Dr. Lee Baer talks about OCD symptoms and treating Obsessive Compulsive Disorder with OCD medications and cognitive behavioral therapy. Included in the discussion: coping with obsessions and compulsions, what to do about obsessive and intrusive thoughts (bad thoughts), defining and treating scrupulosity and OCPD (Obsessive-Compulsive Personality Disorder) and more.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "OCD: Getting Control of Your Obsessions and Compulsions." Our guest is author and OCD researcher, Lee Baer, Ph.D. Dr. Baer is an internationally known expert in the treatment of obsessive-compulsive disorder. He is an associate professor of psychology at Harvard Medical School and the director of research at the OCD unit at Massachusetts General Hospital as well as the OCD Institute at McLean Hospital.

Dr. Baer has written two excellent books on OCD:

1. The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts
2. Getting Control: Overcoming Your Obsessions and Compulsions

Before we get started, I also want to mention that we have an OCD screening test on our site. Please click the link and check it out.

Good evening, Dr. Baer and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Is it possible to actually get control over your obsessions and compulsions? And, if so, how?

Dr. Baer: It is good to be here. Most of our patients do see much improvement in obsessions and compulsions, using either behavior therapy, medications or a combination.

David: Does it take both cognitive behavioral therapy and OCD medications to make a significant recovery or will one of those suffice?

Dr. Baer: For people who are very severely affected, both are usually needed. However, for milder or moderate cases, sufferers often do very well with cognitive behavioral therapy alone, if they are willing to work hard.

David: Maybe you could explain how cognitive behavioral therapy works and give us an example or two of using it with an OCD patient?

Dr. Baer: The simplest example is someone with contamination fears who washes their hands too much. The behavior therapy, in this case called exposure and response prevention, involves having him/her touch things he/she thinks are contaminated and would usually avoid, (this is the "exposure" part) and then resist urges to wash for as long as they can (this is the "response prevention" part). Over a few practice sessions, their fear and avoidance goes down. We modify this basic approach for other types of rituals (another name for compulsions) and obsessions.

David: It sounds very rational and easy -- the therapist teaches the patient his or her thoughts are irrational and the patient comes to understand that. But apparently, it isn't that simple or everyone could be easily cured.

Dr. Baer: I usually say that behavior therapy is simple, but not easy. Some people are not bothered enough by their symptoms to be willing to endure any anxiety during treatment. Also, as you know, most Americans would rather take medications and get better fast. Our colleagues in London notice this is less true of their patients, who usually would rather not take OCD medications but want to do behavior therapy instead.

Finally, when people have many different kinds of obsessions and compulsions mixed together it is more complicated to devise an effective treatment program. For example, when they have only obsessions in their head, but no observable compulsions.

David: Are there a great number of people with OCD who have that difficulty?

Dr. Baer: Yes, we think so. As a matter of fact, although the large majority of people who come to our clinics have both compulsions (physical actions they perform) and obsessions (bad thoughts or images), door-to-door surveys suggest that most people in the world with OCD have mainly obsessions. That is the reason I wrote my latest book, Imp of the Mind. I think that many people who have seen people on network TV shows washing their hands, or checking locks or light switches may not have identified their problem as Obsessive-Compulsive Disorder.

For example, a new mother with obsessions about harming her baby, or a man with sexual thoughts (homosexuality, incest) that he feels very guilty about. So these may really be the most common kinds of OCD.

David: And some of these obsessions can be deeply disturbing, like thinking you want to kill your baby or something similar. We talked a bit about controlling the compulsions using cognitive behavioral therapy. But how does one keep these deeply disturbing intrusive thoughts from entering into their minds?

Dr. Baer: A big part of the problem is that our natural first impulse is to try to push the thoughts away. Unfortunately, we now know this only makes them stronger. It is like telling yourself not to think about a pink elephant. The harder you try, the more you think about it.

So the first thing we teach is to let the thoughts pass through your mind, even if they are disturbing. We also teach that everyone has bad thoughts like these from time-to-time, the difference is that people with OCD dwell on them more and feel more guilty about them. Then we have the person expose herself to things she obsesses about. For example, if she is afraid of violent thoughts, we might have her watch a violent movie, if she usually avoids things like this. This is how we modify the usual exposure and response prevention for what I call "bad thoughts".

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David: Why is it that some people are able to have these disturbing, intrusive thoughts and accept them as just a "passing thought" and others with OCD are extremely worried that the thoughts will translate into action?

Dr. Baer: One reason is that most people with OCD are very concerned with certainty. They want 100% assurance that they will never act on their thoughts. However, while people without Obsessive-Compulsive Disorder accept that there is never such a thing as absolute certainty, they can accept very low risks. Another thing I've noticed is that many of these OCD sufferers are, and have been since they were children, very concerned about what other people think about them. This may be why they almost always obsess about doing the most socially inappropriate thing they can think of.

David: One more question from me and then we'll start with some audience questions. Have scientists figured out what causes OCD?

Dr. Baer: Not completely. There are probably many different ways that OCD can develop. In a very few cases, children and adolescents develop OCD symptoms immediately after a strep infection (strep throat), which causes some swelling in specific parts of their brains. They then get better with antibiotic treatment. However, this is a tiny percentage of cases, we think. There seems to be at least some genetic component, as well. Finally, we have found recently that some people can develop OCD symptoms after some traumatic stressful situation.

David: Do most individuals then develop Obsessive Compulsive Disorder in their younger years vs. as an adult?

Dr. Baer: The most common age of onset is between about 18 and 22. It would be very unusual for OCD to first appear, say, in someone in their 50's or 60's. However, children as young as 3 or 4 can occasionally develop OCD, and we have seen some people in their 60's and 70's develop OCD when they become very depressed.

David: We have a lot of audience questions, Dr. Baer. Here's the first one:

happypill1: What if part of the sufferer's Obsessive Compulsive Disorder is not being able to go to therapy?

Dr. Baer: Of course it depends on how the OCD interferes - for example, if they are afraid of contamination outside the home, this would require one approach. If they can't get out of the house because of checking locks or retracing, this requires another. We have been developing computer self-help programs to try to help people who can't get to behavior therapists, with some encouraging results.

David: Can a person get good results from self-help or would you recommend that they seek professional treatment?

Dr. Baer: I recommend that they try self-help first. If it is going to be successful, they should see results within a couple of weeks. After my book Getting Control came out in 1991, it was nice to get letters from people in parts of the country without behavior therapists that they were able to get better with self-help. Of course, for more complicated cases, a professional is needed. And if medications are necessary, a psychiatrist is needed.

shelldawg: Hi. My name is Shelly and I have had OCD for about 3 years. I'm only 15 and my case is very unusual and has to do with self mutilation. How can I deal with that and why am I affected with OCD?

Dr. Baer: There are many problems that are related to OCD. Researchers call these "OCD spectrum" problems. For example, we see many people who pull out their hair, or pick at scabs or pimples on their skin. There are other people who feel urges to do things that are self-injurious. These are called impulsive behaviors, because they are not caused by fear or anxiety, but usually feel like an urge building up until they are done. We have other techniques, like "habit reversal", and "dialectical behavior therapy for these".

David: Is there hope for a significant recovery for someone like Shelly?

Dr. Baer: Many people learn how to control their impulses with the techniques I mentioned above, usually with the addition of a medication. So the short answer is, yes. I forgot to add that Shelly will need to see a professional to help her with her problems. In my experience, these do not respond well to self-help.

David: So Shelly, I hope you talk to your parents about getting some professional help and you can show them the transcript of this conference if they need more information.

flipper: I can't get rid of my intrusive thoughts. What do I do?

Dr. Baer: It is not possible to force them out of your head. The best approach is to let them pass through on their own. It would help if you could figure out what are the situations that trigger your intrusive thoughts, and then expose yourself to them. Also if, guilt is a major part of the problem with the intrusive thoughts, meeting other people with these thoughts, or talking to a compassionate clergyman can be very helpful. I've run a group for people with bad thoughts for 2 years, and the participants find it very helpful in reducing their guilt. If behavioral techniques don't help, the addition of SRI medications is often helpful.

JagerXXX: Doctor, is it a normal symptom to have these guilty thoughts and actually convince myself that I did them, even when I KNOW I didn't?

Dr. Baer: It absolutely is! Some people I've seen obsess about having caused an accident while driving, or having molested a child, and even though they get reassurance, they sometimes confess to having done these things, sometimes to the police!

scrumpy: I have, for many years, had fears about garbagemen, sanitary towels and any woman who has had a baby or anyone who is menstruating. I avoid all of these people. If I come into contact with them accidentally, then I feel disgusting and a lot more feelings too. I was leading a very good life until I went into a kitchen when I shared a house and there were soiled sanitary towels in the bin. Why is it that I, in one second, lost years of therapy and it took years before I made progress again?

Dr. Baer: It sounds like you have fears of contamination. The kinds of things that bother you are very common triggers. I have found that problems like yours often respond very well and very quickly to exposure therapy and response prevention. Also, feeling "disgust" is a very common experience,, instead of feeling anxiety in OCD. Some people feel "dirty", or "just not right" too. I don't know what kind of therapy you had in the past, so I can't comment on why the relapse - fortunately behavior therapy's results tend to last for many years after treatment.

