Walking or hiking don’t seem to cut it; it has to be something as intense as running or biking.
Most people I know with depression haven’t gotten much out of exercise. I think I have lucky chemistry. Well, unlucky chemistry followed by lucky chemistry.
Ah, here’s why Benadryl doesn’t make me sleepy!
You Americans get all the good drugs 😀
A lot of small studies of a lot of different psychoactive effects. Maybe most of them are synergistic with caffeine, but as an anxiolytic, it seems unlikely.
Do you have any objective measure that you are too intrigued, or just that you’re an outlier?
Thanks for posting this! I did a bunch of research on my own and your post adds a lot of things I never ran across.
I wrote up a bunch of notes on /r/slatestarcodex about my own personal experiences with GAD that turned into panic earlier this year.
Oh, one optimistic note: I had low level anxiety for years; I’d always wake up feeling “ugh” and feel that way frequently through the day. Then it turned into panic early this year, which was the about worst thing I’ve ever gone through. The good part is that it forced me to get serious about things like sleep hygiene and taking care of myself mentally.
But the really good part is that it forced me to realize that the “ugh” feeling is not an objective truth about the world. I have sensations, and I used to freak out about them, but now I know they’re not harmful, and I can retrain myself to not associate them with fear.
So for a long time I just put up with low level “ugh”, but when it got severe I realized it’s something I can directly address, which makes me much more optimistic about improving my life in the long term.
Phenibut is highly addictive and dangerous? Now I’m worried (no irony intended) — for a while at least, several folks I know in the local rationalist community seemed to be treating phenibut as a smarter replacement for alcohol as an inhibition-lowering drug at parties.
(The local lore does say not to use it with alcohol unless you want to be the topic of cautionary tales, though.)
I would also like to hear more detail about the dangers of Phenibut. I have a good friend who uses and recommends it, and I’d like to make sure he’s informed as to the risks if they’re significant. I don’t see major negative info on Erowid, although I don’t see a lot of info there at all. On r/nootropics I see some argument about it on both sides.
I have used phenibut when I absolutely had to sleep. It’s water soluble and very bitter but will give you a fabulous night’s rest. If you feel the urge to continue you will need to double the dose each day thereafter. By day three you will probably be taking enough to induce horrible queasiness and possible vomiting.
That’s as far as my experience goes. Reports on harm reduction websites like bluelight suggest that within seven days you will need prodigious doses to do anything and can expect very unpleasant withdrawal symptoms.
I have had nothing worse than a little light headedness after single use and felt emotionally buoyant for the next few days.
Here you go: http://mindandmuscle.net/forum/42324-another-phenibut-casualty
I think the biggest problems are with frequent use.
… holy crap, some people do a lot of that stuff.
Okay, less worried now about friends who use a gram of it occasionally.
I often hear comments about how bad it is, and then I look and see that the person was taking 2-3g a DAY. This is absolutely insane. I take 350mg once every couple of weeks/months to smooth out difficult mood oscillations and it works amazingly well. Its effects are invisible, transparent, below the threshold of perception. I don’t see how I could get addicted to it: I don’t feel any effects from it, apart from the lessening of bad moods/circular thinking.
r/nootropics staying away from anything nootropicy is a hyperbole, there’s even a thread named “Beginner’s Guide to Phenibut”, which recommends a high starting dose first thing in the morning, along with a stimulant. At least the thread is marked high risk.
Doubling, or continually increasing dosages to get the same high
sounds likeis a really bad idea, no wonder some people get awful withdrawals.Anecdotally: I have a friend who has used beta- and alpha- blockers for occasional panic attacks. She says they work extremely well and have the added plus of knocking out the moderately debilitating nightmares she was getting, at the cost of being somewhat sedating.
(Edit: It’s worth noting that this was only *after* using fluoxetine to decrease the frequency of panic attacks from “pretty much every day” to “once every 2-4 weeks”.)
For me, panic seems to be a feedback loop between sensations in my torso and the part of my brain that’s supposed to let you know that you’re dying. So I suspect beta blockers would have helped me a lot, and I wish I had heard about them before getting a benzo prescription.
I have found beta blockers extremely good at helping with exposure therapy getting over a panic disorder associated with public speaking.
Basically, the panic started when I felt I was getting too anxious and people could see.
The beta blockers meant that physical symptoms of anxiety are very well masked, which actually in turn (and over time) reduced my anxiety.
I take beta blockers whenever I have a speaking event (including in meetings) which is more often than I’d like. The downside is it means I can’t exercise on the day I take the beta blocker (because it prevents aerobic output).
Overall, I found them very very effective.
A little off topic to anxiety, but harkening back to the previous article and weird treatments that only exist in other countries, what’s the deal with Rubidium Chloride for depression? There have been a handful of studies in English and it’s approved as Rubinorm in Italy, and apparently is dispensed by an institute there.
It appears to be fast acting (!) and with relatively few side effects, but with a metal like that one kinda worries that it has some lithium-esque horrific toxicity outside of its dose range.
I’ve always been fascinated by Buspar just because it’s such a misfit, but I guess not being very effective is a good way to become a pharmaceutical dead end. I’d be interested to hear from anybody who tried it.
Also, re: Benadryl—I mostly just use it for sleep, but I’ve found doxylamine succinate much more pleasant than actual Benadryl/diphenhydramine, as far as OTC antihistamines sold as sleep aids go. Might just be [probably is] a placebo thing, but every third or fourth time I try diphenhydramine I feel too drowsy to actually sleep, like I’m locked in my body, and I have to force myself to get up and move around until I reach a point where I’m sufficiently alert to sleep. With doxylamine I mostly just get a nice buzz.
I have been taking Buspar for several years, originally prescribed as an adjunct to Cymbalta (no longer taking), Wellbutrin (no longer taking), and Lamictal (that one a bit non-traditional, I am aware) for treatment-resiatant depression with a lot of anxiety.
I didn’t feel a large effect, but it did seem to chill me out a bit, which is more than I can say of the great many drugs I have tried.
The main downside is that I have very quick withdrawal symptoms if I don’t take it on time.
I tried Buspar and saw absolutely no effect whatsoever, positive or negative.
What happened to the MealSquares disclaimer that said (paraphrased from memory) “use MealSquares in a sane manner, i.e. don’t try to live off of one thing for long periods”?
I liked that disclaimer. Do we now think it’s OK to live off of MealSquares alone for long periods?
Not sure, looks like Scott rewrote the blurbs when he added Apptimize, another CFAR alum startup 🙂
FYI, our official recommendation is that things like fresh fruits, vegetables, fish, etc. are an irreplaceable part of a healthy diet until proven otherwise.
My impression after reading this textbook
was that the research supporting the effectiveness of acupuncture is surprisingly good. (Western researchers don’t think acupuncture works for the reasons Traditional Chinese Medicine says it does.) Acupuncture is used more often for chronic pain than anxiety though.
Is it really a good idea to rely on a book entitled “evidence for X” to determine the state of evidence about X?
The book discusses randomized controlled experiments using sham acupuncture. It claims that these merely show that acupuncture is a very broad class of treatment. Well, maybe, but why practice real acupuncture if shams work? Why puncture the skin? Why learn about locations? It claims that manipulation is the important part. That sounds like the god of the gaps to me. In any event, the particular gap can be easily tested.
As a patient, sham acupuncture is not an option, although acupressure, shiatsu, and western massage are. I don’t know any studies comparing acupuncture to massage, so maybe patients should stick with acupuncture. But I will stick with describing it as the best placebo known to man. (I don’t like Scott’s phrase “unnecessarily medicalized.” The medicalization may well be a necessary part of the placebo.)
Thanks for the response.
The title of the book is “An Introduction to Western Medical Acupuncture”. Note that no one has written a book called “An Introduction to Western Medical Reiki”. So if you don’t want to update on the research the book presents, you can update on the fact that three British people with graduate degrees wrote a book about acupuncture that includes sentences like
who are affiliated with an organization that says things like
In other words, if you don’t want to take a detailed look at the acupuncture evidence base, the fact that it’s persuaded people who seem like serious scholars to investigate acupuncture further should tell you something. I doubt you can find any group analogous to the British Medical Acupuncture Society for homeopathy, firewalking, astrology, faith healing, magnetic therapy, or reflexology.
The word “acupressure” is often used for treatments that are similar to acupuncture but don’t puncture the skin. For example, this list of the best-selling products on Amazon includes an acupressure mat. My current guess is that acupressure works pretty well. I don’t have detailed knowledge of how it compares to acupuncture.
The book mostly agrees with you on that point:
My impression from reading the book is to a first approximation, a trained acupuncturist will get good results if they stick a needle in the area you are feeling pain (assuming they don’t puncture a lung or otherwise cause damage to an internal organ), and mediocre results if they stick a needle in some other random part of your body (due to the extrasegmental analgesia and central regulatory effects of acupuncture the book discusses).
So you’d at least agree that out of all the different treatments that you currently think are placebo, acupuncture is the one that’s most likely to not be placebo? Do you have any theory for why treatments that look kinda like acupuncture seem to perform better than other “placebo” treatments?
My best guess is that the medicalization is exactly how it works. Thus I recommend acupressure over western massage. I don’t know how medicalized shiatsu is.
Strength of effect has nothing to do with likelihood of being a placebo. Among interventions that I currently think are placebo, there are many that I think are much more likely not to be placebo than acupuncture. For example, surgery for chronic back pain.
My mother, who teaches speech making for a living recommends hypnotherapy for severe anxiety about speech making.
My own recommendation is to do speech&drama exams as a child, the examiners could give Vetinari lessons in the raised eyebrow.
(Disclaimer: I am a trained hypnotherapist. I am not a licensed medical health professional. I don’t treat mental health disorders, although I have worked in conjunction with medical health professionals to provide hypnotherapy as a supplement to medical treatment. Nothing I say here should be construed as medical advice.)
Hypnotherapy is somewhere toward the center of a multi-dimensional continuum with axes whose farther ends approach “unnecessarily medicalized relaxing thing,” “lifestyle changes,” and “therapy.” It’s not magic, and its effectiveness with organic disorders is usually limited. But for functional issues it can approach magic. (And ask me about the lady with the very real back problem I helped sometime.) To be fair, an argument can be made that it works on a placebo sort of effect, and I think there’s a lot of truth to that. But since some subjects do exhibit functionally different brain activity under hypnosis, there’s almost certainly something “real” going on under there as well.
The thing about hypnotherapy is that it involves hypnosis and hypnosis feels good and it’s extremely relaxing and that in and of itself is really, really helpful to people with anxiety. One major issue with people with long-term anxiety is that they can literally forget how to relax. Hypnotherapy can both provide short-term relief through externally enforced relaxation and teach techniques to help the client (Psychiatrists like Dr. Alexander has patients: hypnotherapists have clients.) learn to relax by themselves again. So at the very least, hetero-hypnosis and/leading into auto-hypnosis can provide a tool which can be as effective as medication in some people, with zero danger of negative pharmacological impact.
