Dr. Saltzman,

I sent you another email on a slightly unrelated topic, but received no response. I'm not exactly sure if it was received.

This matter, however, is a bit more urgent, I suppose. My question is, I seem to have little or no affect. There are certain things in my life that would seem to warrant such emotion, but it just doesn't seem to be there. I cannot cry and if I do, it seems forced. I have not always been this way, and am by no means a sociopath. I'm not sure the cause of this change which has been taking place for a year or so now. I should mention that I take Xanax on a daily basis and also drink alcohol, though not to an extreme (with alcohol). Could Xanax be the cause of such unemotional behavior, I'm starting to feel like Hemmingway towards the end, or could it be organic?

I know the information is limited, but if you could, I would appreciate any information you could give me.

Kate (23 years old, U.S.)

Kate--

Xanax is a medicine used most often to calm anxiety, so it certainly is possible that its calming effect could have gone too far, leaving you without access to feelings you imagine would be appropriate. And, of course, any change in mental state also could be organic. The doctor who prescribed the Xanax should be told what you have told me, and asked what to do next.

I hope this helps,

RS

Dr. Saltzman,

I appreciate your quick response. The doctor that prescribed me Xanax is a family doctor, and as I believe has no ability to prescribe such drugs. I have been taking this medication for three or so years now, I'm not sure exactly. I do not see anyone besides her and call every fifteen days to get a refill, I mark it mentally on my calendar. I suppose I was simply curious as to this somewhat extreme lack of affect. I am hesitant to bring any problems to her attention, as she may take me off the medication, which I have grown physically and mentally accustomed to. In turn, as your suggestion stated, I don't think that she would be capable to answer any questions which I may have and to be honest I simply don't feel like relating the question to anyone else, as it seems slightly tiresome and fruitless.

Thanks again, I do appreciate your response,

Kate

Dr. Saltzman,

I noticed with curiosity that you posted my question in your archives. My question still remains, however, now what? If my doctor is negligent it has been to my benefit, I suppose. Nothing else has ever seemed to work for my particular problem, I have seen my fair share of legitimate doctors and soothsayers, so to speak, but what now? I don't desire to be a drug addict of any kind, but living in a fantasy seems a bit better than the real world. I find that malaise has overcome me, often too lazy to eat (actual laziness) and I cannot seem to study for lack of will power. I suppose it is a good thing, a beneficial thing, to post my story, so that unsuspecting people may not fall into the same pitfalls that I have, but as a person and not a group of random individuals, what should I do?

I realize that this may be going beyond your scope as a random conversation through an e-mail, but still if you could, what would be your advice?

Thanks,

Kate

Kate--

Although I responded to you privately first, I later posted our email conversation because it illustrates so well a point that I have tried often to make here on my website: just because anyone with an M.D. degree and a medical license has the legal right to prescribe any drug in the pharmacopeia does not mean that such a person should be prescribing any and all drugs. Psychiatric drugs should be prescribed by people trained in psychiatry and human psychology—not family doctors who usually have no training in psychological issues. I suggest, by the way, Kate, that you click on that link and read what I said there, for it touches in many ways on your situation.

I have seen much damage done because some medical doctors--inferior ones in my view--would rather write a prescription than take the time to find out what really is the matter, and how best to help the patient to deal with it. Popping pills may be an adequate solution for a purely organic problem—a strep infection, for example--but a pill is not a solution, in my view, for the kind of complaints which brought you into the office of the doctor who prescribed the Xanax. Your "pitfall," as you called it, consisted in consulting someone qualified to prescribe for strep throat, but not for the anxiety problems which brought you into his or her office.

That said, and with the understanding that I will also post this reply on my website so as to help others in similar circumstances, let me now try to respond more personally to you and your situation. I understand that you have a nine year history of panic attacks, and that, over the years, you have consulted various doctors, including a psychologist, a behavior modification specialist, a psychiatrist, and a practitioner of eye movement desensitization and reprocessing (EMDR), and that the only treatment which seemed to help was Xanax to which, unfortunately, you now find yourself addicted.

