How long has it been for you?

Thank you for your reply. I see a counsellor whenever I can (albeit not as often as I would like due to the cost). I spent some time on sertraline back in 2021 (dosage starting at 50mg and increasing to 100mg) but I'm not convinced it helped and I came off medication. It seems to numb you, but without addressing the actual problem.

Things were at their worst in 2021, I improved slightly over the course of 2022 and 2023 but the last 3 months have been particularly challenging and I've had a return of certain symptoms (hyperventilation) that I thought had stopped ages ago.

Thank you for your reply. I certainly understand your comment regarding counseling and would share with you here that therapy in that regard rarely meets with success in the abatement of your particular difficulty. I am presuming by portions of your response that you suffer from Panic Disorder and the unexpected panic events that accompany it. I'd like to explain this in further detail, but would preface it with some discussion about Sertraline as one medication among SSRIs in general.

The target of SSRI efficacy is to increase the circulation of the neurotransmitter serotonin by blocking its reuptake. This specific neurotransmitter is generally upregulates the nervous system to improve mood, it is best suited in the treatment of unipolar depression. Its use in treatment of anxiety disorders, particularly Panic Disorder, most typically produces mixed effects and more often results in either no impact upon anxiety or alternatively a paradoxical reaction in the context of accentuation of the features of anxiety and panic events. Additionally, the side-effect profile of SSRI medications are variable and blunted sensory effects is among common complaints.

While benzodiazepines remain the class of drugs truly capable of literally preventing Panic Disorder and staving off general anxiety, they were moved to Class IV controlled substance due to the immense increase in recreational use, together with the addiction potential of the short-acting benzodiazepines. Thus, their access is most typically through psychiatry, where these specialists possess the greatest knowledge and familiarity with this class of drugs, their use and regular evaluation to avoid dependency characteristics.

Clonazepam, in particular, is the actual drug of choice in treatment of Panic Disorder and despite rhetoric damaging to its reputation, has an excellent safety profile and very low addiction potential.

I expound upon the above information because pharmaceutical companies rushed to fill the gap in the wake of benzodiazepine re-classification and restriction in the hopes of capturing a larger market. The problem is that SSRIs and SNRIs demonstrate a data profile riddled with mixed results that, very frankly, are telltale signs of ineffectiveness with respect to Panic Disorder and generalized anxiety.

It might also be of considerable interest to you that the most common origin of Panic Disorder is intense separation anxiety in young childhood. In those early years, children with significant attachment to parental figures typically become withdrawn when first entering the social environment often encountered in compulsory primary education. These children tend to isolate themselves, feel distant from others and work to avoid attention drawn to themselves. It is a pattern that can prevail throughout school years and many times penetrate adult life as well.

Separation anxiety also undergoes transformation from the patterns experienced in childhood years and as older teens and adults, these persons tend to feel somewhat apart from mainstream society in that they engage in limited social settings thought to be most comfortable and generally sense that a fundamental basis of insecurity prevents them from achieving what they know to be their fullest potential. In other words, while the anxiety is present in adulthood it is seldom directly associated with separation characteristics. This profile varies among those afflicted and aside from separation anxiety, Panic Disorder can also arise from other significant traumatic events.

Panic Disorder itself is more purely a catecholamine response in the context of fight-or-flight response that is innate in origin. Changes in physiology during the response are misinterpreted as symptoms of an impending serious health event that subsequently manifests generalized health anxiety in many but not all instances. Vigilance is also a response to fight-or-flight that tends to result in more of an inward rather than outward focus due to irrational health concerns.

Hyperventilation arises from prolonged increase in respiration that is also a normal consequence of fight-or-flight. CO2 blood gas imbalance actually creates a cyclic premise where the increase in blood gas imbalance creates greater fear, resulting in even greater hyperventilation and so on. There is also a driving need to flee to safety and this is again, a common feature of fight-or-flight, more commonly term panic event. In the absence of effective treatment, panic events can occur regularly without warning and vacillate between milder and more intense panic responses. Remember that persons with generalized anxiety tend to engage in shallow breathing without awareness. If persistent, it will very gradually impose changes to blood gas balance and produce a sensation that a deep inspiratory breath is difficult, which serves to increase respiration and subsequently result in hyperventilation.