It can also be extraordinarily effective with phobias and specific-trigger anxieties, as it provides a very focused way to apply desensitization. Skilled hypnotherapists can often extinguish even quite severe phobias with one or two sessions.
Regarding meditation, I have not read the two reviews that Scott cites, so I won’t comment on them. However, I have read this 2014 paper which reviews 47 trials and may be of interest. This review found moderate evidence that mindfulness based meditation can improve anxiety (as well as depression and pain) “when compared with nonspecific active controls,” with effect sizes that fall between the ranges cited in the abstracts of the other two papers. That is, the effects do not seem to be as strong as cited in the first review, but seem more definite than suggested by the second review. Interestingly enough, the 2014 review found that mantra meditation programs (such as TM) did not improve any outcome measured. However, due to the small number of studies with adequate methodology, they qualified this by noting that “the strength of this evidence varied from low to insufficient.” So maybe there just could be something to TM but there are not enough good studies to demonstrate its value, but I would suggest holding off on sending any large checks to the TM foundation just yet.
Bacopa can work in as little as one dose for me but I may just be very sensitive to serotonergics (I can feel escitalopram wearing on / off and get results from fluoxetine in a week).
Not very convinced that the SNRI are all that helpful for anxiety, at least in me, NRI make me rather more anxious / obsessive. And the side effects were fairly bad for me (get a Viagra prescription to go with it…) .
Also would love to see a similar post about social anxiety in the future!
Well, now we have an exact measure for “Worse than useless” 🙂
How to know you have anxiety? Just like with depression, minor and life-long versions of it easily go unnoticed because instead of thinking “something is wrong with me” it is more likely you think “well my life is not good”.
Proposal: can you say painful, tight upper trapezius muscles are a sign of it? This a typical place where “pop-science” says “stress is stored” and about 50% of people I know have this muscle stiff and really enjoy getting it massaged. I think they tend to be anxious.
I also think it comes from people reacting to always, 24/7 having light anxiety by slightly pulling their shoulders up towards their ears, “turtling up”, a defensive move. Thus their upper traps are engaged all the time and get stiff.
Note: I do this, and it sucks, constant chronic pain and stiffness in those upper traps.
The difference IME is that GAD has “free floating” anxiety: once a problem you’ve been worrying about resolves, the same level of worry transfers full force to something else. Even if that something doesn’t logically make sense to worry about.
As for sore back muscles I’m not sure that’s the case. My sample size of one tells me that I only get a sore back from spending too much time at the computer (poor posture) and obviously doing back day at the gym. Then again I hate massage with a passion so there could be “built up stress” there I don’t know about.
The upper-trapezius thing turned out to be ergonomic for me. Spending countless hours hunched over a laptop turned out to be a bad idea; who knew? I have a standing desk, which seems to have helped. I’d suggest seeing a physical therapist and getting your working conditions evaluated; it made a big difference for me.
Helped as in, if you tilt your head left and right you can no longer hear crunchy noises from the upper traps?
I have the upper trapezius thing.
Also, I know I have something amiss because I can have incapacitating unhappiness about *literally nothing* in the midst of a period in my life when *literally everything is perfect.*
Yeah, that’s how I realized my depression is an external thing: I caught myself grousing about some incredibly minor inconvenience, and realized that the feeling of discontent had come first, followed by my brain trying to find something to blame it on.
Why is anyone surprised that antihistamines work? As I often point out, SSRIs and SNRIs are based on antihistamines. Fluoxetine (Prozac) is just Diphenhydramine (Benadryl) with some extra dongles on it to give it a longer half-life so that patients can take fewer pills and have an easier withdrawal. Benadryl is a totally reasonable treatment for anxiety — and if your panic attacks give you hives, then it’s probably doubly useful.
And mirtazapine is basically a potent antihistamine with some weird noradrenergic and serotonergic side effects. It’s used for anxiety, although I’m not convinced it does anything for it beyond the antihistamine effects. In any case it wasn’t listed in the article and it deserves a mention.
I’m not a pharmacologist, but doesn’t Prozac have like 100x as much affinity for SERT, and Benadryl >100x as much affinity for H1? Chemical structure doesn’t really matter compared to what receptors/transporters it’s agonizing.
And how does a chemical decide which transporters or receptors to agonize or antagonize if not by the binding interactions dictated by its structure?
The typical dose for Prozac for anxiety is about an order of magnitude lower than the dose of diphenhydramine in a single Benadryl. The daily dose of Benadryl for allergies would be about 2 orders of magnitude higher than the dose of Prozac for anxiety. This suggests that, taking the in vitro receptor binding assays at face value, the normal dose of Benadryl ought to be more or less as effective as Prozac.
On the other hand, if you want to prescribe Benadryl you have to convince a patient to take 6 pills a day instead of one, and with a shorter half life (12 hours compared to a 4-6 days), tapering off is going to be difficult. Also, you lose the placebo effect of having someone in a white coat give you powerful prescription medicine.
As an aside, weren’t you telling us the seretonin imbalance theory is one of the lies we tell to children? You know, partly true, but that the reality is way more murky. In that light, how much do the binding assays really matter? How important is selectivity?
“The typical dose for Prozac for anxiety is about an order of magnitude lower than the dose of diphenhydramine in a single Benadryl.”
Where are you coming from here? A single Benadryl tablet is typically about 25 mg, average daily dose of Prozac is around 20 mg.
Furthermore, if you were right, then this would make Prozac even less of an antihistamine once you considered dose than it was just considering the binding.
Very small changes in structure can have very large changes to function. CO1 and CO2 are pretty similar-looking, but they have very different effects on the body.
Yes, it’s more complicated than just “low serotonin”, but that doesn’t mean it’s magic and has nothing to do with any receptors. And I get the impression that histaminergic effects are a lot more direct and well-understood than antidepressant effects.
I was under the impression 2.5 mg Prozac was the starting point for anxiety, and you ramped up if necessary, apologies if I was mistaken.
I think your CO/CO2 example perfectly illustrates *my* point. They both bind hemoglobin and myoglobin, they’re both toxic to the extent they out-compete oxygen.
The resemblance between Diphenhydramine and Fluoxetine isn’t accidental. There was a deliberate multi-decade effort to transform several antihistamines into *better* antidepressants by fiddling around with the little functional groups on the sides. The antihistamines did have some known antidepressant properties to start out with.
Yes, taking Prozac for allergies would be a waste of money; I didn’t mean to suggest that plan. I was just trying to say that even taking the binding information into account it’s unsurprising that taking a lot of Benadryl (150mg — 25mg every 4 hours) gets you some of the same effects as a little bit of Prozac (2.5mg). If Benadryl works as well as 20mg of Prozac then I’m an order of magnitude less unsurprised, but still not shocked.
Re: lies to children
Of course the serotonin receptors/transporters have something to do with it, I didn’t mean to suggest that they didn’t. I just wondered how you weighted the in vitro measures of binding to various receptors and transporters against whatever other information exists. What parts of the brain do fluoxetine and diphenhydramine get into, what is the relative abundance of various receptors/transporters there, are there effects in anxiety/depression/bipolar/OCD mediated by non-serotonin (and non-norepinephrine) neurotransmitters, and if so, which ones, and what effects do fluoxetine or diphenhydramine have on their transporters or receptors, and how large are all those effects compared to the effects on serotonin? I think antidepressants are wonderful, and obviously not magic, and I’m honestly curious about the grown up version of the story. Perhaps in another post?
I have read Susan Greenfield’s The Private Life Of The Brain. It’d be awesome if you completely spontaneously decided to review that, as I think this one of the most read layman books about this. She argued something that to my layman mind meant that depression is not about lacking the effect of serotonine but the opposite, being too sensitive to the workings of serotonine and thus Prozac is trying to overload the serotonine sensors and turn them off basically.
Disconnected thoughts from my own GAD experience:
Regular sleep and exercise make a huge difference. It’s really night and day. Getting a consistent 8 hours and doing 15-20 minutes of HIIT a day is not a huge commitment but it’s great for anxiety and general health.
Cutting down on coffee is ok when it’s possible. Caffeine is too useful for me to give up easily, but I’ve had good effects when I dropped it.
The anxiety notebook thing is really good. I went to the woman who developed it a few years back and she really helped me out a lot. I strongly recommend it.
SSRIs were more useful with the GAD-induced depression than the anxiety itself, and suddenly having sexual dysfunctions is unsurprisingly not great for your anxiety. Bupropion is better but even then I’m very glad to be off of it.
In terms of “alternative treatments” I found that reading / practicing Stoic philosophy is actually quite useful, since apatheia is pretty much exactly what you want when you’re anxious. Short of that, literally saying what you’re worried about out loud helps: putting it into words and hearing them spoken makes the ridiculousnessmore evident.
This list is strikingly useful and I have already recommended it on. Thank you very much for taking the time to compile it, and to put it on a foundation of studies and meta-analyses.
I’m particularly happy with your emphasizing that “there are lots of options”. The anxious people I know try to maintain a bubble of stasis around themselves, which unfortunately can leave them stuck with suboptimal treatment.
>CTRL+F “cannabis”
>0 hits
So let me throw that out there: Cannabis
Also, someone I know had months of suicidal psychotic episodes trying to come off Klonopin until she gave up and went back to the original dose. So there’s a case report for you.
I know two people who use Cannabis in this manner and swear it’s the only effective treatment they’ve ever tried (and they’ve tried just about everything else on this list).
The disclaimer is that their anxiety is more tied to PTSD rather than GAD.
The same is the case for the aforementioned Klonopin-addicted person – her anxiety seems to be tied to PTSD, and cannabis has worked far better than anything else.
I’ll throw in another anecdotal data point that says the same. It’s comorbid with PTSD in this case, too.
It always made me anxious. Not paranoid, just a “too deep, I am sinking into this depth” feeling, and could feel panic coming on as a feeling of an iron blade in the nose. I completely don’t understand people who think it is relaxing or making them laugh and take things lightly. I do remember having laughs under that influence but even those were the desperate gallows humor feeling type.
Instead, alcohol and l-theanine make me relaxed. Of course one of these is healthy the other is not such a good idea.
I was dating a girl a while back who was in grad school for psychology. Apparently, she told me that the runner’s high is similar to, well, getting high on weed. She said — and I’m probably remembering this incorrectly — that the hormone responsible for the runner’s high is similar to the THC molecule in marijuana so they sort of have the same effect.
Maybe this is why aerobic exercise helps to decrease anxiety?
Funny, I’d always heard endorphins were similar to opiates. But hey, maybe your brain just gives you a cocktail of all the good stuff.
