Dear J.R.--

The questions which you posed for my professional opinion are thorny and complex. I will get to that, but first I want to explain why I am opposed to ordinary physicians writing prescriptions for psychiatric medications, although, clearly, they do have the legal right and the power to do so if they choose.

Since you are asking me about Zoloft, I will use that drug for an example. I might recommend to a client that he or she give Zoloft a try, but my recommendation would have been preceded by hours--often many hours--of heart to heart conversation, not just about the presenting complaint--social anxiety in your case--but also about the client's personal history, thoughts and feelings, goals in life, etc. And then, if my client did decide to begin the Zoloft experiment, that tryout of a substance which works by altering the chemistry of the brain would take place within the already well-established context of our psychotherapeutic alliance. I stress the word "experiment," because my attitude towards Zoloft and its sisters is this: no one can explain how or why they work,  and their effects are all over the map--good for some people, not for others; therefore, when employing one of these mind-altering agents, both doctor and patient ought to watch carefully for any and all changes, and be sensitive to what they see.

In doing this careful watching, the effects, if any, of Zoloft upon the client's anxiety would constitute only one possible observation among many. The client and I might also have to consider such a theme as the one you raised--how Zoloft might affect the client in accomplishing important goals in life: creativity in your case. And often such effects are not so easy to discern. They are not just gross side effects like weight gain, or grogginess, which any family practitioner should be able to discuss with the patient, but delicate, subtle distinctions between one psychic state and another. Making such distinctions requires both time for extended conversation--a rarity, apparently, among physicians in twenty-first century practice--and also the listening skills, and awareness of psychological nuance--also not common among physicians--which are the hallmarks of the competent psychotherapist.

Furthermore, in my experience, many family practitioners seem far too eager to prescribe medications. These days the most common transaction between family practitioner and patient looks like this: the patient comes with a complaint, and after a very brief conversation, and a short examination by the doctor, leaves with a prescription in hand. Indeed, some of my M.D. friends have told me that the patient would not leave satisfied unless having been given a prescription--some kind of prescription--by the doctor. In other words, good advice without a prescription would not be acceptable. And the majority of those prescriptions are for substances that do not work to heal disease anyway, but only to alleviate symptoms. So, unfortunately, many family doctors these days are largely in the business of hearing complaints and prescribing medications, even if the patient does not need them, and even if what is really needed is a change in conduct, and not a prescription at all.  And they are encouraged and abetted in this behavior by the drug companies which push their products aggressively by means of expensive advertising aimed at doctors, by means of free samples which then are passed out to patients, by means of promotional activities such as golf tournaments, vacation junkets, by means of all kinds of gifts sent to doctors' offices, and even by means of direct cash rebates to those same docs.

Anyone who has tried to watch the evening news on American is familiar with the amazing glut of drug advertising aimed at encouraging consumers to recognize diseases they didn't even know they had, and training them to demand the "little purple pill," or whatever is the flavor of the month, from their doctors.

The incentives are all in the wrong direction. The doctor feels coerced from both sides to be a script-writer--the patient demanding relief from symptoms and the corporation which is in the business of pushing drugs upon the public--and the doctor has no real interest in resisting this unfortunate pressure to misuse the pharmacopeia.

That said, let me get to the gist of your question. If I have it right, you are not depressed, nor have you ever been. And, although you do see yourself as a shy person, you have made a good adjustment to your shyness, and feel OK with it. You consulted your doctor about some sinus pains and other complaints--nothing really serious--and after four ten minute consultations she has diagnosed your physical complaints as psychosomatic, believes that they are the somatization of your social anxiety, and believes that medicating the anxiety with Zoloft is the best course of treatment.