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David: Scrumpy brought up the fact that she had an OCD relapse after several years of doing well. Is that common?

Dr. Baer: An OCD relapse can be caused by several factors. Sometimes things like pregnancy can lead to relapse, or a major life stress like marriage or moving or changing jobs. Also, when people stop taking SRI medications that have helped control their OCD symptoms, about 50% notice a recurrence of symptoms in the months following.

David: Here's a description of Scrumpy's OCD symptoms, then we'll continue:

scrumpy: These are my biggest fears: I can't seem to get past this stage when I was told I was in the same room as someone who had just had a baby. I froze then I went all hot and cold in a matter of seconds. I found out the baby was 3 months old and the lady would not be menstruating anymore. I feel anxiety as well as fear. I had behavior therapy before when I relapsed.

David: Here's the next question:

PowerPuffGirl: Would the speaker please give some behavioral examples of mild vs. moderate vs. severe OCD?

Dr. Baer: We have a residential program at McLean hospital for people with severe OCD. Most of these people have not responded to many different medications. Often to behavior therapy as well. Some of these very severe OCD sufferers need help to even get into the bathroom, or out of bed, or out of the shower. Some are so affected they can't eat!

By the way, Moderate OCD is usually treated on an outpatient basis. These people are usually able to work, or go to school, but their day is interfered with by OCD symptoms. People with mild OCD rarely come to our clinics, but they can benefit from self-help OCD books.

David: Please post the phone number where people can find out more about the residential program.

Dr. Baer: If anyone has severe OCD, they can contact our residential program manager Diane Baney at 617-855-3279 for information.

David: To those in the audience, if you have found some effective method or way or coping with or relieving your OCD symptoms, please send them to me and I'll post them as we go along. That way others can benefit from your knowledge and experiences.

bedford: What should family members do so they are not enabling the OCD suffer? Any good books out regarding this? When is Imp of the Mind due out?

Dr. Baer: Easy question first - Imp of the Mind is out Jan 15th 2001, but amazon.com is taking orders now, and probably shipping now.

Dr. Gravitz has written a good book on families and OCD. I don't remember the title, but it came out a year or so ago. Most self-help OCD books, including my Getting Control, include one or more chapters for family members to read about how to try to help (often by not helping so much!)

scrumpy: Herbert L. Gravitz, book for families is called Obsessive Compulsive Disorder, New help for the family. I have it in front of me.

Nerak: Can you explain the difference between OCD & OCPD and how one treats OCPD (Obsessive-Compulsive Personality Disorder)?

Dr. Baer: OCPD is obsessive-compulsive personality disorder. It is really what we mean when we say that someone is "compulsive". These people are very detail oriented, they can be workaholics, they can insist that family members do things exactly the way they ask them to, they have also been traditionally described as "stingy" with emotions and with money, and they may have trouble throwing things away. Notice that they do not have the classic obsessions or compulsions of OCD. Honestly, there is not much research on treating OCPD because most of these people don't come to us for treatment - their symptoms may bother their family members, but usually not the person him/herself. However, when a person has BOTH OCD and OCPD, we often see the OCPD get better as the OCD gets better.

David: Here are a few audience tips for coping:

PowerPuffGirl: I've found that by addressing the cognitive/ emotional piece, specifically in terms of, for example, contamination fears, that clients have seen great success.

JagerXXX: I find that drinking and using substances can lead to terrible OCD episodes.

joshua123: Doctor, I have scrupulosity and I am trying to find help for the last 7 years. It is extreme and I have been on many meds. I need a specialist in the San Francisco bay area. Do you know how I could obtain this?

Dr. Baer: As far as behavior goes, Dr. Jacqueline Persons is an excellent behavior therapist, with offices I think in Oakland and SF. For medication, Dr. Lorrin Koran is very experienced with OCD and is at the Stanford medical school. Finally, if you happen to be covered by Kaiser Permanente, I recently participated in major training program for 90 of their therapists to learn how to treat OCD. They seemed very competent. Good luck.

David: And could you define scrupulosity for us, please?

Dr. Baer: Scrupulosity is usually associated with religious or moral guilt. Usually the person is worried about having committed a sin. The Catholic church has written about this for centuries, and their is even a religious organization called "Scrupulous Anonymous." I know they have a web site too.

EKeller103: Could Dr. Baer please discuss the connection between OCD and Ruminating?

Dr. Baer: Ruminating is worrying or thinking about something over and over again. Often it is about real life things, like not having enough money, or whether something will work out or not. Therefore, ruminating occurs in depression and in anxiety. Obsessions are a very specific kind of ruminating, about being dirty or contaminated, or about having made a mistake, or about things being out of order and not perfect, etc.

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David: I want to touch on the area of medications. What are the most effective medications for OCD?

Dr. Baer: The antidepressant medications that are called SRI drugs. These all increase the serotonin available in the brain. They are Anafranil (Clomipramine), Prozac (Fluoxetine), Luvox (Fluvoxamine), Paxil (Paroxetine), Celexa (Citalopram Hydrobromide). There are other drugs that work too, but these are the first line treatments. I forgot to mention Zoloft.

poe: Hello, I'm Poe. I've just been diagnosed with OCD and depression. I was put on Clomipramine but it made me too sick. I have to wait until the 10th to get a different medication. The waiting is the worst part. What can I do in the meantime to keep from going more frustrated and incapacitated?

Dr. Baer: For the depression cognitive therapy can be very helpful. Dr. Burns's book Feeling Good is a classic. Of course, I'd also suggest you try some self-help for the Obsessive-Compulsive Disorder. This is especially important because all of these drugs can take up to 12 weeks to have any effect on OCD symptoms.

David: I think Shelly mentioned this earlier, but here's a similar comment from Poe:

poe: Lately, I've thought of self injury as a way to cope with the ocd and depression. How do I go about repressing these urges?

chilly: I take Paxil, which relieved the depression and Aderall and Paxil should relieve anxiety, yet my "need to control" through senseless OCD habits still persists. What can help?

Dr. Baer: It is important to distinguish suicidal thoughts and self-injury for this reason, from urges that seem to build up to do something to relieve the tension. Suicidal thoughts are caused by depression and hopelessness, while the urges to do impulsive acts to relieve tension are part of the OCD spectrum disorders.

David: Earlier, Dr. Baer mentioned that people with OCD sometimes start out by being highly critical of themselves. Here's a comment from Chilly along those same lines:

chilly: My self-injury began in trying to improve my looks, which I have obsessive thoughts about. This habit has done the exact opposite! It makes my looks worse, is defeating the purpose.

Dr. Baer: Another of the disorders that is part of the OCD spectrum is "body dysmorphic disorder" where the person thinks that some part of his or her appearance is ugly or somehow not right. We often see people who pick at their skin or other things to try to improve their appearance. For this disorder, I recommend Dr. Phillips book "The Broken Mirror".

Steve1: How much association does Obsessive-Compulsive Disorder have with Panic Disorder and if you have Panic Disorder what are the chances of you developing OCD?

Dr. Baer: There is some overlap between OCD and panic disorder, but much less than we would have expected. The vast majority of people with panic disorder will never develop OCD. I mentioned at the beginning that in a few cases of OCD, traumatic experiences may have triggered the symptoms, and we often see both panic and OCD symptoms co-existing in these cases.

dofraz: Please provide some therapy techniques for non-medicated children diagnosed with OCD. I need help with a 4 year old girl. We are looking for information. We have met with several doctors who have diagnosed her with OCD. My daughter will not count past 9 or say most people's names. We were working with a behaviorist with very little success.

Dr. Baer: At the risk of sounding like a bookstore, I would strongly recommend that you get Dr. John March's book(s) on behavioral treatment of children with OCD. He explains how, at Duke University, he modifies behavior therapy in terms kids can understand and gets excellent results, usually with no, or very little medication. The techniques are the same in treating kids as adults, but of course it has to be explained differently.

David: Here's an audience comment on how medications helped her:

MalibuBarbie1959: Luvox has helped my symptoms but Anafranil completely took it away.

Dr. Baer: These are the only two SRI drugs that are sometimes prescribed together. They often seem to complement each other when a single drug doesn't work.

astrid: Is an obsessive thought about suicide something that I should be concerned about or should I try to dismiss the thought along with my other obsessive thoughts?

Dr. Baer: If the thought is about wishing to be dead, or is part of feeling very depressed and hopeless, then it is NOT considered an obsessive thought and shouldn't be treated as one. Then it should be treated as a serious symptom of depression. But some people say that they don't wish to be dead, and are not depressed, but sometimes get images of harming themselves that get stuck in their heads. These could be obsessive thoughts. Of course, it is important to take any suicidal thoughts seriously and see a professional, and it will probably take a professional to tell these thoughts apart. I would therefore suggest talking to a professional before trying self-treatment for this symptom.

ict4evr2: I have suffered with Obsessive Compulsive Disorder for as long as I can remember. It has been a very secretive, private illness. However, others have obviously seen bizarre behavior. I have made a feeble attempt at drug therapy once. My question is do people with OCD develop other major problems later in life if OCD is not treated early?

