My Treatment Proposal Was Approved By My New Psychiatrist!

I self-referred to the Rapid Access Clinic at Burnaby Hospital Mental Health and Addictions Services in July 2015. Your file remains open for six months after which another self-referral is necessary. By December of that year I called Burnaby Mental Health to make an appointment with one of their psychiatrists because the treatment recommendations were not working for me. On the phone while attempting to arrange an appointment, I was told that my file was closed. I checked the dates of my referral and knew for a fact that the six month period had not yet elapsed but still my file was closed. I was forced to re-refer myself. 

My referral went through in January but it wasn’t until June 29th that I received an appointment. Rapid Access is a misnomer. Then, a couple of weeks before the June appointment, I received a call to reschedule for July 8th. I was fed up by this point and barely hanging on. My anxiety shot up, panic attacks increased, my agoraphobia worsening by the day that I feared I would not be able to make it to the appointment. It was only through being heavily medicated with benzodiazepines and the support of my mom that I succeeded in driving the seven and a half kilometres to Burnaby Hospital. 

I have been a patient at Burnaby Hospital Mental Health on and off for years. Dr. Paul Waraich is the psychiatrist I usually saw. When I called to confirm the date and time of my appointment, I was told that I wasn’t in the books. The lady on the phone checked the schedules of the other psychiatrists there and said I would be seeing someone else. I misheard her and thought I would be seeing Dr. Jerome Lee. The night before my appointment, I was having trouble falling asleep and so I looked up Dr. Lee online. I was horrified to learn that he was the doctor who had treated Eddie Young. I didn’t know Eddie personally but learned after his suicide that he was the cousin of a former tenant. Not only that, I also learned that he was being investigated by the BC Coroner’s Office in the death of Eddie Young. There was also mention about a sexual harassment suit against him. Unfounded or not, these charges made me anxious. 

Somehow, I managed to fall asleep in the early hours of the morning of July 8th and when I got to my appointment, I learned I would not be seeing Dr. Lee but Dr. Ronsley instead. Luckily, it turned out Dr. Ronsley was just the kind of psychiatrist I was hoping for. He listened to me without rushing me. He asked a lot of questions, took a lot of notes and read the proposal I had written in which I asked for a specific treatment plan that I believed I needed in order to overcome my panic disorder and agoraphobia. 

And he agreed! I was so elated and finally felt like I was on the right track. Now, together with Dr. Ronsley and my family doctor, the three of us are working together in treating me. I feel hopeful for the first time in years and I am very aware of how lucky I am to have found doctors willing to listen and work with me. 

I know the mental health system is broken here in BC as I’ve been a patient for the last sixteen years. When I first began accessing mental health services back in 2000 as a minor, I found the system easily accessible and fast. But once I aged out, things changed. The resources for adults were fewer and harder to access. Whether that was due to changes within the system or differences in available resources for adults versus children and youth, I can’t be sure. What I am sure of is that for adults with mental health issues, services are severely lacking, especially in smaller communities on the island and here on the mainland. 

I can’t help but feel utter sympathy for the countless people trying desperately to access services they need and failing. That it takes months to even access a service, to me, is a human rights violation. The only advice I can offer is don't give up. Demand access to services. It's your right. Call the many non-profit organizations and ask to speak to mental health advocates; many have them on staff or as volunteers. Contact the media. Raise a fuss. Otherwise, nothing will change.

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Remeron and Effexor Together (Mirtazapine & Venlafaxine)

Mirtazapine 15mg Image by Garzfoth

My new psychiatrist thought it a good idea to try adding Remeron (Mirtazapine) to my current meds (Effexor and Klonopin) but I had to lower the dose of Effexor from 225mg to 150mg and only start with half a tablet of Remeron. The lowest pill form is 15mg so I split it in half and took 7.5mg at night, which really helped with my insomnia.

Since both Effexor and Remeron are antidepressants there is always a chance, though rare, of Serotonin Syndrome, a potentially deadly drug interaction. And hence the lower dose of Effexor. I've tried Effexor with other drugs in the same class and never experienced any negative symptoms.

I've been on this new cocktail (150mg Effexor, 7.5mg Remeron, 0.5mg Klonopin) for a few weeks now and I definitely felt better on 225mg Effexor and 0.5 Klonopin. I can't say whether Remeron is working or not for my depression/anxiety because I'm on such a low dose and because I know that 150mg of Effexor does not work for me. I've lowered it before and felt my depression worsen.

I've googled this combo and some people swear by taking both and they're at an even higher dose of both drugs than me. Some at 262.5mg - 300mg Effexor and 15mg-45mg of Remeron. I think the dosage caps depend on the country you're in and/or which form of the drug you're taking, ie. XR.

I'm not sure what to do. Up the Effexor and stay on the low dose of Remeron? Ever since I lowered the dose of Effexor and added Remeron, I've felt as if the Klonopin wasn't working at all. It worked wonderfully before I decreased Effexor and started Remeron.

This combo is not working for me so I'll contact my doctor as soon as possible to see if I can up my Effexor to my original therapeutic dose.

