Mental medicine

Prescriptions and divorces are granted freely, but there are taboos against both.


Michael Alvear
August 5, 1999 8:00PM (UTC)

How do you notice the absence of something? When you're repeatedly hit on the head with a hammer and it suddenly stops, will you experience pleasure?

The absence of pain is different from the presence of pleasure. Luvox didn't
give me any pleasure. It didn't change my personality or give me an "edge"
socially. It didn't make me more charming or outgoing. It didn't help me focus or concentrate better or do my work more effectively.

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What it did was escort the sisters of seizure out of the room. Out of the house, really. After a few weeks of 150 milligrams a day, most of my
physiological reactions were gone -- the air "hunger," the weak spells, the
panic attacks, the obsessive thinking.

I dropped out of therapy soon after my symptoms disappeared. I walked out the way I walked in -- without knowing what was wrong or what I needed to talk about. I had done with pills what I could not do with willpower, prayer, meditation, yoga or therapy.

As socially disapproved acts go, the decision to get on "mental medicine" is
on par with the decision to get divorced. Prescriptions and divorces are
granted freely, but there are widespread taboos against both. Divorcis and
patients get accused of not trying hard enough, of being quitters, of looking
for an easy way out. Both suffer for years before approaching the taboo's
threshold, and cross it after realizing the only other option is to keep suffering.

Doctors grant prescriptions for the same reason judges grant divorces -- to stop years of pain and suffering and allow the parties to build better lives.
Doctors and judges are the only ones to bear witness to the wrecked lives before them, but it is we who pass judgment. When a weight's been lifted off you, people complain you look too thin.

Critics believe SSRIs cauterize the pain and suffering fundamental to
personal growth. They dismiss Zoloft (a widely prescribed antidepressant)
as "Soul-off." It's a question I wrestled with constantly. In the rush to
relieve the pain, did I leave myself behind?

And never mind ordinary people like me, what happens to the extraordinary
when we pump them full of neurotransmitter regulators? What if genius,
madness and greatness are the products of biochemical imbalances? If Holden Caulfield had been given Prozac, would he have lost the orneriness, the implacability, the pain that made him a beloved hero for challenging society's hypocrisy?

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While I am still no fan of SSRIs, my stridency against them diminished in
proportion to their effectiveness. The truth is, Holden Caulfield would have
been in no danger of becoming a castrated critic of society. Most antidepressants don't change your personality. They don't make you feel better about things that should upset you. They lift the disabling weight of a disorder so you can feel the pain, pleasure, sorrow or joy appropriate to
the situation. Antidepressants as a prophylactic to life is pure "weed
theory" -- a theory growing through the cracks of inhospitable facts. There's nothing to support it, but the theory grows anyway.

Most people on SSRIs are as caught up in their emotions as the rest of the
world. But now, instead of crying for no apparent reason, SSRI users cry when
they're sad. Now, instead of their hearts racing without cause, their hearts pound away
when they're in danger. Now, instead of repeating endlessly, SSRI users' thoughts have a beginning, middle and end.

Luvox worked. And it worked without changing my personality. The real
issue with antidepressants isn't that they'll fundamentally change your
character. It's that you have to sacrifice so much to be on them. Critics
of the pill-popping nation rarely acknowledge what it takes to stay on a
regimen of antidepressants. Even doctors frame the side effects as minor
inconveniences. Like sex. Or rather the lack of it. Now there's a minor
inconvenience.

Sex on an SSRI is like copping a feel with an oven mitt. The drugs rob you
of the mood, then they rob you of the mode. You start off not wanting to and
you end up not being able to. And even when you are willing and able, it
still feels deadened, like there was a condom snapped tightly over your
brain stem, making sure pleasure didn't leak out.

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Involuntary teeth grinding is another common side effect. It wasn't unusual
for me to literally bite myself awake. Examining the blisters on the inside
of my lower lip, my doctor could only shrug and say it was a small price to pay
for the peace I was getting in return.

Luvox also robbed me of the pleasure of getting drunk. High crime or
misdemeanor, the light buzz of a glass of cabernet turned into a vague,
distasteful fogginess.

Critics are right about one thing -- getting on an antidepressant is easy.
What they don't tell you is that staying on it isn't. Nearly half of all
people taking SSRIs stop taking them within six months. This is a stunning
noncompliance rate. The easy way out is a lot harder than it looks. If the
pills are such an easy shortcut, why do people quit taking them?

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The high dropout rate speaks to fundamental questions about SSRIs: What are you willing to give up to have a "normal" life? Is it sex? Is it the
embarrassment of involuntary hand tremors? Is it a sound sleep? What
abnormality are you willing to take on for the hope of normality?

I lasted a little over a year on Luvox. I wanted out. Maybe I wanted sex
without the oven mitts, maybe I was tired of the sores in my mouth or maybe I was just in denial -- it had been so long since I'd had an anxiety attack, maybe I thought I was "cured." But mostly, I just couldn't get past the fact I was on "mental medicine."