Now I am going to level with you, Kate, and in doing so, I will be expressing opinions with which some of my colleagues are sure to disagree, some because they will feel personally criticized or devalued by what I have to say, and others, perhaps, because they have more faith than I do in chemical treatment for psychological problems such as anxiety disorders, panic attacks, and the like. But I think this topic is too important to be approached without complete honesty. Naturally, I could be mistaken in my point of view, but since I have it, and since it is based on experience, I will share it with you and my other readers.

I know some people swear by EMDR, particularly as a treatment for post traumatic stress disorder, but I am not sure that EMDR is much good as a treatment for the kind of agoraphobic panic attacks which trouble you. I think agoraphobia is best treated, at least as an initial approach, by psychodynamic psychotherapy which attempts to reveal and explore the basic fears which underlie the agoraphobia, not simply by trying to quell the symptoms with anti-anxiety medication, or without exploring those fears, as EMDR, a completely automatic process, does. The popularity and--in my view--overuse of EMDR underscores a problem I see in the entire field of medicine including psychology and psychiatry: once a practitioner has learned a technique which seems to work, he or she might rely on it even when it is neither appropriate nor effective. As this is sometimes put, "the man with only a hammer will always be looking for nails to pound."

Now EMDR is a simple technique which can be learned in a few minutes. Basically, the practitioner asks the patient to watch a moving object (a finger perhaps) as it moves from right to left while attempting to focus on the difficult, frightening, or painful feelings. Yes, according to some studies this sometimes seems to help, but, as I said, I think the best results for EMDR involve treatment for PTSD which I beieve is a very different problem than your agoraphobia.

I don't know what approach your psychologist used, Kate, but not every psychologist can help every patient. Sometimes it is necessary to try more than one doctor until you find the right person, the person who is the right match for you. But at least the psychologist did not simply rely on dosing you with Xanax as your family doctor decided to do. As I see it, your doctor probably was mistaken in writing that first prescription for Xanax, and was certainly mistaken in continuing to allow you to refill it. Xanax is a potentially addictive substance which is intended and approved for short term use (no more than a few weeks), and is neither intended nor approved by the FDA for the usage your doctor has been allowing. Essentially this doctor has enabled you to become addicted to a substance which can not really heal your agoraphobia, but only mask it while possibly taking a physical and mental toll. Family doctors in particular make this mistake far too often, probably because they are accustomed to prescribe medicines for the treatment of acute problems (strep throat in my example) for which drugs really are appropriate and curative. But Xanax cannot cure agoraphobia. 




Furthermore, to write a prescription for a powerful mind-altering substance without providing ongoing, supportive counseling for the patient is, in my opinion, tantamount to malpractice. Let me repeat something which I have said often on this website: no one should be taking psychiatric drugs without also having regular appointments with a doctor who has time to hear the patient's concerns, to ask questions if necessary, and to regulate the dosage or change the medication if necessary. Your doctor, in my view, is not doing that job, and I advise you to find a new one right away.

Let me explain how I use such drugs as Xanax in my practice. Suppose, for example, that a client has difficulty in flying due to anxiety or downright fear, but that person must use airplanes from time to time. Now a psychodynamic approach to fear of flying might involve a lengthy exploration of the client's primal death anxiety and the denial of that anxiety by means of projecting it onto the specific circumstances of boarding an airplane (which in reality is safer than automobile travel) rather than facing the truth that anyone might die (cease to be, I mean) at any moment, and certainly will die sooner or later. In other words, the patient's fear of flying really may be fear of dying denied. Helping to bring the patient to this understanding seems to me a useful approach for many reasons, but it would also be expensive in time, money, and energy, and since the client must board a plane only from time to time, a long course of therapy, although useful, might not be necessary. Instead of analyzing the client's denial of death, and opening that existential can of worms, I might suggest foregoing talk therapy, and using Xanax, but only on the days that she must fly. In practice, I will suggest that the client try Xanax once on a non-flying day, just to get the dosage right and to be sure that she can function properly when under the influence. Then, on the way to the airport, the client can take the Xanax, and be able to board the plane without too much upset or terror. The same would be true of a client who fears public speaking, but must make some public addresses in the course of work. Xanax thirty minutes or so before taking the stage certainly can help.