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Treatment Proposal: Getting the Treatment YOU Want

I feel so light today--not because I'm flying high on benzo's--because I finally feel the weight of desperation, frustration, hopelessness, depression, suicidal ideation, anxiety and panic lifting. I can't even recall the last time I felt, for lack of a better term, normal. Like I could cope with life and enjoy waking up in the morning to face the day.

Ever since I was first diagnosed with GAD and Panic Disorder sixteen years ago at the age of sixteen, I have felt at the mercy of this disorder and more than that at the mercy of family physicians, psychologists, psychiatrists and therapists and social workers. Everybody to an extent had their own opinions about what I needed to do to get better, to cope.

Well, finally I had had enough. I was paralyzed with anxiety and my agoraphobia severely restricted my movements. I was in a catch-22 as I could not physically get to group or one-on-one therapy which I desperately needed in order to get over my agoraphobia.

I knew exactly what I needed to get better and so I wrote out a treatment plan and presented it to my psychiatrist. And it worked. Be firm. Stand up for yourself. I was ready to be shot down by my psychiatrist and had that been the case, I would have moved on to someone else until I got what I wanted.

Since Blogger won't let me upload a word doc or pdf file, I will post my Treatment Plan below as an example. I tend to go on and on, lol. Your letter does not need to be as long.

_________________________________________________________________________________

Treatment Proposal 

Prepared for: Dr. R******

Prepared by: Sonja J*****

Date: June 11, 2016 

Objective 

To minimize anxiety and panic attack symptoms as to allow me to fully commit to group therapy and exposure therapy. 

Proposal 

Clonazepam 0.25mg per day for three to six months in conjunction with CBT, exposure therapy and mindfulness meditation. 

Rationale 

Since the December 2015, as an adjunct to my current meds (Effexor 225mg and Quetiapine 50mg) I have first tried Escitalopram, which worked for barely a week before it suddenly stopped. Then I tried Buspar and that had no effect whatsover. Finally, I tried adding Prozac. The side effects were immediate but I stuck it out for nearly two months without any noticeable effects. 

Besides these three medications, I have, through the years, tried almost every antideppressant out there, including tricyclic antidepressants, tetracyclic antidepressants, atypical antipsychotics and even an anticonvulsant. None of these helped with my anxiety and panic attacks, not to mention my agoraphobia. 

Recently, I have tapered off Quetiapine and have replaced it with Amitriptyline 25mg for my insomnia. The only other medication that I am currently taking is Effexor 225mg per day, which only works for my depression. I know this because I twice went off Effexor thinking that it did nothing for me only to have my depressive symptoms return. Once I was back on it at my usual dosage of 225mg, the depressive symptoms ceased. 

At this point, I am wary of trying any antidepressants for my anxiety as I have no hope that these drugs will have any effect on my severe anxiety. The only medications that work for my anxiety, panic attacks and agoraphobia are anxiolytics. 

Having said that, my proposal to you is to prescribe me a very low dose of Clonazzepam (0.25mg/day) for a short period of time, two to three months. This would allow me to immediately commence group therapy here at Burnaby Hospital Mental Health. It would also allow me to start exposure therapy as well as mindfulness meditation. I believe that the reason I have not been successful with the above therapies is because my anxiety is severe. I am unable to concentrate on anything, I have trouble sleeping, feel restless most days, have difficulty eating due to constant nausea. 

I need something to take the edge off. Just a little so that I can think straight and concentrate on my therapies. Every time I try exposure therapy, I panic. My body feels disconnected from my rational brain and before I can even try to calm myself down, my legs are spiriting me away from the “threatening” situation. The terrifying thoughts come so fast and with such conviction that my body just reacts and I flee. In that moment it’s impossible—or at least feels that way—to stop and think rationally. I don’t know what to do anymore. 

For the last few weeks I have felt hopeless about the future, hopeless about ever being able to cope with my disorder and have felt an almost complete lack of motivation to even try as my anxiety just keeps getting worse. But I’ve been fighting it every single day. I am certain that I would greatly benefit from a small dose of Clonazepam. About a month ago Dr. Brar, my family physician, prescribed me 0.25mg for a few days because I was overwhelmed by intense anxiety and it helped me so much. I was able to concentrate again, to sleep soundly and a sense of hopefulness returned that I haven’t felt in almost sixteen years on antidepressants and antipsychotics. 

Exposure sessions build on each other. One session every week or so doesn’t do much good in the long run but that is all I have the energy for right now. I am hoping to make exposure a daily practice and Clonazepam would make that possible. After a while I will have the necessaty skills and confidence to continue exposure and other therapies without the use of a benzodiazepine. 

Conclusion

For me, the benefits far outweigh the potential risks of benzodiazepine use. I have never abused drugs, prescription or otherwise. I have take Ativan on an as needed basis for years without problems. But Ativan is only effective in emergencies and that’s how I take it. Clonazepam, on the other hand, is longer acting and works much better for my severe anxiety. Being able to take a low dose for a couple of months would give me the opportunity to fully commit and carry out a variety of therapies that in combination will help me to regain a sense of control over my anxiety and allow me to cope again. 