From my admittedly limited experience with opiates (mainly some codeine and two morphine shots in terrible pain post op), I don’t think THC is at all comparable to them…
Maybe she was thinking of opiates more than THC…
I thought that endorphins were, quite literally, endogenously produced opiod agonists?
FWIW, my anecdata is that weed and exercise have completely different feelings.
That’s the etymology…
Too lazy to find a real cite, but “cocktail of the good stuff” is about right. From https://en.wikipedia.org/wiki/Neurobiological_effects_of_physical_exercise#Euphoria: “Current medical reviews indicate that several endogenous euphoriants are responsible for producing exercise-related euphoria, specifically phenethylamine (a stimulant), β-endorphin (an opioid), and anandamide (a cannabinoid).”
And then there’s this: Artificial recreation of happy memories may become the next big weapon against depression
I think she was referring to the endocannabinoid Anandamide.
The “runner’s high” I’ve experienced comes in two flavors. One is simply the pleasure of moving.
The other…is weird. When I was depressed, running for more than three miles (but NOT for fewer than three, and NOT any other kind of exercise) would sort of melt the black ice in my brain. It didn’t resemble any drug I’ve taken, but it was more like the descriptions I’ve read of opiates than anything else. Soft, soothing, “merciful.” Sometimes very loud rhythmic heavy metal has a weaker version of that effect.
looks at the nearly-empty 200 gram bucket of phenibut he has been steadily working through for more than a year now
O-oh…
OT:
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Also, the HTTPS links may not share cookies with the HTTP site, leading to the “new posts since…” javascript being useless. If you intend to switch to HTTPS, this may just be a bullet that has to be bitten.
>We have sort of finally beaten into people’s thick skulls that depression isn’t just being sad, and you can’t just turn your frown upside down or something – but the most common response to anxiety disorders is still “Anxiety? So what, everyone gets that sometimes.”
Genuine question from endless ignorance:
If it’s not just being sad, how do we tell them apart? Do they show up in a brain scan or a blood test?
Depression is diagnosed through a self-report of sensations and behaviors, so no physical test. People who are depressed report the inability to enjoy things and the inability to initiate activity. And this goes on for several months with no change.
Sad people are experiencing a sad emotion but still retain the capacity to enjoy things and take action. And this state does not persist for months at a time.
A way to understand could be SAD (seasonal affective disorder). Some people, who don’t get enough sun light in winter report not enjoying things and losing the ability to initiate activity. They aren’t sad, they’re body is just not letting them be as active as they normally are. Then there are side effects of distanced relationships and poorer work performance that start to compound on each other to make the problem even worse.
Depression is not SAD but it’s a close enough example to show how it’s more than just experiencing an emotion.
Wait, are we talking about depression or anxiety disorders, here?
I thought your question was about depression.
Anxiety would be similar. Again no physical test and the differentiation would be in intensity and duration.
Maybe one person gets anxious before a test. This is normal. A phobia or severe anxiety would mean the person is literally sweating from fear of the test. It is still a self-report measure but normal anxiety allows you to continue with your life in a relatively normal manner. An anxiety disorder is disrupting your life in some way.
I had depression- for me, it was like the severe grief you feel at a bereavement, but brought on by things like ‘doing simple tasks’ and ‘cleaning the kitchen’.
And then you’re in the corner sobbing about cleaning the kitchen and you know what doesn’t help with depression? The feeling you get when you’re crying over not being able to clean the kitchen.
Anxiety- had some of this as well-
phobias I can’t speak too, but general anxiety…you ever have a big project you were anxious about? One that dragged on forever and was a constant source of stress for a long time? And you know how even after the project is done, you still feel stressed and freaked out until you realize that the project is over and you can relax?
That. But without the conditioned response part. You’re just generally freaked.
(NB- while I had the anhedonia and what not described, I can’t say that crying jags are part of normal depression, plz do not generalize my experience.)
The difference between being sad and depression:
You probably can generally find some reason why you’re sad or something that is making you sad. Depression is often, on the face of it, there’s no reason or no one single triggering event.
Being sad eventually resolves itself. Depression doesn’t.
You can do things you like and enjoy to help lift yourself out of sadness. With depression, gradually the things you used to like and enjoy don’t matter anymore, so there’s nothing that you particularly want to do in preference to sitting there listening to the lacerating voice in your head pointing out all your faults.
Shakespeare had it pretty right in the start of “The Merchant of Venice” when Antonio is trying to explain to his friends that no, he doesn’t know why he’s “sad” all of a sudden, and they keep putting forward reasons – you’re worried about your business! it’s a woman! you’re trying too hard to be successful and respectable!
It comes on you and hangs on and it’s just always there; sometimes less, sometimes more. It’s very wearying and wears you down.
Sadness can be sharper but shorter. Depression is heavy all the time listlessness and no reason to do anything.
Depression can resolve itself. I’ve been through many depressive episodes, and most of them eventually subsided on their own. I’d just wake up one day and things wouldn’t be so awful. Only the very worst one, which was triggered by my divorce, required therapy and medication.
Of course, there’s always the next episode, so I guess “remitted” might be a better word than “resolved”. I’ve come to view depression as something I just have to live with, like the weather. I know that many people are more severely afflicted and don’t have this option, though.
Yup, depression can resolve itself. I know personally.
Do you have any opinions on SJWort?
I think I’ve seen studies saying it doesn’t work for anxiety. Given relatively high potential for interactions/problems, it wouldn’t be a good bet even if you’re committed to alternative medicine.
Not at all. I’m just someone who’s had very poor reactions to SSRIs and was looking for something which wouldn’t knock me out and make me incapable of work/sex/life. Know SJwort is available over the counter and is supposed to be The Alternative Medicine Which Isn’t Bullshit.
SJW is an SSRI. And it Isn’t Bullshit only in Germany.
A couple comments:
1) This “If you can’t find (or don’t want to find) a good therapist, there is preliminary evidence that a good self-help therapy workbook (“bibliotherapy”) is about as good as real therapy”
In terms of information I would say this is correct. The benefit of therapy is the human connection and empathy of the therapist. Empathy is healing and I’ll explain that better in the next thing. Therapy gives the same information as a self-help book and if information is all you need then great, but many people need the human connection to enact change.
2) “Massage therapy, acupuncture, aromatherapy, and everything else in the category of “unnecessarily medicalized relaxing thing” all perform very well as long as you don’t look too hard for a suitable control group. Yes, these are probably placebo, but they’re very effective placebos and if they both work I would rather take a placebo than an antipsychotic.”
I don’t think these are placebos, per se. What’s happening with these “treatments” is the activation of the para-sympathetic system, and that allows the body/mind to relax. Ok, so that sounds like “duh” but I think the trick is that anxious people don’t know how to relax and things like massage use shortcuts in the nervous system to force them to relax against the will of their conscious mind. Empathy does the same thing but on an emotional level.
Could these things be “unnecessarily medicalized”? Yeah, I would say so, but our current insurance system requires medical endorsement in order to pay. In the same way you would prefer a working placebo over an anti-psychotic, I would want insurance to pay for a massage over an anti-psychotic.
By “books are as good as therapists”, I mean “they are shown to treat the condition, as measured by whatever objective measure, as well as therapists do.” Unless you want to pick apart the objective measures (which admittedly is often justified) I don’t think there’s a lot of room to say “But humans add…”
I agree “placebo” is a complicated term here, but I mean that AFAIK real acupuncture performs no differently from sham acupuncture, and although I haven’t seen studies I would be surprised if real aromatherapy performed differently from smelling any pleasant-smelling thing. The point is that the activity itself is inherently relaxing, and any “control” activity that was also inherently relaxing (as far as the patient could tell) would do equally well. If you want to call that active non-placebo parasympathetic activation, fine.
I would suspect that if it’s the human connection that’s doing the work, then people in the “read the book” group won’t successfully complete the “therapy”, and their treatment failure won’t be counted, just as someone who hates their therapist and stops going won’t be counted as a failure of talk therapy.
Of course they’d be counted. Anything else defeats the entire purpose of randomization, which is to break the correlation between patient and treatment. You may be interested in the phrase intention to treat analysis. The harder problem is what to do with people who vanish completely. They didn’t get the treatment, but you don’t know whether they did well or badly. The Cochrane review Scott cited makes the conservative assumption that they did badly.
I feel like at some point, society needs to have a reasonable discussion about exactly what “health insurance” should and should not pay for.
We seem to be leaning in the direction of “anything that improves patient outcomes counts as health care and should be paid for” but we don’t typically discuss it in that manner, and it often only surfaces in contentious debates about birth control or other such things (when I was in the Navy, there were rumors that a female shipmate got the Navy to pay for her breast implants under the assertion that she had anxiety and they would improve her self esteem).
But surely there’s a line somewhere, right? We just seem to have a really hard time defining where it is. What if I can credibly prove that my stress and anxiety are reduced by having sexual intercourse, but my anxiety issues make it difficult for me to obtain this on my own? Basically what I’m getting at here is, why doesn’t Obamacare offer me free prostitutes?
I’d do it the way it’s already done – cost-benefit analysis. I personally have no issue with health insurance paying for prostitutes (in fact I’m quite frankly intrigued by the therapeutic possibilities). It’s just a matter of measuring its effectiveness relative to other interventions.
Can you think of any hypothetical thing you WOULDN’T support health insurance paying for, so long as we concluded that it truly did benefit the patient, with benefit being measured by “the patient says it benefits them.”
I enjoy watching hockey as a form of stress relief. Should my employer pay an insurance company which pays for my subscription to NHL Gamecenter live?
Basically, what’s going to stop people from using “I need this for my mental health” as an excuse to get health insurance to subsidize their entire lives?
I’d probably exclude most leisure activities that are beneficial qua leisure activities, but in any case I wouldn’t trust self-report as sufficient evidence of effectiveness.
But in the end, isn’t “self report” pretty much the only way we measure outcomes for stuff like depression and anxiety?
How do you know whether an SSRI is working or not aside from asking the patient “are you feeling more or less depressed now?”
Wouldn’t this also be the standard with acupuncture, aromatherapy, prostitutes, and free netflix subscription?
Should my employer pay an insurance company which pays for my subscription to NHL Gamecenter live?
Insufficent – they should equip and field their own team.
@anodognosic
I’d probably exclude most leisure activities that are beneficial qua leisure activities,
While I don’t disagree with you, you’re cutting out funding for hydro therapy (swimming) (and most other exercise) most service animals (who wouldn’t want to get paid for having a pet?) and a whole host of other things which we do for fun and because it makes life worth living.
@Matt M have you ever read a depression screening questionnaire? It’s not as crude as you make it out to be. Plus, self report is not the only way to determine whether someone is depressed, it’s simply the most convenient.