Dr. Baer: Other disorders do not develop, and the OCD usually remains at about the same level if not treated; although, of course, more relationships and job situations are affected as people have OCD longer. But many people come to us in their 50's and 60's seeking treatment for the first time, and respond very quickly.

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kimo23: Define Primary Obsessional Slowness, please and where information can be found on this type of OCD.

Dr. Baer: People with primary obsessional slowness do everything extremely slowly. They can get "stuck" in bathrooms for many hours at a time or in showers until all the hot water runs out. They usually describe not being able to start an action until it feels perfectly right. This problem does not respond to self-treatment and almost always requires medication in addition to behavior therapy. I talk about it in Getting Control

Slate: My husband has OCD. He is doing really well in terms of not acting out compulsions, as a result of some work with exposure and response prevention. But his obsessions often focus around flaws he sees in ME. For example, he recently told me that on our wedding day he was happy to be married, but he'd been distressed the whole day because he couldn't look at me without seeing a speck of dirt in my eye and he felt so horrible about thinking that when he was getting married.

David: I'm sure this is very tough to deal with. What suggestions would you have, Dr. Baer?

Dr. Baer: We are testing a new kind of treatment for OCD which is called cognitive therapy for OCD. It seems to be effective for the kinds of symptoms you describe about perfectionism. It involves having the person examine his thoughts for cognitive errors or distortions common in OCD. I included a chapter describing this technique in my book The Imp of the Mind along with a case illustration of this new technique.

David: I know it's getting late. Thank you, Dr. Baer, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com.

Dr. Baer: The questions were excellent. I enjoyed participating.

David: Thanks again for coming, Dr. Baer. Good night, everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Dr. Michael Jenike talks about one of the most difficult aspects of Obsessive Compulsive Disorder (OCD), obsessions, including obsessive thoughts, intrusive thoughts, disgusting thoughts and what to do about them. We also discussed medication for treating OCD, Cognitive Behavioral Therapy, and treatment-resistant OCD.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "What To Do About The Obsessions Part Of OCD." Our guest is Dr. Michael Jenike.

Understanding that everyone in the audience might have a different level of knowledge, here's some basic information about Obsessive-Compulsive Disorder. There's even an OCD screening test on our site.

Just so everyone knows, obsessions are unwanted, recurrent, and disturbing thoughts that the person cannot express and that cause overwhelming anxiety. (i.e. fear of germs or toxic substances, did I unplug the coffee pot?, etc.)

Our guest tonight is Michael Jenike, M.D. Dr. Jenike is a psychiatrist at Massachusetts General Hospital, a Harvard Medical School professor and his primary research interest is in obsessive-compulsive disorders. He has written numerous articles for scholarly journals on the topic, authored a book entitled "Obsessive-Compulsive Disorders: Practical Management," and he is a member of the board of directors of the Obsessive Compulsive Foundation.

Good evening, Dr. Jenike, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. What is it that causes certain individuals to have obsessive thoughts?

Dr. Jenike: Thanks. Everyone has intrusive thoughts, but people with OCD give them special significance and they get stuck in their minds. We really do not know what causes Obsessive-Compulsive Disorder in most patients, occasionally, it can occur after strep infections or head injury, but this type of cause is very unusual.

David: How do the obsessions get started?

Dr. Jenike: Patients often report that they have a sudden onset of some thought that upsets them, for example, that they did something hurtful to someone else, said something inappropriate, or some sexual thought that is repulsive to them, like wanting to molest their children or parents. We don't know why some people get these types of thoughts stuck in their heads. For those without OCD, we're able to chalk those off to "passing thoughts". What is that makes a person with OCD obsess about them? I wish I knew, but I don't. If I get a thought that seems bizarre, I just let it pass. If I had Obsessive Compulsive Disorder, I would try to find some significance in the thought and somehow determine that I was a bad person, etc.

Interestingly, the more one tries to get rid of such a thought, the more it intrudes. The classical example is telling someone without OCD not to think of a white bear for the next 5 minutes. In careful studies, this has been shown to cause the thought to come much more often, so telling OCD patients to force the thoughts out of their heads, just makes things worse.

David: So what is the answer to ridding yourself of these obsessions?

Dr. Jenike: Good question. We know what not to do.

The first thing to do is to educate the person. once they know that we all (except me, of course) have such thoughts and that they are normal, that often helps a lot just by itself.

Next, tell them not to try to force the thoughts out of their heads, but just let them pass naturally. Don't try to read any significance into the thoughts. If you are obsessing about wanting to have sex with your baby, don't interpret this as you being a bad mother, the thoughts, have nothing to do with the character or motivation of the person. They are produced naturally by the brain, and if you have OCD, your normal filtering mechanism does not work so they get stuck.

There are medications that may lessen considerably the thoughts, and even lighten your interpretation of them. In some patients, we use what are called "loop tapes." These are tapes on which a person records, in their own voice, the disgusting thoughts and plays them back for a couple of hours per day, until they essentially become boring. This lessens, greatly, the hold that the thoughts have on the person.

One final thing, Dr. Lee Baer has a great new book coming out called: The Imp of The Mind, due out in January 2001. I don't get any royalties, but after tonight maybe I can make a deal with him!

David: I want to touch on one thing you said before we get to some audience questions. Earlier, you mentioned that we should let the obsessive thoughts pass naturally. Of course, people with OCD have great trouble with that. Is that something that can be taught in therapy?

Dr. Jenike: The main thing that can be taught, is that these thoughts come into everyone's minds and are normal. This helps a lot.

So, the problem is not that OCD patients have abnormal thoughts (we all do); it is their interpretation of the thoughts and their holding onto them, as if they have some intrinsic value.

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David: Here are some audience questions.

GreenYellow4Ever: Sometimes obsessive thoughts literally keep me awake for hours. Do you have any suggestions for how to deal with the "thought train" so that I can get some sleep?

Dr. Jenike: See how helpful a psychiatrist can be!

I would start with a careful evaluation; both medically and psychiatrically. The doctor needs to know the complete situation. For example, do you have any other problems? Depression would be a common reason for sleep problems.

Also, one needs to evaluate what medications you are taking, some can interfere with sleep. Often, just changing the time you take the medications may help.

If you are laying there at night with little stimulation, that is a fertile time for the mind to get going with obsessive thoughts. I don't think I can give specific treatment recommendations for someone I don't know, but these are general approaches.

kmarie: Hi, Dr. Jenike. What's the best medication for treating OCD?

Dr. Jenike: Here's a good discussion of current medication treatments for OCD." The main OCD medications that are used have been evaluated in so-called placebo-controlled trials. The ones shown to be partially effective are, Anafranil (Clomipramine), Luvox (Fluvoxamine), Paxil (Paroxetine), Prozac (Fluoxetine), Celexa (Citalopram). There is some evidence that Effexor is also helpful, but there are still no good studies. The medications generally need to be used at high dosages for three months, to evaluate if they will help or not. It is important for the patient to know this, since many psychiatrists give up on the medication after a month or so, and they also may be using low dosages. They are used to treating depression more than OCD, and depression often responds faster and with lower dosages.

David: KMarie, there's also a lot of information on OCD and medications here. For information on specific medications, including side-effects, you can to go to the HealthyPlace.com medications area.

Dave*: Are obsessions the same as ruminations?

Dr. Jenike: If you use standard definitions, ruminations and obsessions are technically different.

Obsessions refer to the thoughts in OCD, and ruminations refer to things that get stuck in one's head when one is depressed. Ruminations generally make sense to the depressed person; while obsessions are usually experienced as nonsensical to many OCD patients.

For example, a depressed patient may ruminate about how he cheated on his taxes twenty-five years ago and what a bad person he is, while a patient with OCD will have thoughts like, " I want to have sex with the Virgin Mary; or I want to kill my mother;" etc.

Linlod: I have been struggling with molesting obsessions for awhile. I am on medications and they help. I am also doing Cognitive Behavioral Therapy (CBT). When will I habituate?

Dr. Jenike: First, we should explain habituation. It is a description of what we hope happens when you keep doing what makes you anxious, which is at first get more and more anxious, and after time, get used to whatever you fear. This is called habituation. Almost all people with OCD will habituate to the anxiety eventually, and medications help a lot.

Cognitive Behavioral Therapy, CBT is actually (in my opinion) the best treatment for OCD. Medications are often used with CBT.

cwebster: What is the difference between Obsessive Compulsive Disorder thoughts (e.g. wanting to kill Virgin Mary) and psychotic delusions? Both seem upsetting to the thinker.

Dr. Jenike: The difference between a psychotic thought and an obsession is that the psychotic person believes the thought, while the person with OCD knows that it is nuts, but has very strong feelings about it. And this brings up an interesting point. (Having said that, I better come up with something good!).

With OCD, the person intellectually knows that his or her fear or obsession is not warranted, but the person still has a feeling inside that it is true. If you don't have OCD, the thoughts and internal feelings match, but if you have OCD, the feelings are very disturbing and paralyzing. Even though, the cognitive part of your brain knows that, some people can be on the edge and occasionally believe that their obsessions are real, but most know the difference.