My doctor tapered me off slowly, reducing the dosage by 25 milligrams every few weeks. I stepped up my meditations, prayers and yoga -- I knew I couldn't just get off the pills and hope for the best. I figured if I had a plan I'd be strong enough to manage without pills.

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I was wrong. The sisters of seizure rose slowly, rubbing their eyes from the
long sleep. It wasn't long before they brandished their pickaxes again.
Everything came back: the chest pains, the feelings of panic and dread, the
rapid breathing, the wrenching fear that I was going insane.

But the worst was my obsessive thinking about time. It gathered like a
squall. If I were balancing my checkbook, I'd stop in the middle to put
away some books, then I'd stop in the middle of that to write a letter, which
I'd interrupt to take on something else, all the while worried about what I
hadn't completed. I was consumed with the idea that I was running out of
time. I would stand in the shower, angry I wasn't soaping up fast enough.

My doctor wrote on his prescription pad and handed it to me. "I don't want
to get back on Luvox," I said, ignoring his hand. He pressed the slip of paper on me. "Call him," he said. "He specializes in anxiety
disorders, he's got an astonishing success rate and he does it without
medication."

Ponce de Leon Avenue is one of Atlanta's oddest streets. It's two lanes of
decaying southern elegance and urban blight yielding to an in-town revival.
Well, at least the symbolism is right, I remember thinking as I pulled up to Dr. Crowe's office.

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I stepped into a room whispered in earth tones. Chris Crowe is a towering
man, 6-foot-4, with twinkling blue eyes. He mitigated the threat of his height with a calm, soothing voice. Soon after we met he made a remark I'd never heard before from a psychologist: "We should be done in 12-15 sessions."

I immediately disliked him. I don't trust people who promise profound
changes in a short time. But his steady, dignified and scientific view of
what I was going through won me over -- that, and the fact that he described
every symptom I suffered better than I could.

Dr. Crowe is a cognitive-behavioral therapist. The term is an oxymoron,
juxtaposing two opposing views of psychology. Cognitive therapy was
developed by Aaron Beck in Philadelphia in the '60s. Its basic premise
is that misguided thoughts cause pathological anxiety. Change the thoughts,
reduce the anxiety. Cognitive therapy broke from traditional psychotherapy
by ignoring emotions and traumatic childhoods. It only cared about thoughts and beliefs.

Behavioral therapy, on the other hand, sneered at every school of psychology. It didn't care about thoughts, beliefs, insights or the unconscious. Founded by Russian physiologist Ivan Pavlov and American psychologist B.F. Skinner, behaviorism sees pathology as learned behavior. And, it posits, what is learned can be unlearned. A dog conditioned to salivate when a bell rings right before feeding can get unconditioned if the food no longer appears after the bell.
No one has to put the dog on the couch to identify underlying food issues.

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It's fairly remarkable that these two schools of thought, so radically
different from each other, have turned out to be so mutually dependent as a
treatment for anxiety disorder.

Though few studies have compared cognitive-behavioral therapy with medications, the existing data suggest parity. But medications are a hare to therapy's turtle. They provide faster relief, but they'll only get you to the finish line if you're
willing to refill prescriptions for the rest of your life. Stop the prescriptions and you stop the relief. Therapy, on the other hand, seems to be effective for years after the last session.

No one knows what the noncompliance rate is for therapy relative to medication, but it's probably high, if my experience is any gauge. There are no side effects to therapy -- but what it lacks in unintended consequences it makes up for with intentional pain.

Behaviorism has a charming theory called "intentional exposure," which is a
fancy way of saying that the way out of pain is to go through it, over and
over and over again, until it goes away on its own.

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"You mean the way to stop my shallow breathing is to breath shallowly?" I
asked Dr. Crowe incredulously. I did not want a lesson in Zen koans. "Yes,"
he replied. "We're going to mimic the shallow breathing in a controlled
setting." He gave me two thin straws with instructions to pinch my nostrils
and breathe through the straws in my mouth.

After a few minutes, Dr. Crowe asked me to rank, on a scale of one to eight, how similar the breathing felt to the breathing in an actual anxiety attack.
"Eight," I replied. "Excellent!" he said.

Excellent? This sucks, I thought to myself. And so our sessions would go.
I'd rank and he'd exult. "Eight." "Excellent!" "Eight." "Excellent!"

Homework is to behaviorists what multiplication tables are to taciturn
teachers -- an indispensable way to torture students into a more evolved state. Suddenly, I was faced with more homework than I'd had since high school.

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When I first came to Dr. Crowe I was thinking along the lines of
stopping, not increasing, the debilitating physical sensations I experienced.
Imploding myself through structured and repeated exposures to panic-like
physical sensations was not what I had in mind.

The success of a behavioral program depends on how much you're willing to
inflict and withstand pain. Which explains the dropout rate. Scheduling
discomfort is one thing; keeping the appointment is another. I found myself
saying, "OK, it's time to experience heavy pressure on my chest and the
feeling I'm going to pass out." Most of the time I couldn't bring myself to
do it.

There's a sadistic streak running through behaviorism. If your hand hurts
because you stuck it in a meat grinder, behaviorists will tell you the pain
won't go away until you stick your arm in all the way to your elbow.