There are other ways, to be sure, in which Xanax or one of its sister benzodiazapine medications (Valium, Klonopin, etc.) can be used properly, and for more extended periods. For example, if a patient presents with symptoms of panic disorder which are severe enough to interfere with ordinary daily functioning, the proper approach, in my opinion, is to begin treatment with an antidepressant medication such as Zoloft or Paxil along with ongoing psychotherapy. However, those SSRI antidepressant medicines often take several weeks to being working, and so, to bridge that time gap, I may suggest one of the benzodiazapines which then can be gradually withdrawn as the Zoloft or Paxil begins to take effect.

But these cases, you see, involve using Xanax on a now and then basis, or within a circumscribed time frame, not every day as you have been doing, Kate. Xanax was never intended to be used that way, but only for a brief time, certainly not for months or years. Further, Xanax, although very useful in certain circumstances, is a powerful substance which, if not used carefully and monitored constantly, may produce various negative side effects (including hallucinations, suicidal ideation, depressed mood, and memory loss), and which carries with it a high potential for addiction, as well as physical and psychological risks during withdrawal when the drug is discontinued. I have seen heroin withdrawal and Xanax withdrawal, and withdrawal from Xanax, if true addiction has been allowed to occur, is worse. In my experience, withdrawal from Xanax addiction can take up to a year or more, and if not done carefully and with proper medical supervision, may result in problems with rebound anxiety, agitation, panic attacks, severe muscle cramps and even, not infrequently, seizures. In other words, Kate, Xanax is not a drug that should be used carelessly, nor for long periods. Your family doctor, in my opinion, made a poor choice in putting you on Xanax to begin with, and continues to compound that error every time he or she signs off on another refill.

What to do now? The malaise of which you speak is a direct side-effect, I imagine, of Xanax, and I cannot agree that your doctor's negligence has been to your benefit as you wrote—quite the opposite: not a benefit at all, but a curse. Your statement, in fact, that you have benefitted from all this, is your addiction talking. When you have recovered from this addiction, you will see how misguided those words really are.

Kate, if you were my patient, we would begin to talk about your life, your history, your attitudes, your relationships, your fears, all of it. At the same time, I would begin encouraging you to reduce, very gradually, your dosage of Xanax, aided by the guidance of a competent physician. I hope you will consider this advice carefully for it is, in my opinion, the only feasible and proper course now that you have become so heavily addicted. You have been using Xanax for far too long already—years too long--and it is time to kick the habit.

Dr. Saltzman,

I appreciate your advice. I have known for quite some time that I am addicted to Xanax, the addiction is both mental and physical. I know that if I have taken the drug, my chances of having a panic attack are significantly less, and so both mentally and physically the drug has allowed me to continue with my studies. I do not, however, like the side effects of being 'high' to the point of laughing inappropriately, or not being able to concentrate. On the other hand, I do enjoy the feeling of unreality, the feeling that nothing quite matters at all, for this I have been given the nickname by friends as [words deleted]. I also do agree with you the EMDR is laughable, and could never quite convince myself of its 'mystic powers.' As for the psychologist, we did not get along well. Our relationship ended up turning into a pissing contest as to who was more intelligent, I'm not sure why. I saw through the theory of behavior modification, just psych yourself into believing everything is fine. I suppose it just never seems like a good time to quite taking this medication, I cannot afford the time needed to have the terrible withdrawal symptoms, and I am sure that I may have to deal with uncomfortable situations that I have avoided for so many years. I am tired though of the monotony of taking this drug day in and day out, and I feel tired and quite often and worn out. I cannot simply throw on some cloths and go to class as everyone else does, I feel that I must adhere to a strict and set regiment, set by only myself, taking a certain number of pills at a set time of the day. One day, however, I will have to quit taking them and that will be a sad and terrible day indeed.

Sorry again for my long answer, you don't have to respond as I there was no question poised. I would appreciate if you didn't post this, unless you feel a strong need to. Also, on a personal note, I do greatly value the attention you have shown me, even though this problem has been ongoing for a long time and I am still young, no one in many years has shown the slightest bit of interest or concern in any of these 'problems.' You have (and I'm not trying to feed your ego) shown more concern than just about anyone else, and for that I am grateful.