In any case, this is partly why I would exclude most leisure activities qua leisure activities. Yes, they are beneficial, but I think we can safely leave people to seek it out on their own, especially if they are simply stress relief activities.
@keranih I would not fund leisure qua leisure, but that doesn’t exclude some activities that could be considered leisure but have a targeted psychological purpose, like the examples you mentioned.
Also, I’m not against the government funding public goods that make life more fun, like parks and public gyms and such. I just wouldn’t tie it in with medical spending.
“Also, I’m not against the government funding public goods that make life more fun, like parks and public gyms and such. I just wouldn’t tie it in with medical spending.”
And where does “funding breast implants for an attractive female coworker” fall on this scale?
But on a more serious note, I have seen the screenings and no, they aren’t that simple, but I feel like a sufficiently motivated person could deliberately engineer answers as such to ensure that they qualify for whatever it is that they want (see: how easy it is to get a medical marijuana card in California)
In other words, once free prostitutes are on the table, you can bet that I’m going to take that survey and say that I regularly feel anxious about my sexual attractiveness, and that after I get the “prescription” I want, I’ll start answering that my feelings have improved quite a bit… but they aren’t entirely gone (after all, don’t want them to declare me cured and withdraw my treatment!)
Matt, it’s ultimately a numbers game. Medical marijuana cards are easy to get in part because they don’t cost the government anything and no one really cares. If people are gaming the system, make the rules for certain interventions more stringent until only a few unreasonably motivated people are liable to work that hard to circumvent them.
>>And where does “funding breast implants for an attractive female coworker” fall on this scale?
Probably it falls under “obviously not true”?
Hey, if those things didn’t qualify as a “public good” then the term has no meaning!
There are certainly far more useless things I KNOW the Navy has spent money on!
The breast implant story seems like it might be an urban legend; there’s a similar story about the Swedish army paying for breast implants for its female soldiers.
Well in this case, I can personally verify that there WAS such a woman I worked with who DID have the surgery. She was only a couple years in, junior enlisted, came from a poor background, so not likely to have a ton of money (although I suppose it’s not entirely unreasonable to think she saved up for them herself).
She was also pretty neurotic so it seemed somewhat feasible that she could convince someone she had a mental health condition and that this could help. I dunno, it was *probably* just a rumor, but all the pieces seemed to fit…
It should be noted that cosmetic surgery generally does not cost “a ton of money”; not being covered by insurance and/or public health services, providers actually compete on costs and somehow manage to find extra-strength Tylenol for less than $25/pill. Breast enhancement seems to cost somewhere in the single-digit thousands of dollars, and I’ve known poor-ish young women who considered that a very good investment of hard-earned money (and no, not because they were working in the adult-entertainment industry).
My inner libertarian is completely opposed to this idea but my inner troll fully embraces it.
…most service animals are pets? This is extremely surprising to me. Can you elaborate?
Oh, I was very confusing, I apologize.
Service animals are animals. Pets are animals. There is a non-trivial number of people who have abused the common factor and claimed service animal status for their pet animals – to include requesting reduced (or no) cost food and health services.
@ keranih
Who are they requesting this from?
Back when I lived in a much smaller/sleepier community, it wasn’t uncommon for the local news “controversy of the week” to center around some guy who brought his dog into Wal-Mart, got kicked out, then insisted it was a service dog, then Wal-Mart apologizes, then we find out it’s not REALLY a service dog, and on and on and on…
The upshot here is that there ARE in fact people among us who just want to bring their dog into the store with them and have figured out that if you yell about it being a service dog people will let you. I have no meaningful statistics on what the prevalence of this is, but it DOES happen…
@houseboatonstyx
I do not have any lit to cite, my apologies. From conversations with multiple animal rescue and animal control personnel as well as more casual comments in vet waiting rooms, I would guess something between 5 and 20% of the animal owners seen by those three groups have used some variation of this “scam”. More worrisome (but not as frequent) are animal hoarders who have some degree of certification as a “rescue” group in order to support their animal keeping habits.
Edit: Oh, and then there is this.
The proper term of art is I believe Emotional Support Animal, which does seem to translate to “Unnecessarily Medicalized Relaxing Pet-like Thing”. About 98% less paperwork and 100% less training than a true Service Animal. And proportionately fewer legal privileges, but so long as the average restaurateur doesn’t know any better an ESA letter probably will let your beloved Fluffykins join you at the table at Spago and hopefully not pee on anything (100% less training than a service animal).
Right now, this seems to be a minor annoyance. In the proposed new world where the government pays for / make insurance companies pay for all the medicalized relaxing things, yeah, my cats are becoming registered ESAs as soon as I can get the paperwork in. And generalized anxiety disorder seems to be one of the go-to diagnoses for therapists in this racket.
Some students at my university have started getting permission to bring their dogs with them to exams. I think this is probably not a good precedent…
Effort/Result-wise, there’s a simple bottom line, well, two lines, on dogs in stores, restaurants, etc.
1. Any Service Dog who misbehaves can be evicted by the manager or any employee who does not wear an apron.
2. Any change in the law defining SDs and their rights, would require a big change to the Americans with Disabilities Act, a federal law.
If a real, most officially-documented, SD is hassled, the handler can call 911 and the local police are required to come and explain the law to the manager and handler. In practice, police and managers and the SD organizations I’m associated with, go with “If the dog is well-behaved, walks like an SD and quacks like an SD, okay.” Most fake ESD’s are small, carried by owner, thus not much problem, and the owner may really need their help, official or not.
Other situations are too rare and complicated for this comment.
I’d do it the way it’s already done – cost-benefit analysis. [….] It’s just a matter of measuring its effectiveness relative to other interventions.
In the 90s my husband had a job in Silicon Valley whose health benefit company cheerfully paid for my various woo woo treatments. When I remarked on that, they said, “We’ve found that the people who use those, don’t get sick as much.”
So that’s where we could look for an overview: how many companies have found it worthwhile to cover that category of treatments, and how it has worked out for them. They should be compared with companies that cover recognized preventive things, rather than with companies that cover neither.
It seems to me that the relevant term is “insurance” not “health.” We don’t buy insurance to pay for everything that has a large benefit to cost ratio—ice cream, say. If something has a large benefit to cost ratio for you, that’s a reason for you to buy it, not a reason why you should pay an insurance company to buy it for you, or why someone else should.
Insurance makes sense for low probability/high cost events, since most of us would rather pay a hundred dollars with certainty than a million dollars with one chance in ten thousand, especially if we can’t get a million dollars and not paying it means death.
Current health insurance combines actual insurance with a different service—making decisions for you that you don’t have the expertise to make. There is no particular reason why those have to be linked.
So far as the common idea that health is somehow different in nature from other good things, such that everyone has a right to have health care provided for him, I have never been able to make sense of it. I can understand arguments for greater equality, utilitarian or otherwise, but not “health equality yes, housing and food and clothing equality no.”
I have the somewhat uncharitable suspicion that many of these arguments are made as justifications after the conclusion that healthcare is fundamentally different has already been reached. It’s a matter of life and death – but so is food, and nobody wants nationalized food provision. It’s something that strikes at a random time, and you might not have enough money for it at the time – but the same applies to any kind of insurance. When you need emergency care, you are not in a fit state to evaluate different options, so the free market doesn’t work – and yet people manage to write wills and then have them enacted at a time at which they are even less able to make decisions than when they need emergency care.
If I am going to continue being uncharitable then I would say that I think the reasoning comes down to the idea that: the US has private healthcare, and it is expensive and works badly; every other civilized country has nationalized healthcare, and it works great; the US needs to stop being so irrationally ideological and move to the obviously correct option that everyone else has already taken up. It’s a stance based on inaccurate information, but it’s an easy one to take, and if you want to differentiate yourself from anyone who leans libertarian, for fear of getting a label attached to yourself and being thought of as a tribal ideologue, then this is an easy way to do it. Free market works – except for healthcare, where it doesn’t. Done. Oh and there’s probably some reason for it too.
As I said, this is a mean accusation for me to make, but I think there is a little of something in it. Committing yourself to the center ground is no more rational than committing yourself to the blue or red tribes, but this never seems to be brought up.
Anecdotal evidence would suggest Lyrica may not have debilitating side effects, but does get you very, very high. I feel like you mentioned this in an older post, or maybe it was on crazymeds. Anyways, I live in Thailand where it’s available OTC, the generic when you can find it isn’t even too expensive. It’s fantastic, both for recreation and for situations that are likely to cause a lot of anxiety, though perhaps not those involving social interaction. Whether the pretty strong euphoric effects are a positive or negative is of course up to the users judgment.
I don’t have anything specific to say about the content of this post, but thank you for writing it. I’ve been hoping for it since you wrote the depression post.
In a previous thread you had good things to say about serzone as an antidepressant. Do you have opinions about serzone (or trazodone) as an anxiolytic?
One also hears good things about the evidence for the effectiveness of hypnosis, but you didn’t mention hypnotherapy. Any thoughts?
I went to a hypnothearpist. He did nothing, I entered no altered state of consciousness, nothing he said or did had any effect on my emotions or actions. He just told me to close my eyes and then told me a story about me feeling things which I didn’t feel and seeing things I didn’t see.
It was a crushing letdown because an altered state of consciousness sounded like the only possible way to treat my perfect self-reinforcing, self-repairing depression and anxiety. What is supposed to happen? Not in vague platitude terms, what is the actual sequence of events that is supposed to occur when I walk into the office. I want to know if this result would be repeated, or if this guy was just bad at it.
I haven’t been to a hypnotherapist, so I can’t tell you what’s supposed to happen, but I have managed to pull off self-hypnosis, so I know it’s a real thing from experience.
Either your therapist was bad at it, or you’re particularly resistant to entering hypnosis. Though a good hypnotherapist should notice that you’re not actually entering that state, I’d think. So maybe both.
(Please see disclaimer above. I am a trained hypnotherapist. I am not a medical health professional. Nothing herein is medical advice.)
That’s not necessarily an “or” question.
It sounds like the therapist described was trying to pull an Erickson. The problem with trying to pull an Erickson is that you pretty much have to BE Erickson to have consistent results, and that position has been permanently closed. My Voice Will Go With You is an amazing, inspiring book, but it must be read with a great deal of humility. 🙂
There’s also no way at all to know how much and what quality training the hypnotherapist had, since there are few if any jurisdictions which license or certify them, and very few educational programs for them which are likewise certified or approved. They might just have been oblivious.
And of course some people (*holds up hand*) are resistant to heterohypnosis to the point where it is, practically speaking, impossible for them. I can reach a reasonable depth of trance with autohypnosis: no hypnotist has ever been able to convince me to enter a trance directed by someone else. People like me are incredibly rare but we do exist. In most cases a skilled hypnotist working with a willing subject can find an induction which will allow the subject to reach a reasonable depth of trance and helpful suggestions to be reinforced.