The worst exercise, by far, was the "intentional worrying" Dr. Crowe
prescribed for my time obsession. It's similar to "systematic
desensitization," a technique developed by the famous psychologist Joseph
Wolpe to cure phobias. But instead of focusing on feared places (crowded
rooms) or animals (snakes), the "intentional worrying" desensitizes you to
the thoughts, feelings and physical sensations brought on by obsessive
thinking.

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Instead of waiting for the next wave of obsessive thinking to
overpower me, Dr. Crowe instructed me to intentionally set it off. I'd speak
whatever thoughts and feelings I had out loud, putting myself into a state of panic, and then would endlessly repeat them until the level of obsessive thinking (and its attendant anxieties)
decreased to half its highest level. Sometimes it took up to 40 minutes -- 40 minutes just to get the noise level in my head down by half.

I was demoralized by the exercises. They were hard, and there was little
progress to serve as reinforcement. In addition to the "intentional
exposure" exercises, I was supposed to be doing three to four "progressive muscle
relaxation" exercises every day (a combination of tensing and releasing
different body muscles and deep breathing), each lasting 10-15 minutes. The real stuff hurt bad enough; why was I trying to manufacture it? Luvox was so much easier.

I often did not do the homework, and in our sessions, Dr. Crowe had yet another issue to deal with -- my sense of guilt and shame. How do you explain to yourself, let alone another person, that you didn't have the discipline to do the work required to help yourself?

My symptoms got worse, but in a perverse way they helped me see that I might be on the right track. "The needle moved," I thought to myself. "Maybe in the wrong direction, but it moved." And maybe it's true that the night is darkest right before the light.

My first real breakthrough was on the cognitive side. I stopped thinking I
was spiraling into insanity when I had an anxiety attack. Dr. Crowe didn't
cheerlead me into thinking positively about the attacks. Instead, he gave
me a lesson in physiology. "It's normal to have fairly wide variations in
body functions," he instructed. "Throughout the day, blood pressure goes up
and down. So do sugar levels, muscle tension and heart rate. Most people
aren't even aware of them, because they're so subtle. But unlike most
people, the limbic part of your brain is on guard 24 hours a day, scanning
for the slightest variation in any of these functions. When it senses a
change it rings the danger alarm and makes your body react like you just
stepped between a grizzly and her cubs."

According to Dr. Crowe, I was misinterpreting normal sensations as
pathological symptoms. When I finally got it -- that I wasn't going insane -- I could almost hear the sound of understanding clicking into place. The realization didn't stop the attacks from coming, but I learned to have a certain detachment from them. My anxiety attacks took on the cast of a burglar alarm going off in a deserted house. I could walk around the
property and see that nothing was wrong -- except that the alarm kept going off by mistake.

I started doing the homework more and more. When I ranked the severity of breathing through the straws, they slowly dropped from eights to sevens,
sixes and fives. And just as slowly, my real breathing attacks receded like
the tide, lapping at less and less of the shore.

One day it occurred to me that I had gone several days without a bout of air
hunger or feeling like the strike of the clock would choke me. It had been
at least 15 years since I could say that.

Most days I operate with a 90 percent reduction of symptoms, but sometimes I end up red-lining the anxiety meter without any provocation. One night last week I couldn't sleep because I was taken over by an all-too-familiar set of sensations. Nothing important kept me up -- not the worry of an important meeting or an urgent project -- nothing but a racing heart, shallow breathing and a sense of dread. I realized the next morning that I hadn't done my exercises for the past few days. I did most of them by the time the sun set.

The protocol for the treatment of anxiety disorders is proving a prophetic
observation by William James, the 19th century Harvard philosopher, on the
nature of emotions. In 1884 he ignited a debate that still rages in
psychology and the neurosciences, by posing a profound question: Upon
encountering a bear, does a person run because he is afraid, or is he afraid
because he sees himself running?

It's a chicken-and-egg question. What comes first -- the conscious awareness (thought) or the physiological reaction (emotion)? James scandalized his peers by siding with the latter. Today's neuroscientists are throwing their hats in with James. It's a well-known fact among neurobiologists that the brain processes sights and sounds in milliseconds while even the simplest thought can take several seconds to form.

Cognitive behaviorists like Dr. Crowe very much believe in James' theory and have
developed a protocol around it. The treatment doesn't target the bear or how you feel about the bear -- it targets the running. By cognitive "restructuring" (correctly interpreting the difference between symptoms and sensations) and "extinguishing" behaviors (breathing through straws eventually stopped the shallow breathing by wearing out its effects),
cognitive-behavior therapy produces remarkable results.

Dr. Crowe told me he rarely sees his patients again once they've gone through the four-month program. I hesitate to say whether I'll see him again. I'd like to pronounce myself cured, but I'm afraid to claim what may be asked back.


Michael Alvear

Michael Alvear is the author of "Men Are Pigs But We Love Bacon," a collection of his sex advice columns, to be published by Kensington Press in May. He lives in Atlanta.

MORE FROM Michael Alvear



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