Kate

Kate--

I want to encourage you to begin moving towards getting off this stuff. Managed properly and done very slowly, the withdrawal would not necessarily have to be bad (although it might be). But you would need a good counselor to work with you, both on getting off Xanax, and also on getting to the bottom of the agoraphobia. There are such people in this world.

I will honor your request not to publish any of your last letter if you wish, but if you would allow it, I think putting at least some of it on my site might help others in similar difficulties. It is important for people to understand what addiction is, and how it can happen.

In any case, I was happy to hear that at least my caring about your situation was helpful.

Dr. Saltzman,

I suppose I don't have any problem with you posting my last response, but if you could, leave out the nickname I told you. Unfortunately that might make me identifiable to many people I know. An interesting thing happened as I was reading you last letter, only a few minutes ago. I called my doctor earlier today to tell her that I am going to run out of my prescription before I normally call to have it refilled, I have been using it more often than I should, technically. A nurse from her office called me back to tell me that she will increase it to twice as much as I take now. The timing was slightly ironic. She did however mention that if I needed any more than that, I should speak to a psychiatrist. Sorry to add that in, but I thought you might find it a bit funny as I do, sad but in a dark way rather funny. I must ask, simply to clarify something you said, besides finding a competent doctor, do you believe I should talk to a psychologist, as you can probably tell I am rather hesitant.

Though taking up days of your time, I hope you won't quite hate me for this last question. THANK YOU and sorry for the needlessly complex responses, I suppose I am just not good at being succinct.

Kate

Kate--

You will need the help of a psychotherapist to begin to deal with the fears that you have been covering up with Xanax all this time. The medical doctor will help with the physical difficulties of withdrawal from Xanax, and the therapist will support you in the withdrawal period while helping you to confront your actual problems.

Be well.

Dr. Saltzman,

I thought you might find this a bit interesting, considering I imagine you do not hear what happens to most of those who ask for your advice. I dragged my feet a bit, as people tend to do when trudging on a familiar yet slippery slope, but did eventually see a ‘competent’ doctor. This man has informed me that now I must go into inpatient detox, which I will, with sincere reticence, do over the summer—it is not feasible right now with classes and no classes equals no medical insurance. I appreciated your advice, which I did at last begrudgingly take, as so often happens when people say things that you yourself know and yet don’t want to admit.

Kate—the girl to whom Xanax is robbing of emotion

Kate--

Glad to hear from you. Thanks for this consideration.

Our correspondence which I posted already has helped several people. I would like your permission to post this update as well.

In any case, please let me know how your detox goes. Also, I would be interested to know what the competent doctor told you about your situation and about your previous doc.

I know you will be better without the Xanax, so I encourage you to follow through on this by all means.

Be well.

Dr. Saltzman,

I am very glad to hear that others have benefited from what I would consider a very poor misjudgment on the part of my family doctor. I unfortunately see two doctors now, a psychologist and a psychiatrist. The psychologist said that I was the most evasive person he has come across in his thirty-five years of practice (I don’t take that as a compliment). The psychiatrist indicated that he often has to clean up the messes left by people that don’t know what the hell they are doing. He also said that I could see a number of psychiatrists who would write me prescriptions until doomsday but that was not at all what I needed. I feel a bit dumbfounded and angry that I will have to share a hospital bed with people detoxing off heroine, when I have always taken these drugs under legal circumstances. Regardless, I know that whatever the reason, I am still in the same rocky boat those people are in. I must admit it is a bit disturbing; I have never been in a hospital and have never had so much as a cavity or any such thing. I am glad to hear that you responded to me, I sent this last e-mail as simply a follow-up, but it is amazing to me not being a computer savvy person that a person who lives as far away as you do from me could find some common ground, some reality tunnel, if I wanted to get psychedelic—amazing.

I have no problem with your posting this message what-so-ever, and I will inform you how it goes in the hospital—reluctant as I am.

Thanks,

Kate (PA)

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