(Disclaimer, again. Not a licensed medical health professional. Not medical advice.)
I responded generally to a reply to this, but I’ll answer your specific question directly. Please note that this is going to get long, and I apologize if I get too detailed. 🙂
A good hypnotherapist will act in a professional, competent, and sympathetic manner. They will first do a reasonable evaluation of your mental status, and inquire as to your goals for hypnotherapy. This is not only necessary to plan the course of therapy, but to ensure that the client’s needs are within our scope of practice to address.
(Note that the ACTUAL first thing I’d do is explain to you the costs of the session and ask you how you planned to pay. There’s also a new-client questionnaire, etc. This post is about the actual therapy part.)
If you were to come to me and say that your issue was “self-reinforcing, self-repairing depression and anxiety,” here is what I would say:
“Hypnosis can absolutely be very useful in addressing issues like these. And if you feel that being able to deeply relax would improve your quality of life, as a little break from your worries, I’d be pleased to help you enter hypnosis today. But what you’re describing sounds like something a licensed mental health professional should discuss with you in detail. Before I help you address the specific issues that you want to improve, I’d ask you to do that. After you’ve talked to someone who can help you evaluate the underlying issues, I’d be happy to offer you hypnotherapy if they felt it would be useful in their course of treatment.”
After that, if you wanted to proceed with hypnosis (and/or if you had already been to a LMHP and they had approved the use of hypnotherapy to supplement their treatment) I’d perform some suggestibility tests. Without going into a lot of detail, these tell me the way you are most comfortable taking in information, and that tells me in turn the best way to communicate with your critical mind and reassure it that it’s okay to give me access to your subconscious.
After that, I’d decide which induction to use, based on my evaluation of your suggestibility and your readiness to enter hypnosis. I know, literally, dozens of them. In a sense I know an infinite number, because I can adapt them individually for the client and the circumstance*. But basically it would be either a rapid induction (instants are a little showy, IMO, for therapeutic hypnosis, although in some cases they work really well) or a progressive induction. While I was performing the induction I’d be doing various things to get feedback from you to see how it was going: if it wasn’t working, I’d adjust my induction accordingly, possibly even stopping and talking to you about what might help you enter hypnosis more easily.
Once you were in hypnosis, I’d help you reach a comfortable depth, again observing you for various indicia of depth and suggestibility, and then give you suggestions tailored toward addressing whatever it was that brought you to seek hypnotherapy.
Then I’d bring you out of hypnosis after some general positive suggestions. Once you were “out,” I’d reinforce those suggestions as appropriate, as people remain very suggestible for a time after “awakening” from trance. Once I saw you were back in the real world, I’d tell you how I thought it went – usually, very well 🙂 – and discuss possible future sessions. Then I’d ask you to sign the bill and send you on your way with good wishes.
Any other questions?
*In another sense, I only know one: taking the subject from “not hypnotized” to “hypnotized.” 🙂 It sounds a little obnoxious, but skilled hypnotists are good examples of the old saying, “The novice sees many paths to the goal: the master, one.”
I’m kind of annoyed how everyone just assumes that it never occurred to me to talk to a therapist. I did that. I have been seeing one therapist or another for two-thirds of my whole life, been on a bevy of drugs, went through a full course of ECT with no result, and was the first person at the trans-cranial magnetic stimulation practice for whom the treatment did absolutely nothing.
The guy I saw didn’t do anything to see what kind of “induction” would work, and did not do anything that I would recognize as being any kind of “induction” after the first session (there, he put his finger in front of my face for a couple seconds and then told me to close my eyes and started talking.) So I gather that indicates he was just a dope.
What are these “inductions”, what is an “instant” one, and how does it work?
I completely understand how frustrated you are about that first issue, but I have to say that. Not only for legal reasons, but for ethical ones. I’m not a psychologist. If you need one, it would be wrong for me to say that you don’t, or even imply that you don’t by addressing your issue myself. I’m here to help you, not make things worse. Although the metaphor’s not exact, it’s a little like me seeing you get by a car in front of a hospital and deciding that even though there’s an ER handy, I have first aid training so it’s totally cool if I just go ahead and set your obviously fractured leg.
That being said, I’d ask you if you had seen a therapist. I’m writing in hypotheticals here, and you can’t get everything. 🙂 If you said you had, I wouldn’t hassle you about it, although I wouldn’t give you any suggestions related to the specific issue under treatment without their say-so. If you had and they wouldn’t approve, or if you declined to do so, I’m sorry, but I wouldn’t address that issue with hypnotherapy. I’d help you with other things, but not that.
It’s not entirely fair of me to judge the hypnotherapist you describe based only on your say-so, but taking you at your word, yeah, he was a dope. That sounds like a combination, in unknown ratio, of bad training, excessive ego, and incompetence. (could be any mix up to and including 100% of any one.) The “excessive ego” part is him thinking he can do Ericksonian-style therapy without being, you know, Milton Erickson. If you’d like to know more about the particular issue I’m describing, Google the book My Voice Will Go With You and read some descriptions of it. Erickson was famous for, as an example, telling a raging alcoholic a story about a cactus in the desert and afterwards, he never touched a drop of liquor again. Which is awesome, but for we mere mortal hypnotherapists (Note: Erickson didn’t think anybody but licensed psychiatrists should be allowed to practice hypnotherapy, which is ironic.) some actual formal hypnotic induction and structured suggestion is usually a good idea. Trying to do what he did without being him: results may vary.
Inductions are the processes used to help a person enter the hypnotic state. The classic ones are things like you see in the movies with a swinging watch or a metronome or what have you. Those are completely functional, but in actual practice, they don’t work so well for a given fraction of the population. This phenomenon is why many psych textbooks still claim that only half the population can be hypnotized to any significant extent. In point of fact, everybody without extremely atypical neurology and/or severe mental health issues can be hypnotized, and the vast majority of people can be hypnotized by another person. (What most people call “self-hypnosis” most hypnotherapists call “autohypnosis,” and there’s actually a reason for the distinction. Being hypnotized by another person is called “heterohypnosis.”) What those studies actually showed is that only about half the population is subject to being hypnotized by an old white guy in a lab coat reading a prepared script off a clipboard. 🙂 I am a white guy, I’m approaching old, but I don’t wear a lab coat, I don’t use a clipboard and I’ve literally never failed to hypnotize someone who approached me and asked to be hypnotized.
“Instant” inductions, as the name implies, are inductions designed to take someone from a normal “unhypnotized” state to a reasonable depth of trance in one go. Almost all stage hypnotism performances feature instant inductions – the deal where the guy stares at someone, taps them on the shoulder, and yells “Sleep!” and they keel over like they’ve been blackjacked. That’s an instant induction. Rapid inductions (there is no bright line between “instant” and “rapid,” although I have a funny story about that one too) are generally thought of as ones that take more than a few seconds but less than a minute or two. After that come “progressive” inductions, which can take anywhere from a few minutes to an hour or more. Experienced hypnotists find them very boring, but if you know what you’re doing they always work, because, as I like to say, eventually the subject will go into trance just to get you to shut up. 🙂
As to how it works: Literally, nobody knows. Ask me again in a hundred years when we’ve started to make real progress in understanding how the brain actually functions as opposed to having mapped it and begun to understand neurochemical processes. But some fMRI studies seem to indicate that there is a real biological thing happening, not just roleplaying (which was a common theory for a long time, although roleplaying doesn’t mean quite the same thing to a psychologist that it does to a normal person.)
I myself favor the theory that it’s an atavistic mechanism overriding the process of consciousness. Basically, you’re triggering the “fight, flight, or freeze” mechanism in the brain. People talk about “fight or flight” fairly often, but they usually leave “or freeze” off, and that’s just as important. If your brain determines that something unusual is happening, and it can’t process it with the normal cognitive process, it will do what some hypnotherapists call a ‘transderivational search.” It other words, it will try to find an explanation and an appropriate response, fast. This will usually be something on the “fight/flight/freeze” axes. If fighting and flight are not appropriate options, you will freeze, and in that moment of “freezing,” your subconscious is open to direct input. (Because there’s no TIME to think at normal cognition speed. The subconscious works FAST.) If the appropriate input is given and a suggestion to enter a hypnotic trance is made, the brain will follow it, because it offers an escape from the unresolvable conflict. Why this makes progressive relaxation inductions work is a little more complicated, but the theory seems to cover it.
Well, that got long. (Again.) What else would anybody like to hear me go on about? 🙂
Do you think you can do it over Skype?
Disclaimer: last time I tried (in person with a guy who also had an MD) it only halfway worked. It was relaxing but trance I don’t think I ever entered (neither did it seem to help any).
I know I can perform hypnosis over Skype, as I’ve done it so many times I have literally lost count. If you’d like to discuss it, feel free to email me. My email is my first name@my whole name.com. I can even provide a reference to someone far more skilled than I, if that were to be necessary. 🙂
This makes me incredibly suspicious, a claim that you could induce an altered state of consciousness in someone with a word and a smack though it is regarded as “showy”. Like, “You are almost certainly lying, and if you are not lying, that is even worse” kind of suspicious.
What is possible in this state that is not in a normal state? To try and go around the bland glittering generalities I see, lemme phrase this was — What is the worst, most damaging thing you could do with it?
DrBeat, I understand that you are not trying to insult me. And you don’t know me from Adam, so I likewise understand your suspicion. It doesn’t bother me and in fact I think it’s a perfectly reasonable response. But I am not going to debate you as to whether hypnosis is “real” or not, nor as to whether trance inculcated by instant induction is any “realer” than trance entered by more traditional progressive relaxation methods. As a philosopher once said, “Let those who do not know, question. Let those who do move on to other things.” I am telling you things I have observed firsthand and things I have been taught by people I consider knowledgeable. You can believe me, or not, or somewhere in between, as you prefer.
That being said, and with the disclaimers I’ve already made as well as the one above understood to remain in full force and effect, I will answer your questions to the best of my ability.
“You are almost certainly lying, and if you are not lying, that is even worse” kind of suspicious.
I know that’s not a question, but I’m going to treat it as one. 🙂
I am not lying: to the best of my knowledge and belief after reasonable inquiry and observation, it is absolutely true that a person can enter an altered state of consciousness, for a reasonable definition of “altered state of consciousness,” from what appears to be a few words and a sudden tap on the shoulder.