David: A few site notes: Here's the link to the HealthyPlace.com OCD Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this.

For those in the audience, if you've found a way of coping with your obsessions, go ahead and send me your solution and I'll post it as we go along.

Now onto more audience questions:

mitcl: Have you ever heard of Eye Movement Desensitization and Reprocessing (EMDR) for helping treat OCD.

Dr. Jenike: EMDR has been reported to be of some help with Post-Traumatic Stress Disorder (PTSD), but not with OCD.

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MYTWOGRLSMOM: My mind goes constantly. I count everything and I am constantly saying prayers, so nothing "bad" will happen. How can I help myself to stop this?

Dr. Jenike: This is one of the typical OCD symptoms. You need to work with a good cognitive behavior therapist to develop a treatment plan. Also, medications may help.

When you say that your mind goes constantly; it is probably generating obsessions. Then, the counting and praying are actually mental rituals that you do to lessen the anxiety caused by the obsessions. You need to have a plan to stop the rituals, and just feel the anxiety produced by the obsessions. Once your brain learns (and I mean learns) that you will not do rituals, it will tire of generating obsessions. As I said, medications can help this process. Some of your mental rituals, are by now almost automatic, so you will have to make a conscious effort to cut them back. The first step is to list all the mental rituals, and then decide which ones to approach first.

Besides the book I mentioned earlier, another good book is "Getting Control". This book gives all kinds of self help advice.

David: I am getting some questions regarding what constitutes a diagnosis of OCD. You can click the link for that.

Here are some audience comments on what's worked for controlling obsessions:

matrix*: Obsessive-Compulsive Disorder, to me, is like an itch on my arm. I must scratch it and it feels better once scratched, but actually it spreads and gets worse in the long run. If I don't scratch the itch, it gets real bad, but in awhile, it fades away.

cwebster: To reduce obsessions, I take medications (Effexor-XR, Serzone) and tell myself to just let the thoughts go, they're not important. If that doesn't work, I take Seroquel and pass out!

Kerri20: I wanted to share that exposure and response therapy, as well as CBT, helps me a lot.

Dr. Jenike: Exposure and response prevention is the BT part of CBT.

Gridrunner: Have you heard of some success using St. John's Wort or 5-htp to lessen OCD?

Dr. Jenike: Yes, there are a few cases where St. John's Wort has helped OCD. In Germany, there are dozens of studies using SJW for mild to moderate depression, but its use for treating OCD is relatively new. I have tried it in quite a few patients, with not much success. But then again, most of the patients I see now, are on the more severe end of the spectrum.

Bea: What kind of dosage of the St. John's Wort is effective for OCD?

Dr. Jenike: It depends on the preparation. It is approximately three tablets per day of the most commonly available preparations. There is quite a bit of information on the internet about dosing. The dosing studies are with depression, but most people use similar doses for OCD.

HealedHeart: I have a severe fear of germs. I don't exactly know what the fear is, as I'm not really afraid of getting sick. However, I can't touch library books or anything like that, without having to wash my hands over and over. Also, I can never wear anything more than once without washing it.

I am entering the working world and will have to take the public bus. I don't know how I will survive sitting and touching seats that so many other people have touched. What can I do about this?

Dr. Jenike: You are CBT deficient in a big way. For advice, go to the OC Foundation web site, join the OCF and learn about OCD and how to treat it. Medication for treating OCD may help.

The people with fear of germs are actually the easiest to treat, and success rates are great if you do the exposures and response prevention. If you contact a support group locally, they can tell you which local doctors know how to treat OCD.

David: CBT, by the way, is Cognitive Behavioral Therapy. You can read more about how to use CBT to treat OCD here.

Brin: I have been taking Klonopin (Clonazepam) for five years. I decided to wean myself off. I have been tapering for about two weeks and now I am completely off, and I am having horrible withdrawal symptoms. Can you give me any idea of how long these withdrawals can possibly last?

Dr. Jenike: If you are on high dosages of a benzodiazepine like Klonopin, sudden stopping can be dangerous. If the dose is low, there is probably no problem. Withdrawal depends on dosing and length of time you have been on the drug. Since I don't know dosage, I cannot comment intelligently. Even if I did know the dose, I can't comment without being familiar with your case.

Also, I don't know what withdrawal symptoms you are having. I would think that by two to three weeks, you should be back at baseline. Keep in mind that the Klonopin may have been helping anxiety and maybe the anxiety is returning so the problems are not actually withdrawal. Also, Klonopin is not a great anti-OCD drug.

sbg1124: Is it possible for some SSRI's to make OCD worse?

Dr. Jenike: Yes. I think that, sometimes, worsening OCD symptoms (not side effects) actually predicts a good response. That is if the patient can stay on the drug long enough. It is a rare OCD patient who continues to have worsening OCD on these drugs, but I have seen it. Sometimes, the drugs help, but other times, they can make things worse.

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David: Here's an audience suggestion on how to effectively deal with obsessions:

matrix*: I tell someone I can trust to check something (the stove, bathtub water) so they can tell me it's really off, so I don't have to check it over and over. It helps a little.

Dr. Jenike: This is a bad idea! You are actually having someone else do checking for you.

David: Why is that a bad idea?

Dr. Jenike: If you transfer your OCD checking to someone else, you will never learn to cope with the OCD and habituate. It just makes OCD worse and often, eventually, can destroy a marriage and family. People resent this after awhile, and it can get way out of hand, to the point where family members will have to wash everytime they come into the house, or perform hours of checking rituals to keep the person with OCD from getting worked up. I see this all the time.

blair: I have to have constant auditory stimuli when I am at home (I live alone), e.g., stereo, TV, etc., to lessen my obsessive thoughts. I do this instead of dealing with the problem. I even go to sleep with the TV on. Is this advisable?

Dr. Jenike: This works for some people, and I don't see anything wrong with it as long as they don't listen to Nine Inch Nails!

LanaT: Our seven year old has recently been diagnosed with OCD. We don't know exactly how long he has been having his fears, but some of the symptoms we recently learned about, we recall from as early as two. We are curious to know if this is all he has ever known (life with fears), will he be able to gain the intellect to distinguish the rational from the irrational?

Dr. Jenike: This is a very common situation. OCD has nothing to do with a problem with intellect. We have many geniuses (they probably could spell this word) with OCD. It really has to do with a disassociation between thoughts and feelings. The prognosis is great now for kids with OCD. There are many great books out. He really needs to see a good child CBT expert and may need medications. It is important, in kids this age, to be aware of an occasional relationship between strep infections and Obsessive Compulsive Disorder. If he got OCD, or it worsens when he gets a strep infection, he needs very aggressive antibiotic therapy.

Dr. Sue Swedo at NIMH in Bethesda, MD has a number of research protocols for kids with OCD that may be caused by strep and she will sometimes fly kids there.

David: What can happen when a child with OCD develops strep?

Dr. Jenike: The OCD can worsen. Strep can induce the body to produce antibodies against kidney, heart (rheumatic fever), and also against a part of the brain called the caudate. These antibodies attack that part of the brain in susceptible individuals, and this part of the brain is involved in producing OCD symptoms. We, and others have done a lot of neuroimaging studies implicating the caudate, orbital frontal cortex, and other areas with OCD symptoms.

Kerri20: Hello, Dr Jenike!! I actually attended your OCD Institute at Mclean Hospital about four months ago and I must say that the therapy helped me out a great deal. I have learned many useful things there and the doctors and staff are wonderful! I would definitely recommend the program to all!!

Dr. Jenike: Glad the OCD Institute helped. How much do I owe you for the plug! Keep up the great work!

Luckydogs9668007: Dr. Jenike, I am currently on Luvox and I haven't seen any improvement. How long should I give my medication to lessen my OCD.

Dr. Jenike: For Luvox (fluvoxamine) you should be on 300 mg (if tolerated) for about three months before giving up on it and trying something else. Again, CBT (Cognitive Behavioral Therapy) is the most effective treatment for OCD that we have. So be sure you are getting CBT along with medication.

stan.shura: Do you have any advice on dealing with the uncertainty? I have a series of compulsions, rituals. For example, during my bathroom routine, I find that after I've "settled" into bed, I have to go back and check to make sure I did A, B, and C.

Dr. Jenike: Yes, none of us can be certain of anything! Why should you be more certain than me that the door is locked or the stove is off. The treatment for OCD is not to come up with a way to be more certain, but to learn to live with the natural uncertainty of life. You should not check and the uncomfortable feelings will lessen over time. Again, medications may help. Checking, actually feeds the obsessional part of your brain and keeps it alive and well to torment you daily or nightly! Another book that helps some people with this is Brainlock. So, read Getting Control and this book for similar approaches that may help.

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David: A few moments ago, luckydogs mentioned that he/she was taking Luvox and getting CBT, but it wasn't effective. Is there such a thing as treatment resistant OCD? If so, then what do you do?