I can share with you that in my forty years of practice, I never once observed or read report of even a single person suffering a significant or catastrophic event as a consequence of panic disorder, despite common feelings among those with the disorder who sense overwhelming impending doom. In actuality, the events are entirely incapable of causing physical harm of any kind. This is an aspect of reassurance that many sufferers nevertheless have difficulty accepting because of the fact that their fears lie within the realm of irrationality.

As in your own instance, full-blown symptomatic features of panic events tend to dissipate in adulthood and become limited to more specific features such as spikes in blood pressure, gastrointestinal discomfort and dysfunction, globus pharyngeous or a sense of something in the throat, tremulousness, chest discomfort, variable physical unexplained pain, frequent urination, increased heart rate and/or heart palpitations, irrational rumination, general feelings of illness and other symptoms. The relentless nature of anxiety and panic events can greatly diminish one's outlook as well and it becomes difficult to engage one's social or family life with the requisite enthusiasm. The tendency to withdraw to some degree is common but ironically serves to accentuate inward focus upon the circumstances viewed as an inescapable difficulty.

My suggestion to you would to discuss several options with your doctor. One is the prospect of using beta-blockers, particularly metoprolol ER or propranolol. Both of these drugs are on-label antihypertensive agents but also impart an anxiolytic effect that is sometimes sufficient to suppress anxiety. This choice is primarily dependent upon your baseline blood pressure. If it tends to be slightly elevated, then it would be an appropriate choice but if you already have normal to low blood pressure, it's less desirable.

Gabapentin would also constitute another non-benzodiazepine class drug that can offset panic events and anxiety. The reason is that persons with anxiety and Panic Disorder have demonstrated low levels of GABA, or gamma-aminobutyric acid, that imparts a down-regulation of the nervous system and thus a calming effect. While this observation has brought more recent question to whether GABA is a causal factor, persons increasing their levels of GABA do experience relief.

With final discussion of medications, I can emphatically tell you that SSRI treatment does not stop panic disorder or generalized anxiety and in some instances either makes it worse or demonstrates unacceptable side-effects.

In all instances of the medications mentioned as potential alternatives, it's important to start at a low-dose regimen and gradually titrate upward through your doctor until the best effect is observed with the least side-effects.

I will stop here and hope that the information provided will give you a renewed sense toward seeking relief from your symptoms and a more informed position regarding the nature of your difficulty.

Best regards

Hi

Thank you, your message was incredibly thought provoking and useful.

I never thought of myself as having childhood separation anxiety but parts of what you describe resonated strongly with me - I was a very shy, introverted child who always avoided social situations and in part that has continued into adulthood.

You are also spot on about the physical symptoms - I have (periodically) random chest pains, strange sensations in my throat, pain/spasms to my oesophagus area etc.

Could I ask a few questions?

I do feel depressed as well as anxious (quite often at the moment) - is this just another manifestation of my anxiety?

Is panic disorder different to generalised anxiety disorder? Would your advice differ between each condition?

Finally, and most importantly - you suggest that therapy/counselling does not help with anxiety disorders very much. In your view, is medication the only viable way to get better?

Thank you so much for your time.

Hello again.

"I never thought of myself as having childhood separation anxiety."

This response is quite common and it's important to realize that your perspective in that regard is viewed through the lens of retrospect from adulthood back to your childhood forward. Children who experience intense separation anxiety are only able to discern the subsequent impact and not the actual cause. Thus, the impact and to variable degree their persistence to variable degrees throughout adulthood are the factors that constitute initial separation anxiety.

In other words, there is seldom any direct parallel between the initial onset and its subsequent impact. This is true of many conditions.

Regarding depression, I would need to know more specifically what patterns you both feel and respond to in order to determine whether actual clinical depression is a consideration. The most salient features expressed by persons with clinical depression, that can indeed co-exist with generalized anxiety disorder, are constant negative rumination regarding life in general as well as specific issues that reflect sentiments of failure, inadequacy or other self-depreciation. Anhedonia, or the loss of interest or participation of activities that once brought satisfaction and enthusiasm, is a regular manifestation. Irritability or even anger that has no warranted basis.

Changes in personal hygiene, orderliness of your immediate personal environment and/or diminished efforts regarding one's appearance, general diminished outlook on life, tendencies to remain in bed or retreat to one's bed pursuant to feeling listless and lacking energy to engage normal social exchange, adoption of patterns that produce isolation only to ruminate about loneliness and a separation from normal lifestyle patterns.