However, as with many things in life, these things are not what they appear to be. In fact, if I were to simply walk up to someone, even someone extremely suggestible, and simply yell “Sleep!” at them while tapping them, etc., in all likelihood absolutely nothing would happen. Well, actually, I’d probably get the response a rather well-known stage hypnotist did when she did that very experiment. She’d go up to random people on the street, make mystic passes at them, and yell “sleep!” What happened was that every single one of them looked at her as if she were insane (one person can clearly be heard muttering, “Crazy bitch!” on a recording she had made) and kept walking. But if she did the same thing after a very brief pre-talk, most people would go into hypnosis. The tap and the words are the end of the induction, not the whole of it, and describing it as “instant” is a term of art, not literal. Does that make you any less suspicious and/or horrified?
What is possible in this state that is not in a normal state?
Define “normal,” please.
And while you have fun with that, I’ll say that generally speaking, there’s nothing you can physically do while hypnotized that you can’t do while unhypnotized. (The famous “stiff as a board” trick, for instance, can be replicated by a waking person, although it’s much more difficult to hold the concentration necessary.) And as for other things, we get into the argument about whether the hypnotic suggestions and the subject’s responses to them are conscious/roleplaying. Again, that’s not a debate I’m interested in having. You asked, I answered.
Mentally, same basic answer, although I have seen hypnotic anesthesia used to allow very extensive dental work to be performed with no chemical anesthesia and no apparent discomfort on the part of the patient. (I have experienced this, as I often go into a light trance when having dental work done. I rarely ask for anesthesia even though my pain threshold is ridiculously low.) Doctor James Esdaile, for whom the “deepest” state of hypnotic trance is named, performed well-documented major surgeries on hundreds of patients using only hypnotic anesthesia. (Ironically, Esdaile was a Mesmerist, as opposed to Braid, who was the first true modern hypnotist. Esdaile never studied with Mesmer or a Mesmerist, but based his induction techniques and the theory behind them on Mesmer’s “animal magnetism” ideas. Thus proving once again that you don’t have to know why something works to make it work.)
On the other hand, people can learn to disregard astonishing amounts of pain even while completely conscious… although many hypnotists would argue that they are using autohypnosis to do it. 🙂
As far as posthypnotic suggestion, as far as I know, and the experience of every other hypnotist I have ever discussed this with is the same, the old saying that you can’t be hypnotized into doing something you don’t want to do is absolutely one hundred percent accurate.
But…
See my prior comment about the slippery meaning of “want.” You may “want” to stop smoking… but you “want” nicotine more. So you reach for the cigarette and light up, despite what you say and think you “want.” (I use that example on purpose, as hypnosis for smoking cessation can be extremely effective.) If the hypnotist can convince you something is true which isn’t, or isn’t true which is, suggestions to do things which you otherwise wouldn’t do will be readily followed. This is obviously also true in the waking world. But given how much less conscious thought people will give to following a suggestion that their subconscious has accepted, there may not be time for them to avoid following it. Or their subconscious (which isn’t a separate personality, it’s more complicated than that) may decide to follow it for reasons which are absolutely opaque to the conscious mind, but make perfect sense at the subconscious level.
To try and go around the bland glittering generalities I see, lemme phrase this was — What is the worst, most damaging thing you could do with it?
Okay, remember: You asked. Possibilities (as in, things I know are possible either from observation or reports from sources I consider trustworthy) include:
Inculcate false memories of such strength and verisimilitude as to cause the person serious mental distress, up to and including (in extremely suggestible persons) the symptoms of Disassociative Identity Disorder and/or Borderline Personality Disorder. Inculcate phobias and/or anxieties based on specific triggers. Inculcate eating disorders and addictions. Trigger and/or amplify the symptoms of PTSD. Inculcate psychosomatic physical maladies up to and including spontaneous paralysis, sexual dysfunction, and/or persistent hypersensitivity and/or asensitivity. In rare cases, induce actual physical maladies including but not limited to stigmata, the inability to relax and/or contract certain muscles, etc.
Like every tool, it can be used for good or for ill. Everything I said it can do, it can also undo. “Nothing’s good or bad, but thinking makes it so,” and that is nowhere more true than in the application of hypnosis.
Having thrown out all the theories from Mesmer on down that all kinds of influences and energies were involved (the original “animal magnetism”), the idea nowadays about hypnosis, so far as I can make out, is that the practitioner does nothing, it’s all you.
You relax your mind and make yourself receptive. There’s no altered state as such (so what that says for people allegedly not feeling pain under hypnosis, I don’t know), basically it’s a ramped-up placebo effect.
Your practitioner might have been bad, but more likely it’s that your mental defences were too high to breach because you were unconsciously/subconsciously too wary and unwilling to surrender control of yourself (or at least, I imagine that is the way the explanation for its failure would go).
So maybe self-hypnosis might work a lot better for you?
Again, nobody really knows. But also again, there have been some fMRI studies that appear to show there are brain activity patterns unique to the hypnotic state in some people. There is almost certainly something biological behind it.
As far as “the practitioner does nothing, it’s all you,” I think that’s accurate but misleading. There is no animal magnetism nor, as far as we can tell, is the practitioner doing anything on the physical level. I’ve hypnotized people through Skype, over the telephone, and once on a bet through text messaging. So for my part I think we can definitively rule out that there’s some kind of physical interaction at work.
However, many people find it much easier to achieve a hypnotic state with the guidance of a hypnotist. There are even a few who have the opposite of my problem: they can be hypnotized by another person, but can’t seem to achieve purposeful trance without assistance. So when you tell someone, “It’s all you,” that puts a burden on them which I don’t think is helpful and can actually make it more difficult to achieve trance.
At the end of the day, if they don’t want to go into trance, they won’t. If they do, but you give them a suggestion they don’t want to accept, they won’t accept it. (I’ve never failed to hypnotize someone: I’ve had suggestions rejected. All hypnotists have.) Simple as that.
However, “want” is not a simple word, as our esteemed host can tell you far better than I. We don’t always know what we want, and we can often be persuaded that we want things which we didn’t think we wanted, or that we shouldn’t want things which we actually do. Helping people address their wants better is a big part of what hypnotherapists do, and that includes whether they want to be hypnotized in the first place. In that way, hypnotherapists are active participants in the hypnotic process.
Add one more: I react quite positively to your medication info posts. 🙂
Anxiety disorders are the most common class of psychiatric disorders. Their US prevalence is about 20%.
At what point is something common enough that it’s just another variation on normal?
(also WP gives the prevalence at something closer to 2% for both the USA and the EU.)
Isn’t that what the most common psychiatric disorders are–normal variations stretched to the point where they make your life suck? Being sad or anxious is a really common experience, but most people don’t experience them in a pathological way.
But isn’t 20% so frequently occurring that it is, actually, “normal”?
I don’t want to get into the derailing topics, but we could look at, oh, being red-headed, or left handed, which have negative aspects, but are still considered “some sort of normal” rather than pathologic. And they’re less common than GAD, apparently.
Except people really really don’t like having anxiety disorders. Even if it is normal variation, it should still be treated, no?
Unlike, say, mild autism, there suffering from high levels of anxiety is intrinsic, not caused by society or whatever.
Also, these are all anxiety disorders grouped together, you make a mistake by grouping them together. Social anxiety is very different from GAD, for instance.
What’s the prevalence of ‘breaking a bone’?
Do we declare having a broken bone is normal because most people break one at some point in their life, and therefore it shouldn’t be treated?
keranih: Normal does not mean not pathological, and it especially doesn’t mean we shouldn’t treat the disorder. Something like 9% of people over age 80 get glaucoma. But it’s still a disease, and if scientists a few years from now come up with eye drops that magically cure it, we should not withhold them from blind octogenarians to preserve a sense of normalcy.
LTP: I don’t know if we can neatly divide psychiatric disorders into endogenous and exogenous, and then place anxiety in the first column and “mild autism” in the second. I doubt it. Even if we could, though, there’s no guarantee that this would make any difference to how we should treat the conditions. Suppose anxiety is caused by the way society is presently organized. Maybe we discover that it’s mandatory schooling making everybody anxious. Does this mean we should get rid of mandatory schooling? Probably not. Probably universal education is a bell that can’t be unrung and the solution is to continuing distributing Xanax by the bucketful.
The questions of whether a condition is statistically normal, whether we should see it as pathological, whether it’s endogenous or exogenous (if the distinction makes sense, which I don’t think it does), and whether and how we should treat it get conflated all of the time. But they’re really independent, at right angles to one another.
@ Earthly Knight –
whether a condition is statistically normal, whether we should see it as pathological, whether it’s endogenous or exogenous (if the distinction makes sense, which I don’t think it does), and whether and how we should treat it
Thank you, this is what I was trying to come around to. I wish there had been some discussion on the intersection (or not) of these considerations.
I can strongly second avoiding caffeine and getting enough sleep. These have been the most effective things I’ve tried. Note that if you never drink caffeine, you’ll lose your tolerance for caffeine, and then it’ll be disaster if you drink a bit of tea or coffee at some point.
I hear the advice to exercise all the time, but I’ve found that heavy exercise can actually trigger anxiety. My biggest anxiety/panic attack trigger is thinking that I’ll become anxious. Exercise accelerates my heart rate and breathing and other bodily sensations that mimic anxiety. So then I subconsciously think that I’m getting anxious, and that triggers actual anxiety/panic attack.
I’ve found that Benadryl, though it takes longer to kick in, is a more powerful sedative than Xanax. It actually makes me fall asleep. So in that way it’s a very effective treatment for anxiety.
One of the biggest barriers for me is the fact that you can’t drive if you’ve taken sedatives recently, and some of these drugs take a long time to wear off. This is just inherently a problem with sedatives, regardless of mechanism, and I don’t see a way around it. I’m often in the situation of being pulled over on the side of the road having a panic attack and being completely stuck: can’t drive with Xanax, can’t drive with a panic attack.
I saw a large high-quality longitudinal study recently that linked benzos to Alzheimer’s risk (Alzheimer’s is known to be related to GABA). It was convincing enough that I’ve tried to reduce my benzo consumption.
I have good anecdotal experience with zinc supplements, but be careful to only get about 10 mg/day. A lot of supplements have ridiculous doses like 40 mg/day, which will make you sick.
If you get used to the exercise, though, you’ll be better off in the long run. Avoiding heart-rate-raising exercise is potentially a really dangerous mistake where your general health is concerned. Just find a way to put up with it for a while and you’ll get used to it.
When I had panic disorder, I used to power-walk near the walk-in clinic so I knew I could go in there if I had “heart problems.” Eventually I worked my way up to jogging, and then I got used to that and didn’t need to do it near the clinic.
Moreover, I saw a continuing ed lecture aimed at medicos that said experiencing things like increased heartrate while feeling “this is okay” is how to overcome panic. If we retreat further into our cave, the boundaries of what’s safe retract with us. So we have to push the boundaries out and relabel in our heads so that we learn they’re oaky.
They did something like this in a social anxiety therapy group I was part of once. Vigorous exercise to induce the somatic symptoms of anxiety was specifically mentioned as an example, IIRC.