This is the kind of pattern to which I referred earlier. A patient presents a complaint, is heard very little, and leaves with a script. Sometimes, this style of treatment is not entirely inappropriate. For example, a patient presents with a sore throat, and is the tenth patient that week with the same complaint. The doctor already knows which antibiotic is effective, and simply prescribes it. OK. But in a case like yours, I have no respect at all for such an approach. When the etiology (causal factors) of an ailment are far from obvious, such as in your case, better doctoring, in my opinion, would at least require taking a full medical history, hearing also about your personal habits, and certainly taking time to hear in detail about your anxiety if that really is the problem.

Now you say that you do not want to disappoint your doctor, but I recommend that you abandon that priority completely, and simply concentrate on what would best serve you, and which parts of her advice, if any, you choose to follow. You should respect and take care of the doctor by paying her, not by swallowing her advice whole and undigested as if her opinion were beyond question. I imagine that really you already know this, otherwise you would not have written to me.

So, since you have written asking for advice, here it is: now that your doctor has ruled out physical causes for your pains, and therefore concludes that your pains are "psychosomatic"--that the pains are, in other words, a physical expression of the emotional pain of your social anxiety--she has reached the limit of her competence. In other words, if social anxiety really is the cause of your aches and pains, it now is time to consult an expert on treating social anxiety, which is not your doctor.

You said that her attitude seemed peculiar, and I agree. The idea that everyone should be striving for "normalcy," I find bizarre. Personally, I do not root for normalcy, especially not for chemically induced normalcy, and, truthfully, I don't even know what normalcy is. Let me give an example:

Lately, millions of American children are routinely medicated, often from a very young age, with Adderall, a powerful central nervous system stimulant. Although Adderall is known to produce serious side effects such as tremor, restlessness, hallucinations, unusual behavior, motor tics, severe headache, blurred vision, trouble concentrating, chest pain, numbness, seizure, and even sudden death, the children are put on daily doses of this stuff after a diagnosis of attention-deficit hyperactivity disorder, which really is a fancy way of saying that they have trouble concentrating and may seem more restless than "normal." Almost always, these children come to the attention of physicians in the first place because a teacher complains that little Johnny is disrupting the class, and threatens to expel him if he does not settle down. Typically, the teacher, without benefit of psychology training, already has made a "diagnosis," and, with no medical training either, suggests medication as the treatment. Sometimes the "suggestion" is put in very strong terms. In other words, little Johnny is not "normal," and must be medicated so that he can be normal and not disrupt the program.

But what is "normal" about expecting a seven year old to sit quietly for hours in a schoolroom? After all, even if his restlessness inconveniences little Johnny's teacher, in the hunter-gatherer milieu of our ancestors, the environment in which our human brains and primate bodies evolved, so-called "hyperactivity" might have been an asset, on a hunt perhaps--I suppose it must have been useful somehow since it survives into our time--but its opposite, passivity, while it also survives and so must have been valuable in other ways, won't come to the attention of the teacher, and so it, passivity, would seem "normal,"--not inconvenient for the teacher, that is--in the atmosphere of the modern classroom. In other words, let us not confuse "normal" with "good." Once that happens instead of just being sold conformity, or coerced into it politically, we will end up medicated into conformity, a conformity, by the way, not to anything necessarily "good," but just a tranquilized, passive obedience to the demands of the dominant cultural surround.

Now I am not saying that ADHD does not exist, or that Adderall has no use whatsoever, but certainly I am skeptical. Indeed, I am skeptical about all diagnois/treatment scenarios where no one knows if the alleged "disorder" is rooted, in one any particular child, in something neurological or something behavioral or some combination of those. In such circumstances, I always advise delaying medication, and saving it as a very last resort. And I worry that conflating the behavioral with the neurological, as now seems almost routine, discourages trying to understand seemingly inconvenient behaviors as inconvenient to us perhaps, but possibly not at all inconvenient to the child. With that understanding chances are good that some workaround will be found, some middle ground. Without it, the pressures are all towards finding a diagnois, and quick, so that, now having been offically labeled and pigeonholed as a disorder, medication of the child's symptoms is not only advisable, it has become, for all intents and purposes, manditory. And it troubles me greatly to think about all those young, undeveloped brains being bathed constantly in a mixture of powerful and addictive amphetamines, which everyone really knows cannot be good for them, when perhaps the strongest motive for such medication is the teacher's inability, for whatever reason, to deal with the child's behavior combined with the, in my view, foolish notion that one method of education should and must work for all kinds of children.