Dr. Jenike: Yes, it depends on how you define treatment resistant OCD. There are about six drugs to try; you need to try CBT as well; usually in combination with medication treatments for OCD. If that does not work and someone is really disabled by OCD, there are treatment facilities like ours at McLean Hospital where people can stay for awhile to get daily intensive therapy. In extreme cases, neurosurgical procedures are done to interrupt physically the circuits in the brain that seem to be involved with OCD. There are also newer techniques, like deep brain stimulation where these same circuits are stimulated by implanted electrodes. I say this, just to point out that there is a lot of research going on, and that there is hope for people with severe OCD. Motivation to get better and willingness to put up with what needs to be done in treatment are key elements in getting better. Some of the sickest patients I have ever seen have gotten better.

Bea: How do you get a spouse to stop enabling the person with OCD without causing a lot of friction?

Dr. Jenike: That really depends on the situation. Some are easy; some are impossible. If the person is helping to keep a loved one ill by enabling them, you may have to cause friction. Often we have to work with family members for a long while, to get them on our side. The family, patient, and caregivers need to band together to fight the OCD, or all is lost. There is a book by Dr. Herb Gravitz, Obsessive Compulsive Disorder : New Help for the Family, that advises family members of an OCD patient. It would be worth reading in these situations. I spend a lot of time on this issue.

MYTWOGRLSMOM: Dr Jenike, My two-and-a-half year old little girl insists on washing her hands at times and will not touch anything that she thinks is "dirty". Could she have OCD, or acting on things she sees me do?

Dr. Jenike: It could be either. Kids at this age mimic what they see. If you have OCD, she may be watching you. Try not to let her see you do rituals; and work to get them under control. Have her seen to determine if she needs treatment. Often with kids this young, the treatment is very simple and quick. A good children's Cognitive Behavioral Therapist can help a lot.

roc: Dr. Jenike, is there a problem with taking antidepressant medication for the rest of our life? Why is it that every time I get off medications, I relapse. Nothing I've learned in CBT helps, but going back on medications my obsessions are controlled.

Dr. Jenike: Some people with OCD or depression are like this. There is no irreversible problem with staying on these meds for life. The neuroleptic medications are the ones that seem to be more toxic. Many patients are able to use CBT to keep the OCD away once they get a handle on it, but others need medications as well. Relapse, when you stop medication, usually does not occur right away, but more often 2-4 months later. It is very important to do the CBT exercises every day when you are stopping meds.

David: We are going to wrap it up for tonight. Thank you, Dr. Jenike, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a growing OCD community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others http://www.healthyplace.com.

Dr. Jenike: Thank you and good night!

David: Thanks again, Dr. Jenike. Have a good night everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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David Carbonell, Ph.D., our guest, talks about managing your anxiety and panic. We discussed anxiety disorders and panic attacks, how to respond to a panic attack, recovering from a panic attack and using diaphragmatic breathing, anti-anxiety medications, cognitive behavioral therapy (CBT) and progressive exposure used in anxiety treatment.

Audience members shared their ideas for controlling panic and treatments for anxiety including anxiety support groups, helpful books on anxiety, self help tapes for anxiety and video programs to overcome panic attacks.

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Managing Your Anxiety." Our guest is psychologist, Dr. David Carbonell. He is Director of Chicago's Anxiety Treatment Center and conducts seminars and workshops for a variety of professional groups. Dr. Carbonell also makes frequent presentations on anxiety.

Good evening, Dr. Carbonell and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Many of the people who visit HealthyPlace.com feel pretty hopeless and pessimistic about recovering from anxiety and panic. I'm wondering what you would say to them.

Dr. Carbonell: I'd like to tell them that these disorders, anxiety disorders, are both common and treatable. A good recovery is attainable!

David: You make it sound relatively easy. Yet, for many, it's very difficult? Why is that?

Dr. Carbonell: A number of reasons. As your questions indicated, it's easy to become depressed about these anxiety conditions. It's also true that following common sense instincts often doesn't help. There are tricks to getting over these problems. And so I see many people who, in other areas of their lives can solve all kinds of problems, have a lot of trouble with these.

David: When you use the term, "good recovery," what do you mean by that, exactly?

Dr. Carbonell: In the case of panic disorder, I mean a person can get to the point of no longer fearing a panic attack. And when you get to that point, they tend to fade away. So you can live your life without that shadow.

David: A moment ago, you mentioned "tricks" to getting over these problems of panic and anxiety. What were you referring to, specifically?

Dr. Carbonell: The tricks to working with panic all relate to this:

People's gut instincts about how to respond to a panic attack are almost always exactly wrong, the opposite of what will help.

And so, people will hold their breath during a panic attack; will stand rooted to the ground; will flee. All these responses, unfortunately, make it worse. And so a fundamental trick of a panic attack is learning how to respond differently. It requires:

ACCEPTING the panic, and working with it, rather than opposing it.

David: We have one audience member who agrees with you on the reaction to a panic attack:

sher36: I always feel like running.

Dr. Carbonell: Yes, exactly. And you can come to rely on running. But it just invites the panic back, again and again.

David: Does it take therapy and/or anti-anxiety medications to recover from panic and anxiety, or can one do it on their own?

Dr. Carbonell: I think most, not all, people will require some kind of professional help, although I know some can do it with a good anxiety support group. I think the majority of people can make a good recovery, without anti-anxiety medications, if they find a good source for cognitive behavioral therapy, using progressive exposure. And some, though far fewer than actually use them, will require medications.

David: Here are a couple of audience comments, then we'll continue:

aml782: I went to a support group for about a year and it was a big help.

CorwinPon: I have only actually run once. Normally, my legs bounce.

sher36: Nothing has helped me thus far.

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David: I asked the above question because there are plenty of books on anxiety and video programs to overcome panic attacks on the market that purport to cure you of panic and anxiety. What are your feelings about those?

Dr. Carbonell: Well, I think it's hard to do on your own. There are skills which can be taught in those books and videos, but in my experience many people need some coaching to see how to apply them. I think it's all too easy to get the idea that if you just use those techniques, they will protect you from the panic. And that's not how people recover. You need to learn how to work with, and accept the panic, so that you lose your fear of it. Then it goes away. And you'd have to really believe in a book to make that happen without some personal encouragement and coaching!

David: We have a lot of audience questions, Dr. Carbonell. Let's get to a few:

SaMatter: What if the panic attacks and fears are irrational?

Dr. Carbonell: Well, the fears are irrational, or illogical, however you want to call it. In panic disorder, people become chronically afraid of awful consequences, like death and insanity, which do not occur as a result of panic. So the task is one of learning how to calm yourself when you experience these illogical fears. Simply knowing that they're illogical isn't enough.

leg246: Can you exercise to reduce anxiety and how long must you do it to take effect?

Dr. Carbonell: Cardiovascular exercise is an excellent way to reduce your susceptibility. Don't worry about how long to do it at first. The key is to get started with a regular habit. If that's 10 minutes a day of walking, good, you're started!

David: And why is cardiovascular exercise good for reducing panic and anxiety?

Dr. Carbonell: Several reasons. Cardio in general is "good for what ails you", be it depressed or anxious mood, because it gets you moving. It stimulates natural painkillers the body produces. And, especially for panic, it helps you get used to natural physical sensations, like sweating and increased heart rate, which often seem scary.

Mucky: I know in my head that my fear is not rational but my body reacts to those situations which put me in a similar situation. How do I get my mind and body together?

Dr. Carbonell: First, by accepting that you can get afraid, even when you are in no danger whatsoever. Learn that these fears are not a signal of any danger, they're just a false alarm. And then learn some ways, and practice them, to calm your body. Diaphragmatic breathing would generally be the first one to learn.

cosset: I was in therapy for years for panic attacks, but in therapy, I was never taught any skills. It was like, "ok you have panic attacks," and was not given medications or anything. I have learned so much from the anxiety support groups here at HealthyPlace. They have some great hosts and I've learned a lot. I'm actually overcoming the panic attacks...slowly but surely :)

Dr. Carbonell: And on my site, there are instructions, and a video clip, for the breathing.

David: Here is Dr. Carbonell's website.

Dr. Carbonell: You really do need to learn those skills. Therapy without skills is really missing something important.

Sweetgirl01: Can severe anxiety be caused by biochemical factors?

Dr. Carbonell: It seems to be the case that there are biological predispositions to panic disorder and other conditions. Some people are good candidates to get them, others couldn't have a panic attack if they tried. But these are just predispositions. Learning and habit are what maintain the problem, and also offer the way out.

David: I mentioned earlier that many people who suffer from anxiety and panic feel helpless and pessimistic about recovery.

Here are a few audience comments:

Beans96: I've had this disorder for 23 years now. I've tried everything nothing seems to work for me.

sher36: I have read everything and I only seem to get worse with age.

David: I post these so that those of you who are suffering know that you aren't alone with this; that you are not unique or that there is something terribly different or wrong with you.

What about people who are long-time sufferers, Dr. Carbonell. How difficult is recovery for them?

Dr. Carbonell: Yes, these are discouraging sentiments. I've seen this happen to people. And partly it's happened because it's really been less than 20 years that there has been any good treatment at all for this. And in many parts of the country, it's still very hard to get good help.