One of the biggest triggers for anxiety attacks is fear of an anxiety attack. What can work is realizing that an anxiety attack is unpleasant but not ultimately dangerous and giving yourself permission to have them. If you feel one coming on, instead of trying to fight it, just sit down and let yourself have the attack. For many people this can cure them of acute anxiety attacks.
You left out one of my favorite substances, kratom. In my experience, and in the experience of many others, it is quite anxiolytic, legal in the U.S., and safe if used sparingly. Well, as safe as many of the alternative treatments can be, for the time
being. At least it has not been linked to anything really bad like heavy metal accumulation (as bacopa has) or liver failure (as kava has).
I am perplexed at your more or less endorsing benzodiazepines for long term use for some people while you give phenibut such a negative review. Both act on GABA, and it seems from my reading that both should be used occasionally, if at all. I have used phenibut for years with no negative consequences by following two rules – never use more than a gram and never use more than twice a week.
I have been in several SSRIs, Buspar, Wellbutrin, Propranolol, and Strattera now for anxiety and honestly kratom and phenibut, used responsibly (that is, not all the time or in ever-increasing doses) have been the most helpful to me.
For benzos at least we have known pharma quality sources and a lot of experience of what they do. In the case of Phenibut, not so much.
Quality sourcing is definitely a legitimate concern (as it is for just about all the items listed in Section IV). But assuming you’re getting phenibut as advertised, I feel like it’s a bit harsh to call phenibut addictive and dangerous and not say the same of benzos.
You’re right that benzos have years of research and case studies and whatnot but I encountered an awful lot of horror stories about benzos when I was researching them, both lay anecdotes and in the opinions of doctors and researchers.
To be clear I’m not saying benzos are all bad. I don’t think they are. I just felt like the disparity between his review of benzos and his review of phenibut was a bit more than is supported by the evidence I’ve seen.
Your impression of phenibut is very different than mine and most of my friends’. One anxiety-afflicted friend who has taken lots of phenibut, alcohol, and benzos thinks it’s by far the least addictive of the three. I’m confused by why your impression differs so much from mine.
Thanks for posting this! I really appreciate these. A couple of notes/questions:
Isn’t Neurontin (gabapentin) essentially the same thing as Lyrica (pregabalin)? Also, how do you deal with tolerance issues there? If 600mg used to mellow you out for the day and now it’s 1800mg just to keep stable, is there some way to reset that? There’s been some improvement spending a few days every couple of months on short-acting benzos, but is that the best thing to do here? In general, how do you deal with building up a tolerance?
You mentioned MAOIs; does the existence of selegiline and rasagiline (MAOIs which either don’t have the “cheese problem” or have a much-reduced form of it) mean that people will start using them again? (Rasagiline looks like it’s still under patent, to boot.)
I’ve had at least one anecdotal report of magnesium supplements causing vivid, terrifying, constant nightmares. Apparently it’s not expected, but not unexpected either. It was being taken for completely unrelated GI issues, but wow, did it ever make them a lot more anxious.
Lyrica and Neurontin are *supposed to* be very similar, but in practice they seem kind of different to me.
Those two MAOIs are MAO-B selective, which isn’t what we want for psychiatry. There are ways to get seligiline to work in a nonselective way, but then the cheese issue possibly comes back. This is what’s going on with the Emsam patch. My guess is that the cheese issue isn’t a real concern there, but the FDA has said it is and we have to pretend their pronouncements make sense, so no cheese for Emsam users.
I’m very curious–how so?
For meditation or relaxation, I’ve had good experiences with the Sounder Sleep System, which is a number of breathing exercises to do during the day and at night. Has helped with daytime anxiety and with nighttime insomnia.
I think that the diet part can be expanded upon a bit. High-carb vs. low-carb probably depends on the person, how much exercise they do, what sorts of foods they can tolerate, etc. And things like gluten intolerance or intestinal impermeability can affect anxiety levels as well, at least they did for me.
And sometimes anxiety is more ‘existential.’ You have to get out of a bad relationship, change jobs, or make some other big life move to get out of an anxiety-producing situation.
Scott, I’m pretty sure that there is good evidence showing journaling to help with anxiety, you probably just forgot to mention it, might want to edit this post.
This is an excellent summary, I’ll throw in my experiences if they’re useful to anybody:
I have social anxiety, generalized anxiety, health anxiety, and panic attacks.
In my experience, lifestyle changes (and, occasionally, medication) have really helped with the generalized anxiety, health anxiety, and panic attacks, but has not really helped with social anxiety (particularly the physical symptoms).
For dealing with the latter three, avoiding caffeine is huge. I found that around my 18th birthday I started getting panic attacks after drinking too much of a caffeinated drink. I often wonder if drinking a Monster energy drink every day for a year in high school worsened my generalized anxiety, though the my generalized anxiety didn’t present until over a year after I had cut out those from my diet.
Also, I have found that managing my diet really helps. I noticed that I’d feel a strong general anxiety about an hour after I ate certain foods, like clockwork. I’ve found that avoiding overindulging in sweets (no more than ~150 calories of sweets at a time) and minimizing consumption of foods with lots of simple carbs like white grains, pasta/pizza sauce, soda, chai lattes, and so on has really helped. I think the sugar rush triggers anxiety. Also, I’ve found that avoiding very spicy and acidic foods has helped. This is primarily tomatoes, other citrus fruits, and onions, plus a few other assorted things.
I’ve found moderate exercise to be somewhat helpful, but only if I’m consistent with it, primarily long-ish walks and various household chores like vacuuming. I find that vigorous exercise makes me feel anxious, ironically. I’ve never experienced anything close to a “runner’s high”, even in the brief periods I tried more vigorous exercise.
As for medication, SSRIs have helped with all my anxiety save the social anxiety, but they had intolerable side effects: mainly difficulty achieving orgasm, and an emotional flatness (though, I wouldn’t say I didn’t feel emotions, just they were muted) often accompanied by mild dissociation.
I currently have a benzo prescription, Ativan, which is for an as needed basis only. I am very very careful with it, being very aware of the addictive effects. It really helps with all my anxiety, even the social ,though to a lesser extent, it stops the immediate social anxiety but doesn’t reduce my deeper fear of interaction. I take a half a tab maybe once or twice a month, usually in response to a panic attack or a very stressful upcoming situation. If I’m going through a rough period I might take it as often as once a day for a few days in a row. But I NEVER take it more than once a day (the psychological affects last about 6 hours, so I’m still spending 18 hours a day not on the med). I also don’t have a very addictive personality, which helps.
My social anxiety is motivated by deeper fears than my other anxieties, and so I think these methods don’t help with it as much. The only method helpful for social anxiety has been talk therapy and EMDR. The progress there has been much slower than with my other anxieties, too.
I took Buspar a long time ago, and I had to stop after a week due to increased anxiety and intense anger. (Wikipedia backs me up that this happens sometimes.) Note: It was a sorta-off-label use (I may have reported “anxiety,” but that wasn’t the main issue and I don’t think I had an anxiety disorder).
Can I read official suggestions (not just for anxiety)? Is there a good resource that will tell me the “standard algorithm” a doctor might follow for a given complaint, so that when the doctor says, “I tried X; what more do you want from me?” I will have a response prepared?
Minor thing, but your Onion link at the end currently goes through Google; would you mind fixing it to point directly to the article? Thank you!
Once again perhaps I shouldn’t have said anything, now it’s broken due to a missing “http://”…
My 2 cents-worth anecdotal story: the only time I’ve suffered much from anxiety was in 1996 when I came down with non-Hodgkins lymphatic cancer. I’d get panic attacks worrying about dying, which I had a pretty high chance of doing shortly.
The semi-interesting thing was that within a few days I progressed to meta-panic attacks in which I’d get a panic attack not over my fear of dying per se but over my fear of getting a panic attack in public. For example, I’d get a panic attack on the way to the airport over whether I could hold it together during a cross-country plane trip or whether I’d make a spectacle of myself in the coach section.
Xanax proved highly useful in fighting meta-panic attacks because it works pretty fast. After a week or so, just having the Xanax bottle in my pocket everywhere I went served as a talisman that prevented panic attacks over my fear of having panic attacks. After 2 or 3 weeks I stopped taking Xanax, but I carried the bottle for a couple of months.
To lessen panic attacks caused by my fear of dying, I needed to develop more optimism that I’d survive. I found hypnotism useful for that. There didn’t seem to be anything magical about hypnotism. It just served to lull me psychologically into lowering my defenses of skepticism to the point where the hypnotist would read me a pep talk I’d written for her to give me. At first it cheered me up for a couple of hours, then for a whole day. After about six or eight weeks I stopped going because I was feeling more upbeat.
Anyway, your mileage may vary.
I haven’t tried an workbooks for Anxiety but I tried Knauss’s workbook for depression and it just felt really patronizing and hokey. Any advice to make workbooks feel less so?
If you don’t like hokey patronizing things, CBT may not be for you.
That may explain why I don’t like it. It feels like they expect me to be 5 year old. Or perhaps at least one stddev below mean iq
Amen.
You may get a temporary ego boost from showing the therapist you’re smarter, but you will not get any actual benefits. And if that’s all you want, posting on Internet forums is a lot cheaper than wasting a therapist’s time.
If you don’t like hokey patronizing things, CBT may not be for you.
Oh, damn 🙂
Seeing as I have no idea what kind of counselling I’ll be accessing, it may be premature to be getting discouraged, but given that CBT seems to be The New Big Thing I may be (un)lucky enough to get a counsellor who’s all gung-ho about this wonderful new treatment they just learned all about.
I’m trying not to prejudice myself about it so I won’t have my back up when it comes to the “But that’s bleedin’ obvious” advice. Just because I already know this stuff does not mean I can effectively put it into practice, and having to do “homework” and report on it might actually make me put the ‘obvious’ stuff into practice.
If they can just avoid the “Now, children, we’re going to learn all about amazing new things you never heard of before!” tone, it should be okay.
Has anybody ever heard whether Barack Obama used CBT to get over his depression following his election defeat in 2000? Some of the language in his 2nd memoir about this dark spell in his life might be drawn from CBT.
I am surprised that Melatonin and Niacin are not mentioned. Both of them work but each has its side effect (drowsiness & flushing).
Anxiety: Ashwaganhda http://examine.com/supplements/Ashwagandha/ http://www.ksm66ashwagandhaa.com/clinical_trials.html
Motivation/Purpose/Mood Balance: Modafinil http://examine.com/supplements/Modafinil/
Motivation/Purpose/Mood Balance: Caffeine http://www.amazon.com/Double-Strength-Alertness-Caplets-200mg-90/dp/B001QVCSZC
I’ve had a consistent positive performance in productivity and stress relief with KSM-66 Aswhaganda, 37.5mg (1/4th a pill) of r-modafinil and 200mg caffeine 2x a day for almost a year @ 5-7 days per week. This is a n=1 trial of course but this blog post compelled me to put in my experience with substances.