Now sometimes medication is called for. For example, in a case of frank psychosis, when the patient is losing touch with consensual reality, anti-psychotic drugs, although they have some terrible side effects, may be the only way to prevent the patient from being cut off from any meaningful human contact at all. I explained this in my reply to a question about how to treat formal thought disorder. But in ordinary practice, when psychosis is not the problem, my aim for my clients--and for myself as well--is not that one attain "normalcy," whatever that is, but that one's deeper agenda, one's destiny, one's most authentic "self" (as distinguished from one's persona, one's social self), find proper recognition, expression, and fulfillment.

Not to put too fine a point on it, in my view, your doctor's idea that everyone who is not "normal" should be medicated into normalcy is just spooky. But even more outrageous, in my opinion, is her belief that there is no difference between Zoloft and insulin. In truth, except for the fact that your doctor is legally empowered to write a prescription for either one of them, there is all the difference in the world, and that difference ought to be obvious to any physician. Diabetes, an ailment with a well-known and well-understood physical basis, results when the body cannot produce sufficient insulin to cope with the carbohydrate intake of the patient. The treatment is twofold: add synthetic insulin to the bloodstream when needed, and counsel the patient about controlling diet so as to require less insulin. That scenario cannot (and certainly should not) be equated with treating social anxiety, which has no known cause, and which has no magic bullet treatment like diabetes (proper diet plus insulin provide relief) or strep throat (rest and antibiotics allow recuperation). Your doc is confusing apples and oranges here. And, as I recall, your presenting complaint was not social anxiety anyway, but sinus pains, so your doc's idea, to me, seems even that much more far fetched.

This is not to say that anxiety is never expressed in such physical manifestations as facial pain, nor is it to say that part of the treatment for such pain would never include the use of Zoloft. All of that is possible, but if Zoloft were to be prescribed--and that, based on what you have written, seems to me already possibly a bridge too far--the Zoloft would be only a part of the treatment, which should, in my professional opinion, be based primarily in psychotherapy aimed at unpacking and exploring the deeper thoughts and feelings connected with anxiety. In other words, Zoloft might help you to feel better, and it might not (it could even make you feel much worse, as I have observed in my practice), but speaking with a competent therapist about the depths of your fears and anxieties--along with your needs for creative fulfillment, and many other details of your personal experience--almost certainly would help you to better to preceive, understand, and even to value your feelings, including anxiety. And that increased understanding would then, in my opinion, provide a proper foundation for experiments with mind-altering chemicals should that even be indicated.

Regarding your question about whether creativity is reduced by Zoloft, I find no easy answer. After all, what is creativity? It cannot be measured, and seems, most of all, to be a matter of opinion, or, that is to say, of private experience. Certainly "creativity" must be something different from merely coming up with an idea and finding ways to carry it out. I recall one day gazing out upon a beautifully unspoiled meadow as I conversed with another guest at the country home I was visiting. This fellow, a real estate developer, was waxing enthusiastic about his scheme to construct a "planned community" in the meadow, which prospect saddened me more and more as his, in my estimation, ugly ideas emerged in detail. Earlier in the day I had walked amidst that exquisiteness, heard the songs of cardinals and heard their reiteration by mockingbirds. I'd seen foxes running, and, with a stem of grass in my mouth, followed butterflies. It seemed a terrible loss. Then the developer, holding forth with evident pride and self-satisfaction, wound up his spectacle of shameless self-promotion, saying, "Yes, I have always been a creative person, an artist, and this land is my next canvas."

Be well.

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