But it is possible. So all I could suggest is, be aware that your discouragement can prevent you from finding the help that may be more available now than when you first looked. Keep searching and trying!

David: I don't know if you saw my last question, but I'm wondering how difficult recovery is for long-term sufferers?

Dr. Carbonell: In general, recovery is more difficult for those who have suffered longer. They tend to feel more discouraged, and they tend to have incorporated the phobias into their life to a greater degree.

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David: Here's another comment from a long-time sufferer:

ogramare: I would have to disagree. I have had severe anxiety disorders for 55 years and there is no one near where I live that offers the kind of treatment you are proposing. The only thing that has given me a measure of relief is finally finding some anxiety medications that help----but I do feel that it is now a little late in life to ever get well. Some of the treatments for anxiety have been worse than the disease.

David: On the other side, here are some positive audience comments regarding recovery from anxiety and panic attacks, so everyone knows that it is possible:

kappy123: I am currently in cognitive behavioral therapy (CBT) seems to be working and I feel better.

cosset: After 8 or so years of panic overpowering me, I've gotten mad at the attacks, and I tell them, "go ahead, panic, go ahead die in the panic.. I am still going in Kmart" :) It's worked so far, but I am sure I still have a way to go to become panic free.

Dr. Carbonell: Cosset, I think what really helps in what you're saying is that you've stopped trying to protect yourself. When you accept the panic, you start getting better.

Neecy_68: I have been on anti-anxiety medications for two years. Is it harmful to use them for long periods of time? I am scared to go off. I am afraid I will have worse panic attacks than before I was on the anxiety medications.

Dr. Carbonell: You should really develop a plan with the physician who prescribes them. Don't stop taking them on your own. As to long-term effects, it depends on the medication.

kappy123: Birth control pills made my anxiety/panic worse is this possible?

Dr. Carbonell: Yes.

David: Here is information on specific anti-anxiety medications and their side effects.

Lexio: Birth control pills brought on my anxiety and panic after 10 years of being panic free.

David: Here are some of the things that have worked for audience members in relieving their panic and anxiety:

SaMatter: I try to hypnotize myself through an intense/in-depth thought or daydreaming type of situation. I have also been trying to imagine something I really like when they come on. No matter how irrational that thought may be.

linda_tx: I have done self-help tapes for anxiety. After six weeks into the tapes, I was out of my house again.

camilarae: One good solution to controlling the panic is to remember and learn how to breathe correctly.

codequeen: The most helpful solution I've found to anxiety, for me, is to read or watch something funny, such as comic strips, Dave Barry columns, and Marx Brothers movies work best for me.

angel3171: Relaxation tape with guided imagery has helped me along with deep breathing.

Dr. Carbonell: It still amazes me, after many years of practice, how powerful the breathing is. And humor is great!

David: Here's another audience question:

nino123: I am new to this kind of chat and I would like to ask why it is said that panic attacks only last approx 10 minutes. Mine can last 2 to 3 days?

Dr. Carbonell: Nino, I would guess that what's happening is that you're having numerous panic attacks during that time period, rather than one uninterrupted attack. This is often what I find when I review this carefully with clients.

David: I am getting some general questions about what is anxiety and the diagnosis for it. We have a lot of excellent information on our site in the HealthyPlace.com Anxiety-Panic Community.

wildchic: I get nervous when my family travels far. How do I handle this?

Dr. Carbonell: You mean, when they leave you home alone?

David: No, when she travels with them? I suppose she has a safety zone that she feels comfortable in.

Dr. Carbonell: You could look at what precisely you fear as a result of being away. Many people, for instance, get focused on knowing where a hospital is, thinking that they may have some medical emergency as a result of anxiety. Others just have this sense that they might feel like they have to get home "right away", and they won't be able to.

But in general, fears of this type don't indicate an actual danger. They indicate panic, which needs to be addressed by accepting, and coping with, the symptoms themselves. And it will make a difference if your family is understanding of these fears.

David: We have quite a few people tonight, Dr. Carbonell, who are apparently affected by travel:

codequeen: On the same note...I'm attending college, and I always get very anxious every time I leave my family (I'm fine once I get settled in). It's gotten better since I started taking meds but it's still a problem. How would you suggest dealing with this?

Dr. Carbonell: Notice that what you're describing here is anticipatory anxiety. You're fine once you get settled in. Many people forget this aspect of anticipation, and think that, "if I'm this anxious now, how much worse will it be when I get there!" So it will help to remind yourself that this anticipation is the high point of the anxiety - it will only go down from here.

David: Here are some more helpful recovery tips from the audience:

Ken36: My favorite is to keep reminding myself that it's just a physical feeling, and try not to label it at all. I still feel the physical feelings but they pass quicker if I don't find something to blame the physical pains on. It separates me from the problem.

SaMatter: A tip I use is to let people know that I am experiencing a panic attack. Most people are sympathetic.

Another tip I've found that helps, is know yourself, and what situations can aggravate or instigate the attacks, and plan around them. Give yourself an "out".

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ogramare: I recently had surgery and found it very helpful to tell all involved in my care that I suffer from anxiety disorders. It was a tremendous help and a very different experience than when I kept it a deep dark secret.

Mucky: I have a service dog that alerts to my panic attacks. I got him so that I could get out of the house but I am so afraid of being confronted about him that I still don't go out.

nino123: My husband and I went to Tennessee from Maryland and I made him take our trailer for my "safe" place.

Dr. Carbonell: Yes! In general, secrecy hurts, self disclosure will help. And, since most panic attacks involve a feeling of being "trapped", giving yourself an out is a good strategy.

David: Here's a question about "being alone":

camilarae: I cannot be alone any time of the day. I always need someone home. How do I handle this? My husband is really getting frustrated.

Dr. Carbonell: You could evaluate how realistic the need is. If you're like most people in this situation, it's because you fear having a panic attack, not that you need him to keep you alive or sane. And perhaps then you could work with him to gradually increase the amount of time you can spend alone. Getting some help from others to ease the burden on your husband will help too!

nino123: My husband is frustrated also which is a source of my anxiety. It is a trigger for me.

linda_tx: With the Christmas holidays, I find that I'm more anxious in the stores. How do I handle this?

Dr. Carbonell: I think everybody gets more tense during Christmas shopping! Recognize it's an unusually crowded and stressful situation. A few techniques you can use is breathing, relaxation and take breaks.

dak75: Can the dizziness and hand numbness last for days or weeks?

Dr. Carbonell: Certain symptoms, like dizziness, numbness/tingling, and shortness of breath, can last as long as you engage in short and shallow breathing. These aren't harmful, but they are uncomfortable, and the best way to manage them is with diaphragmatic breathing. Most of the most distressing panic symptoms come from short, shallow breathing and hyperventilation.

I mentioned tricks earlier. Here's an important one:

When you set out to take a deep breath, you actually have to start with an exhale. Not an inhale, an exhale, even though that is the opposite of what you expect.

The reason is, you need the exhale, or a sigh, to relax your upper body enough that you can breathe deeply.

RiverRat2000: Along panic attacks and anxiety disorder, I suffer from PTSD (Post-Traumatic Stress Disorder) and agoraphobia is there any help? I'm afraid of people.

Dr. Carbonell: The treatment for agoraphobia, (lots of avoidances caused by fear of panic attacks) depends on getting better at managing the attacks, then gradually re-entering the feared situations.

In your case, dealing with people - a little at a time. With PTSD, where there are flashbacks and recall of a traumatic event, effective treatment involves ways of dealing with the traumatic memories of the past. This is often difficult, but there is help.

Mistymare4: My anxiety totally revolves around going in public and driving like work, grocery shopping etc..

David: Would you say that agoraphobia is the most difficult anxiety disorder to recover from?

Dr. Carbonell: Well, I would say no, but I realize it's easy for me to say. I find others more difficult to treat. But I think the most difficult one is the one you have.

Lexio: What if the fear of going crazy causes your panic attacks? What do you do then?

Dr. Carbonell: You could start by reviewing your history with panic, and considering why you haven't gone crazy yet. If you're attributing your sanity to support people, support objects, limiting your travel, and so on, this can maintain your fear of insanity, even though a panic attack cannot make a person crazy. You may feel like you're going crazy, but it passes! So you need some coping techniques to help you pass the time until the attack passes.

David: Here is a comment, then a question on generalized anxiety disorder:

ogramare: Anxiety medications have pretty well eliminated my panic but I am left with a giant case of Generalized Anxiety Disorder (GAD). I can feel really nervous with no mental stimulation, no panic and no apparent reason. This may be off-topic for this discussion as I have not been here before.

mclay224: I was wondering what are some ways of coping with and eliminating the generalized anxiety?

Dr. Carbonell: In my experience, when someone with GAD also has a history of panic, the generalized anxiety is usually a form of anticipatory anxiety. They're no longer having the panic attacks, but they're constantly "on guard" against them. So it's usually important to discover the ways you have of being on guard, and replace them. Physical tension, limiting your movements, all manner of "self protective" measures like these can maintain the generalized anxiety.

cosset: Little humor: I've found that the fear of going crazy is overwhelming, but once you get past the fear of going crazy, nuts isn't that bad :)

David: And on that note, I know it's getting late. Thank you, Dr. Carbonell, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful.