I have been insanely surprised by the consistent effect and lack of tolerance to the Ashwagandha formulation-it removes anxiety every time (250mgs ksm-66). This is not to say you won’t experience withdrawals like benzos if stopped suddenly, but I have yet to experience any such effect.
Ashwaganhda sounds attractive, but my immediate feeling is fear — that if I dropped my constant anxiety, I’d make some serious mistake, or something could sneak up on me.
YMMV, but the way I got around this was by recalling that anxiety, like almost anything else in psychology, has a significant, but far from total, genetic component. As this genetic component will stick around no matter what I do short of as-yet-non-existent somatic gene therapy, a certain degree of anxiety is inescapable.
Also, I’m sure you have considered that you might be biased by your anxiety in feeling anxious at the prospect of less anxiety.
I wish you’d listed some stuff that would be an option for mothers of young children. They skew towards anxiety and “get enough sleep” isn’t an option for them, as it can take years before their children sleep through the night consistently. See also “exercise regularly”. Young children are very exhausting and anxiety-inducing in themselves and this is partly because most women who have children in the United States do not have a critical mass of other women and children around.
The drugz are not open to them, either. It’s a big problem, it’s millions of women, who tend to resort to options that do not reduce the anxiety to gut through each day.
I have anxiety and am the mother of a 3-month-old. With all due respect, I don’t think this is an entirely fair critique. It’s harder to deal with anxiety as a new mother. But it’s harder to do everything as a new mother! Here are some suggestions; I hope they’re helpful. I absolutely agree with you that not having a community is a big problem.
Diet and exercise–It’s very easy as a new mother to slip into the trap of eating easy things instead of healthy things. Awareness and planning can help improve in this area. If healthy things need to be cooked or prepared in a way that you can’t do holding a baby, make them ahead of time, when you have some support (eg when your husband is home and can hold the baby) or when the baby is asleep. You can take the baby on a brisk walk with a stroller or baby carrier. You can meditate/pray while you feed him/her. Sleeping is hard, but there are ways to help yourself. If you bottle feed, have your husband (if you have one) do a night feed. Consider cosleeping (safely). Nap when the baby is napping (if you can–full disclosure, this never worked for me. I’m just not a napper). If you have a husband, can he get up with the baby on weekend mornings so you can sleep in?
Therapy–A good therapist shouldn’t mind you taking the baby to the appointment. Depending on your options, you could do phone therapy, or you could get a babysitter. Or you could get one of those workbooks Scott mentioned.
Drugs–I presume you are referring to breastfeeding when you say new mothers can’t take drugs. A lot of medications are considered safe (or safe enough) while breastfeeding. For example, SSRIs and benzos are generally considered safe when necessary, and there are least some antihistamines that are considered safe.
Sleep when the baby sleeps.
Seriously. This is about the only way to get enough sleep. My wife, who’s pretty type A otherwise, tried this (up to a point) and actually came close to being not sleep-deprived a few times while she was still home with our kids.
Of course, this means being able to fall asleep at the drop of a hat (or rattle or stuffed animal or whatever the baby was holding…). You’re not going to be able to be completely consistent about this, but every bit helps.
Wow just wow you people. I’m talking about mothers of multiple young children, not one child. You can’t sleep when the baby sleeps when you have other children to care for (usually) alone for as much as 10-14 hours per day. The other suggestions also fail when you have to face schlepping two or three or four or more kids along with you to wherever.
As for the drugs, I don’t mean breastfeeding, I mean the legal risks of taking experimental drugs as a mother in this particular society given its views on drugs and mothers and mothers who use drugs. Even antidepressants can carry lots of legal risk, never mind some of the other more outre options laid out by some of the commentariat.
Even in America, most mothers have more than a single child and this is especially true of housewives, which is what many mothers of young children are likely to be. Which also doesn’t help the anxiety problem, not even being considered part of the real world, which apparently never includes having more than one kid.
First off, I’d like to apologize. I interpreted “mothers of young children” as meaning “mothers who have a young child each” and responded accordingly. But there wasn’t any real reason to interpret it that way; I just did, probably because I’m egocentric and that’s the position I’m in.
I did say that I haven’t found “sleep when the baby sleeps” to be useful advice.
Buying a self-help workbook involves no child-schlepping at all, unless you live rurally and your mailbox is at the end of a long driveway. And my mother schlepped her (at the time) five kids to all her OB appointments, so it can be done. Do you never go anywhere with your kids? (Serious, non-aggressive question. Some kids are harder to take out in public than others, I know that.) What about a babysitter? It’s harder to find a sitter who will watch large families, but it can be done. If you have a local homeschool group, especially a Catholic one, reach out to them. They probably have high schoolers with large-family experience and flexible schedules.
If you’re a housewife, presumably you have some support from someone with a job. Can you find a therapist with Saturday or evening availability? (Depending on where you live, the answer might be no.)
I hardly think SSRIs count as “experimental drugs”. You don’t even need to see a specialist to get a prescription of those. Furthermore, no one except you and the doctor needs to know you’re taking them. I’m not suggesting that you go take the latest experimental thing that you have to buy in a paper-wrapped package from Japan and smuggle through customs, and then announce it publicly every time you meet someone, for heaven’s sake.
This is a general point for people who say they exercise every day, and it doesn’t seem to do much for them. I’ve heard that including days off or days with light exercise pay off because they’re recovery/rebuilding time.
+1 for l-theanine, it has a funny history outside the medical or nootropic community: pick-up artists were using it for approach anxiety, and then they realized it works for generic social anxiety, then, shit, for any kind of anxiety. However they also reported demotivating effects as in “sure I don’t feel afraid of hitting on that girl but I don’t really feel any reasons to do so either”. Kind of numbness.
Combined with a caffeine pill, they are an incredibly good boost. Let me put it this way, if I was a student, I would take all my exams so. It is focused, clear and efficient without being nervous feeling.
I would not say I am anxiety sufferer more than average perfectionist nerd but personally I can vouch for :
– walks in nature areas(less people – the better) – does wonders for my brain and thinking
– mindfulness technique – I knew about it for long time but yoga is what helped me to actually practice it
Exercise does not help that much , but that’s is probably my very performance based approach – I worry about hitting my numbers in the gym. Yeah sure afterwards it feels nice, but overall it probably increases my anxiety
If overachievers in the area of relaxation techniques should look into yoga, then I’d also suggest overachievers in the area of therapy going for the philosophical roots and seeing if Stoicism appeals to them at all.
How much of the effect of Benadryl is from making you sleep versus some other drug action?
Atypical antipsychotics (examples: Seroquel, Zyprexa, Abilify, Geodon) are, as always, overused. Most of them either make you gain lots of weight, put you at increased risk for heart rhythm problems, make you feel terrible, put you at risk of permanent movement disorders, or all of the above.
So when the doctor tells you about all those possible side effects, you now have a reason to feel anxious, and it’s no longer a disorder?
the long history of successful Russian use at least suggests it probably won’t kill you immediately
But will it successfully make you a good Communist?
“bcomes” => “becomes”
Spelling/grammar error.
I heavily challenge the claim that antihistamines are more effect than…
Emphasis mine.
Homeopathy might come out negative because trying something you believe will help, only for it to have no effect, induces anxiety. Are there figures on cognitive dissonance and anxiety?
Quitting caffeine for a year didn’t help me, even though I definitely use way too much. Maybe after two decades my body has learned how to generate anxiety and doesn’t need the crutch of caffeine anymore, or something. Quitting caused me to want to use alcohol instead, which is probably worse. Also I overate and missed my bursts of enthousiasm while my level of anxiety wasn’t any lower.
(My anxiety is mostly comes up after I have talked to someone in real life. I think human interaction causes me to self-signal that I care about other people and their opinions so it puts me in a mode of worrying. This goes away after a few days of being alone again.)
Scott, I want to point out that Lyrica (pregabalin) and, to a lesser extent, Neurontin (gabapentin) are used by some for recreational purposes, and have a reputation for causing some pretty nasty withdrawals, comparable to or worse than benzos for some users. You can check any recreational drug forum if you don’t believe me, the evidence is overwhelming as anecdotal evidence goes.
I have personallly found both of them to be fun and habit forming, especially Lyrica, though I never got any withdrawals.
The most successful strategies in our household involved addressing histamine intolerance, mostly by adding anti-histaminic elements to meals and switching to L-methyl folate for MTHFR reasons.
Alison Vickery and the Low Histamine Chef’s websites were helpful. Breathing exercises, GABA and especially vitamin C and niacin supplements were good for flare ups. DAO supplements for “just in case.”
The anti-histaminics seemed to improve sleep; hard to prove.
What is your opinion of the idea of managing a “sensory diet” for anxiety management long term? I’ve recently come across “Sensory Processing Disorder” and while I try not to self-diagnose, I can definitely sees relationships between my anxiety and sensory over stimulation. The only guidance I can find online relates to managing children with sensory issues and providing them a “sensory diet” – a term which I’m not sure is terribly helpful or applicable. Sensory management might be better? Either way, is management of this kind of over stimulation ever used to treat anxiety? Not just meditation, but essentially providing ways for people to stim to help them relax.
If you’re a regular drinker of alcohol, and you’re self-medicating with drink — stop. Regular alcohol use promotes anxiety and the feeling that you’re being pursued by the hounds of hell. Try this first before you do anything else.
houseboatonstyx said:
“… my immediate feeling is fear — that if I dropped my constant anxiety, I’d make some serious mistake, or something could sneak up on me.”
This is central, isn’t it?
If eternal vigilance is the price of survival, what alternative is there to anxiety?
When you’re in a situation where it’s obviously irrational to ever let down your guard, where it’s stupid to take your medication, what hope is there?
Perhaps you could find a fellow anxiety sufferer, and learn to trust him completely, and then get a good night’s sleep on his watch?
Like I’m going to sleep well knowing there’s somebody just as crazy as I am in the same room with me.
Well, actually I do, but we’re crazy in very different ways/
For an old suggestion of exercise as a cure for emotional problems—more depression than anxiety—see:
http://allpoetry.com/The-Camels-Hump
Taurine crosses the blood-brain barrier and binds to GABA receptors. I take taurine (albeit for my heart) and the first time it made me feel *very* chill. If I recall correctly it is described as a anxiolytic, although only in the short term.
For first-time meditation, I don’t think the link Scott posted is very helpful. The author needs a whole paragraph to inform the reader that they should sit down. I suggest listening to this for 9 minutes. https://soundcloud.com/samharrisorg/mindfulness-meditation-9