I have tried exposure therapy many times but it just does not work when my anxiety level is so severe. After exposure sessions I would feel so mentally and emotionally exhausted that I lacked the energy, strength and motivation to try again. 

In case you are worried about me being able to come off Clonazepam, that will not be a problem. I was on Ativan 2mg a day for months and I had no difficulty tapering off. It is not my intention to stay on benzos for the rest of my life. All I am asking for is a low dose on a short term basis to help me kick start exposure and cognitive behaviour therapy. 

Thank you for considering my proposal. 

Sincerely, 

Sonja J*****

_________________________________________________________________________________

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Insomnia

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Done With Amitriptyline

I gave it a second shot but it didn't do shit for me, except making me dizzy every day, more anxious, increased my panic attacks, killed my appetite and made it ridiculously difficult to piss.

At 50mg with the above side effects and hardly helpful for my insomnia, I reduced the dose to 25mg the day before yesterday and simply stopped at that. I took 2mg of Ativan the next night, slept great, felt normal and had no withdrawal. Which is odd given that seven years ago while trying to come off 10mg, I experienced withdrawal symptoms. They didn't last long, maybe two days. Seven years later at 5X the dose, no withdrawal? Perhaps, the length of time on it--only a couple of months this time--is why.

That's the only positive. I'm glad I'm off it. Now if I could just stop being so suggestible, neurotic and paranoid and learn to trust my own gut feeling instead of always acquiescing to the suggestions and opinions of 'experts.'

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Rethinking Amitriptyline

I've given amitriptyline two chances now. I even upped my dose to 50mg at night for insomnia. While I do eventually fall asleep, I tend to sleep too much and then feel out of it for a while and then the dizziness hits in the evenings.

I've also started experiencing headaches and feel on edge, very anxious without reason. I can feel a panic attack coming. This is unusual for me because 99% of the time I know why I am anxious and what causes me to panic. It's rare that it comes out of left field.

I've also been feeling more depressed but I'm not sure if that's related to this med.

I'm tapering it tonight. I just took 25mg instead of 50mg and I'll see how I react to the dosage decrease.

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Exposure Therapy For Agoraphobia

Image via SlideShare

What is Exposure Therapy?

Exposure therapy is a technique used in treating anxiety disorders by exposing patients to feared situations or objects until the fear is extinguished.

What is Agoraphobia?

The literal meaning of the word is fear of the marketplace or open spaces but in the context of an anxiety disorder, this definition falls short.

Agoraphobia is a fear of experiencing a panic attack in places or situations from which escape might be difficult or socially embarrassing. (Stuck in traffic, driving over a bridge or through a tunnel, crowded theatre, etc.)

At their core, agoraphobics fear feeling trapped, helpless and/or exposed to public scrutiny.

Exposure therapy for agoraphobia is a little different from exposure therapy for PTSD or specific phobias. Since the root of the problem is essentially a fear of panic attacks, exposing the patient to feared situations will not work.

"The agoraphobic is afraid of the upsetting physical feelings he feels within himself when in certain situations. He must be taught to cope with these and not with a situation, otherwise he may manage one dreaded situation after another only to panic in a new one."

The above quote is taken from Dr. Claire Weekes' book Simple, Effective Treatment of Agoraphobia, published decades ago but in my mind the best and clearest explanation of what agoraphobia is and how to overcome it. That's not to say that it's easy. It's simple but difficult. You have to pass through panic. Not fight it or simply bear it until it passes. In Dr. Weekes' words, "[i]t is essential that the patient be taught how to cope with panic." The fear that fuels agoraphobia is the belief that you cannot cope when panic strikes.

Sensitized panic rarely vanishes by simply ceasing to come. It goes only when the panic is taken out of panic; that is, by the patient’s seeing panic through the right way so often, without adding second-fear, that eventually panic loses so much of its fire that the remainder no longer matters.

When I first read this book I couldn't believe that someone who had never experienced agoraphobia could write such a spot on book. I think it's fair to say that among agoraphobics, Dr. Weekes is regarded as a godsend for her clear and simple explanation of a bewildering anxiety disorder. 

I believe the book is out of print now and copies are not readily available. My local library had some of her other books, which are worth checking out, but didn't carry this particular one. I searched online and bought an old paperback from eBay, if memory serves. I haven't been able to find digital editions of it but physical copies are still available on Amazon. Shop around if money is an issue. There are some charging exorbitant prices, in my humble opinion. On Amazon.ca a paperback will run you about $8 CAD. 

These prices are beyond fucking ridiculous. I wouldn't pay this much for the first edition of Wuthering Heights. Ok, I probably would. But only because it's my all time favourite book.

At only 135 pages, the book is slim but packed with information. A second and possibly third reading is a must in order to process everything. At least for me. It's a lot of information to take in for a person suffering from panic attacks and agoraphobia. I once read a review where a reader stated that every time he read the book, he got something new out of it. 

In my next post, I'll talk about two key concepts--First Fear and Second Fear--that I found incredibly helpful and eye-opening. Concepts that I haven't come across in other more recent books.

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