We have a very large and active community here at Healthyplace.com. Also, if you found our site beneficial, I hope you'll pass www.healthyplace.com, around to your friends, mail list buddies, and others.

Dr. Carbonell's website is here.

Dr. Carbonell: Thanks very much for having me!

David: Thanks Again, Dr. Carbonell, for being here tonight. Good night, everyone.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Dr. Granoff is an expert in the treatment of anxiety, panic and phobias. Author of the book "Help, I think I'm Dying. Panic Attacks, Anxiety and Phobias", and the video "Panic Attacks and Phobias Conquered".

Dr. Abbot Lee Granoff: Guest speaker

David: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. The topic of tonight's conference is: "Conquering Your Panic, Anxiety, and Phobias." We have a wonderful guest: Abbot Lee Granoff, M.D, board-certified psychiatrist and a nationally known expert in the treatment of anxiety, panic, and phobias. During the approximately 30 years he's been in practice, he has successfully treated thousands who suffer from panic attacks and phobias. Dr. Granoff has written a book entitled "Help, I Think I'm Dying. Panic Attacks, Anxiety and Phobias." He also has a video: "Panic Attacks and Phobias Conquered" in which patients share their stories and how, through proper treatment, they were able to overcome these debilitating disorders.

Good Evening, Dr. Granoff and welcome to HealthyPlace.com. Thank you for agreeing to be our guest. To make sure everyone is on the same page tonight, can you please define "anxiety, panic and phobia" for us? Then we'll get to the tougher questions.

Dr. Granoff: Anxiety is a generalized feeling of discomfort. Panic is an attack of sheer terror as in the 'flight or fight reaction. Phobia is an unrealistic fear.

David: Since we've all experienced panic attacks in our lives at some time or another, how do you know when it's time to seek professional treatment?

Dr. Granoff: Only people who have experienced life-threatening experiences or have Panic Disorder have experienced panic attacks. There are many who have experienced neither.

David: I think what many people tonight want to know is; is there a cure for severe anxiety and panic disorder? And if so, what is it?

Dr. Granoff: You first have to understand what panic attacks are and why they occur, then one can find a cure.

Panic attacks are a chemical imbalance in the brain which has a genetic predisposition. When stress gets too high, it kicks the part of the brain that causes fight or flight into a panic attack.

David: What are the most effective ways to deal with it?

Dr. Granoff: My book and video go into this in detail. Understanding it is the first step. The next step is to get medication to rebalance the brain chemistry.

David: And we'll get into the medications in a minute. First, some audience questions:

sunrize: Do you feel it is possible to overcome these phobias without medication? I have a fear of medication.

Dr. Granoff: I have treated many patients who have medication phobia. This makes them harder to treat because medications are most often needed to get a decent result.

David: What are the most effective medications on the market today? And how much relief should one expect from taking a medication?

Dr. Granoff: The benzodiazepine tranquilizers such as Xanax (Alprazolam), Klonopin (Clonazepam) or Atavin are the most effective medications available. You get full relief when taking these medications. And taken appropriately, there should be no side-effects. You should feel normal.

Arden: Have you ever heard of the natural supplement SAM-e and, if so, is it helpful for panic?

Dr. Granoff: All herbal remedies are not FDA regulated so anyone could make any claim they want about them. There is no standard dosage and a list of side-effects is not necessary nor medication interaction. Therefore, while some of these herbal remedies may seem to have some positive effect, I remain skeptical.

David: Besides anti-anxiety medications, what other forms of treatment would be effective in dealing with anxiety and panic disorders?

Dr. Granoff: Panic attacks characteristically come and go, so there are many supposed claims of treatment that don't pan out in the long run. Desensitization can be effective but usually requires medications first so a person can feel comfortable in a phobic situation. Some techniques that are used in place of medication include deep, slow diaphragmatic breathing, snapping a rubber band on your wrist, concentrating on relaxing. All of these techniques take your mind off the acute panic.

trayc: Does hypnosis help panic and anxiety disorders?

Dr. Granoff: No. Not in my experience.

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DottieCom1: Is it common for people with this disorder to be on medications for a lifetime? It is the main thing that has helped me.

Dr. Granoff: Yes. Since this is a genetic disorder and we can't fix the gene, the illness usually remains for a lifetime. One has to view panic disorder in the same way as any other chronic illness, such as diabetes, asthma, high blood pressure, etc.

David: So, just to make sure I understand; panic disorder can never be cured, only "managed". Is that correct?

Dr. Granoff: That is correct.

KRYS: I have been treating mine with herbs and vitamins. Do you believe in the use of homeopathic techniques the same as you would a prescription?

Dr. Granoff: No. There is no scientific validity to homeopathic techniques. But if it works for you, do it.

David: We've been discussing anxiety and panic. I want to touch on phobias for a minute. How is a phobia different than panic disorder and what are the treatments for that?

Dr. Granoff: Phobias usually result from having panic attacks. These begin to occur in places where a patient has experienced a panic attack in the past. They become sensitized to the panic provoking situation, which increases anxiety and stress causing another panic attack to occur. The person will then become phobic to that situation, and experience anticipatory anxiety when approaching that situation again. They then become phobic to that situation and will ultimately avoid it.

David: Is exposure therapy, repeated exposure to the situation that causes the phobia, the best means of treatment?

Dr. Granoff: Usually not. Some people will respond to that, however, most people will become panicky in the situation and this will make them more phobic of it. The recent show on 48 hours showed exposure therapy as a new and wonderful treatment for panic disorder. They had spoken to me and had a copy of my book and video, and while they knew my treatment was much more cost-effective and clinically effective, they went with exposure therapy because my technique doesn't make for "good" TV.

David: So, what is the best treatment then for phobias?

Dr. Granoff: One has to get the panic attacks under control with medication, then have the person de-condition themselves through exposure therapy. This is much more effective than exposure without medication.

David: Here are some more audience questions, Dr. Granoff:

cherub30: How can a person who experiences these attacks, not keep repeating the problems that triggers them?

Dr. Granoff: It's not about repeating the problem, it's about repeating the situation without experiencing a panic attack. The benzodiazepine tranquilizer mimics a chemical the brain produces on its own. The genetic disorder kicks in when there is more stress present exceeding the amount of chemical the person can produce on their own.

Martha: Can improper breathing ( i.e. hyperventilation) actually stave off an attack or at least minimize the attack while it is happening?

Dr Granoff: No. Slow breathing is better. When you hyperventilate, you blow off carbon-dioxide and cause tingling and numbness and your extremities, face and head. That is a symptom of a panic attack.

kathy53: What can you use for anxiety attacks if Paxil, Zoloft or Celexa have no effect.

Dr Granoff: They all have an effect. But the antidepressant medications have a secondary effect on anxiety, where as the benzodiazepines have a primary effect. The main concern with the benzodiazepine is addiction, memory loss, and sedation. However, 98% of people using the benzodiazepine use them appropriately even for a life time and do not become addicted. 2% abuse these medicines while abusing alcohol and street drugs at the same time. Sedation and memory loss are dose-related if these side effects occur, lowering the dose gets rid of them. The antidepressants, including Paxil, Zoloft, Celexa and Imipramine, etc., have side-effects which often cause insomnia, weight gain, and sexual dysfunction. For me, it's a no-brainer to choose the most effective and least problematic medication, the benzodiazepine tranquilizers. These are safe and effective to use for a lifetime, if necessary. Also, the drug companies are marketing the antidepressants with lots of dollars because they make lots of dollars on them. The benzodiazepine tranquilizer generic is much less costly.

David: That's a good thing to know.

sassy: I have a lot of trouble with racing thoughts, a lot of daydreaming and stuff. I can't seem to stay focused on anything, always feel frustrated and confused. Feels like I am losing grip here. Can you tell me what that is all about?

Raven1: I have had anxiety attacks for 15 years and nothing has helped me at all. In fact, I tried taking Zoloft and it made me very sick. I'm now taking St. John's Wart. I have been through mounds of therapy, been to many doctors and I feel like I'm never going to pull through and be able to live on my own. I'm almost 18 and need to be helped before it's too late. What can I take that won't make me sick?

Dr. Granoff: The benzodiazepine tranquilizers prescribed by a knowledgeable psychiatrist. Your general practitioner is not qualified to treat this.

David: And that's a good point, Dr. Granoff makes. It's important to go to a specialist, one who knows how to treat anxiety, panic and phobias. Not your general practitioner.

Dr. Granoff: A psychiatrist is the only M.D. who specializes in mental health and is the only mental health practitioner who is an M.D.

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David: Dr., we are getting quite a few questions on exactly what is your technique for effectively treating anxiety and panic? Could you be somewhat detailed?

Dr. Granoff: That's impossible to do in this forum. My book and video explain this in detail.

David: Here is the link to purchase Dr. Granoff's book: Help, I think I'm Dying. Panic Attacks, Anxiety and Phobias. I also believe Dr. Granoff's book is available at the major bookstores. Is that right Dr. Granoff?