Generally, the above description would constitute the presence of clinical depression. Some of these patterns can exist purely as a consequence of protracted anxiety conditions that often foster feelings of hopelessness, it is careful evaluation that makes for a clear distinction because there is anxiety-depression disorder that tends to be aimed specifically toward individuals who demonstrate rather equal patterns and impact of both anxiety and depression rather any predominance of either that would be better explained through a single clinical diagnosis.

Panic Disorder is set apart from generalized anxiety disorder and I mentioned in my response because hyperventilation episodes are more part of the constellation of symptoms associated with Panic Disorder than generalized anxiety disorder. With generalized anxiety disorder, it more constitutes a predominant state of mind that demonstrates what could be described by individuals as a persistent state of situational anxiety that rather than a focus upon any specific target, is free-floating and in the absence of a particular issue but instead daily life in general.

Panic Disorder, is the development of irrational fears associated with exceptional thoughts and sensations of impending doom wherein the specific identity of the source of this danger is unknown. It results in the engagement of the instinctual fight-or-flight response, a series of physiological changes that best prepare the body to either stand and fend off the threat or otherwise flee from it. The distinction with pathogenic fight-or-flight response from that which is warranted under certain circumstances is that the pathogenic form is entirely irrational because the impending threat is unreal, whereas in true warranted instances of fight-or-flight response the threat is clearly present.

Panic Disorder is associated purely with the pathogenic fight-or-flight response due to irrational beliefs and the subsequent physiological changes are misinterpreted as symptoms of a health crisis that serves to intensify the physiological manifestations of fight-or-flight. These physical changes are commonly, but not exclusively, presented as elevated heart rate and blood pressure, increased respiration rate, heightened awareness of the senses, globus pharengeous (lump in the throat), increased norepinephrine (adrenalin), perspiration, cognitive vigilance among other features that prepare the body for fight or flight. Since an actual threat is not present, however, these sensations that are misinterpreted as some type of health crisis can often mistakenly become the source of the threat. Subsequently, health concerns become predominant and engage a constant search via the healthcare environment to discover the underlying cause deemed to potentially be life-threatening.

Panic Disorder can be very debilitating to the extent that it often produces agoraphobia to variable degrees. Again, this disorder was mentioned because generalized anxiety rarely produces hyperventilation and globus pharangeous, but more often muscle tension and associated headaches, tendonitis, bruxism (grinding of the teeth), tempromandibular Joint dysfunction and other physical manifestations common to constant influence regarding anxiety and its relevant aspects of chronic tension.

Regarding psychotherapy, I'd make clarification here. The use of psychotherapy with many cognitive disorders, inclusive of generalized anxiety disorder, can indeed be successful. This type of therapy plays a very primary role in helping people discover a path of return to normal life patterns and it is often employed as adjunctive therapy to pharmaceutical intervention as well.

Panic Disorder, however, is more of a physical issue than a cognitive one and despite intervention with various types of psychotherapeutic intervention, Panic Disorder remains unaffected by such a practice. To employ an analogy, it would be the equivalent of using cognitive therapy to treat an infection. In the context of Panic Disorder, merely because this particular disorder causes temporary change in normal cognitive patterns as part of the fight-or-flight response, does not indicate that cognitive therapy is an appropriate form of treatment to impact Panic Disorder in any manner. Furthermore, even in instances where fear of subsequent panic attacks arises as a pattern of thought in persons with Panic Disorder does not mean that these thought patterns can be influenced by psychotherapeutic intervention.

The source of Panic Disorder has its origins far more in the physical realm than cognitive realm and fight-or-flight response is an instinct that is incapable of being extinguished by cognitive therapy. Pharmaceutical intervention effectively suppresses the ability for Panic Disorder to manifest and thus eliminates the fear associated with its unpredictable nature. Thus, a pharmaceutical approach is most favored with regard to this particular disorder. In other words, merely because there are cognitive aspects associated with Panic Disorder does not establish the means whereby cognitive therapy is effective.

Lastly, the entirety of my discussion with you does not actually constitute medical advice, but rather merely medical information that you may electively choose at your discretion to discuss with your doctor or therapist. I am of the firmest opinion that while the internet is an excellent resource for reassurance through connection with others experiencing similar circumstances, it is the absolute worst resource for medical advice. My presence on this forum is purely in the context of offering relevant medical information and suggestions that should never supplant the direct evaluation, consultation or treatment by your primary care physician or specialists. In the context mentioned above, I am more than glad to offer my time in helping anyone experiencing difficulty.

Best regards