Dr. Granoff: Yes. The video can be purchased on my website.

Smoochie: Is Paxil a good antidepressant for anxiety and panic attacks?

Dr. Granoff: In 30% of cases, Paxil and medications like it make the panic and anxiety worse. In 30 %, it has no effect and in 30%, it seems to help. The antidepressants, like Paxil, usually help when the person has both panic and depression and the depression is the primary illness with panic as the secondary illness. And Paxil often causes weight gain, insomnia and sexual dysfunction.

vick b: Would therapy help at all? And when will the non-addictive drugs for anxiety come out?

Dr. Granoff: The marketing department of the Paxil drug company doesn't want you to know this because they won't sell as many pills. And yes, therapy in combination with medications is the best form of treatment.

David: For the audience: I'd be interested in very short comments on how you effectively dealt with your panic, anxiety, or phobia. Here are some audience responses "on what's worked for you":

wintersky29: changing the way you think, from negative to positive, that's how I deal with it.

Raven1: I have tried exposure therapy for my separation anxiety and it only makes me want to kill myself and more depressed.

cookie4: Paxil made mine worse, switched 5 different times before finding one that works

kristi7: For me, a sufferer for 20 years now, I never had medications other than Ativan for a funeral. I used relaxation techniques and Attacking Anxiety program cognitive behavioral therapy (CBT).

Dr. Granoff: CBT therapy means thinking therapy and understanding your condition and your body's response to it.

Martha: I've read that exercise acts in the same way as uptake inhibitors, is this true?

Dr. Granoff: While exercise can reduce some stress, it is not going to reduce enough to make a difference.

Hemlock: This is very interesting, I had anxiety that was unreal over surgery and I'm on Paxil.

Eileen: Paxil gave me a new lease on life after 24 years of total fear and misery!!

trayc: What about Buspar?

Dr. Granoff: Buspar is not effective for panic attacks.

blusky: I only have problems driving alone but can go places with people without panic.

kristi7: Is there a test to prove the chemical imbalance?

Dr. Granoff: Not for the general public, for research only.

David: A lot of the things we are talking about tonight have been around for a while. Do you know of anything new coming online?

Dr. Granoff: Nothing that I know of. However, with the deciphering of the genetic code we will one day find the gene or genes that produce panic. Once found, cures will be found to fix the gene.

David: Just to jump back for a second Dr. Granoff, is there a reliable test available to check for brain chemical imbalance. I mean, can I go to my psychiatrist and have this done today?

Dr. Granoff: No. The diagnosis is made by taking a thorough history. This is outlined in my book.

diana1: I have stopped taking Paxil-30mg, cold turkey, and had what was referred to by my therapist as "brain firings". It is a sensation somewhat like hitting your funnybone, but in your head for a split second. Is this normal?

Dr. Granoff: You were experiencing withdrawal from the Paxil. This should stop after 4 or 5 weeks. If it doesn't, it is a return of anxiety symptoms, which can be better treated by using the benzodiazepines (Xanax, Ativan, Klonopin, etc.)

jeansing: Is there research being done at this time for finding genes for Panic?

Dr. Granoff: Not that I'm aware of. There are a lot of genes to find for a lot of diseases. It will be placed on the list and hopefully found soon.

panickymommy: Why is it that driving is so hard for me? I cannot drive in places where there is nowhere to pull over; for example, in construction areas or down narrow roads. This is ruining my life!

Dr. Granoff: Most phobias occur in situations where escape is difficult or would prove embarrassing. For instance, driving on an expressway, in a tunnel, over a bridge, in the left turn lane, sitting in a dental chair, standing in a checkout line at the grocery store or sitting in church, a restaurant or movie.

David: What would be an effective way to get some relief from that?

Dr. Granoff: Getting appropriate treatment from a qualified psychiatrist.

figa: Can agoraphobia ever be cured? And if I start exposing myself to my fears, like eating, etc., will my anxiety start to drop, or will I have to take medication? I have lost 14 pounds in two weeks and cannot eat or sleep well.

Dr. Granoff: Medications are usually necessary and effective and safe.

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David: Here's a question about "social phobia", or what many call "shyness":

z3bmw: Hi, have you ever treated a person who talked freely at home but wouldn't talk in public?

Dr. Granoff: Yes. I would have to know the cause of the attacks. Counselors, social workers, psychologists, and your family doctor will tell you to exercise, provide relaxation training and supportive therapy. While that might help some--a qualified psychiatrist will help most

David: Here's another agoraphobia question:

Aussiegirl: I started having Panic Attacks three months ago. Everything was fine before that. The last time I had a panic attack, I ended up screaming and lost control. Since then, I have developed agoraphobia. How can I help myself if I can't leave the house? I couldn't even get to a therapist.

Dr. Granoff: First, get my book and video to understand your condition and how it should be treated. Then, find a qualified psychiatrist to treat it, perhaps by phone at first.

David: Dr. Granoff, I want to thank you for being our guest tonight. You've been helpful and given us more insight into the causes and treatments of anxiety, panic and phobias.

Dr. Granoff: It's been my pleasure.

David: I also want to thank everyone in the audience for coming. I hope everyone in the audience will feel free to visit anytime. I think it's important to support each other and pass along information on what does and doesn't work.

Good night everyone and thank you for participating tonight.

POSTSCRIPT TO CONFERENCE:

Following the conference, Dr. Granoff answered this question regarding medications vs. cognitive behavioral therapy to treat anxiety disorders:

Caroline: The anxiety and panic conference on HealthyPlace.com a few days ago seemed to indicate that you feel that medication is the only way to go and that anxiety disorders are life long conditions only to be managed not cured.

Vast numbers of people have overcome their anxiety problems without the use of drugs. CBT is recognised as the best treatment for anxiety disorders. I personally found the conference made people feel worse. Although you may have been well-intentioned, many people I have spoken to felt the same.

The following is an excerpt from Christopher McCullough's book "Nobody's victim".

Biomedical approaches to treatment similarly employ the disease metaphor. They tend to cast blame on "biochemical imbalance", an approach that rests on extremely shaky assumptions. Psychobiological research attempts to establish causal relationships between biochemistry and emotion.

Because certain medications taken by certain patients make them feel better, researches conclude that the drug corrects the chemical imbalance that was causing misery. This is like claiming that since you feel more relaxed after drinking gin, it's evidence that you were gin-deficient.

Such research sounds serious and important. A presentation at a recent conference of the Anxiety Disorders Association of America was entitled "Increased Regional Blood Flow and Benzodiazepine Receptor Density in Right Prefrontal Cortex in Patients with Panic Disorder." Interestingly, however, many patients recover from panic and anxiety using nonmedical treatments such as behaviour modification, breathing, or divorce without doing anything to their "receptor densities".

Dr. Granoff: "Vast numbers of people" may get temporary relief from anxiety using only CBT. About 60% of people studied get temporary relief from placebo. In my experience, having treated thousands of people, often the relief from only CBT is partial and temporary. Sometimes it has a longer lasting effect.

Medical research shows that panic disorder is usually lifelong. Some people can have one or an episode of panic attacks never having any others. Some people have their first episode with minimal or no relief for decades. For most people, it is a recurring illness which waxes and wanes throughout life. The longer the study, the larger the number of people who experience a relapse.

CBT only is promoted mostly by psychologists, social workers or counselors. These mental health professionals cannot prescribe medications, whereas psychiatrists can prescribe medications and do CBT. You have to be able to read the medical literature with a critical eye and recognize the biases of the researchers.

A combination of CBT and medications is the most effective treatment. I tend to stress medications as my bias because too many people are misinformed about their safety and effectiveness. They become fearful that the medical/pharmaceutical industry is taking them on a royal ride for economics. I certainly use CBT in my treatment along with medications.

My book and video explain why panic attacks occur (stress), causing the genetic predisposition to kick in, causing the brain chemistry to flip out of balance and how the medications and stress reduction of any kind (including CBT) rebalance the chemistry. Although no gene has yet to be identified to cause panic attacks, the genetic link is clear.

In medicine, especially in psychiatry, there is more than one way to skin a cat. Human behavior is exceptionally complex and varied. Hanging upside down by your toes might work to cure panic attacks in one person. If that works for that one person, I can't argue with it. I would suggest they continue hanging. Likewise, CBT might work for some people. If it does go with it.

Realize if you still experience the pain of panic while using CBT, like Kim Basinger did while getting her academy award in the HBO panic show, there are medications that can offer relief.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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1. An Inside Look At Anxiety
   Guest: Samantha Schutz

2. Anxiety and OCD Medications
   Guest: Carol Watkins, M.D.

3. Anxiety Caregivers
   Guest: Ken Strong

4. Anxiety Disorder Relapses
   Guest: Evelyn Goodman, Ph.D

5. Attacking Anxiety and Depression
   Guest: Carolyn Dickman

6. Conquering Your Panic, Anxiety, and Phobias
   Guest: Dr. Abbot Lee Granoff

7. Food and Your Moods
   Guest: Dr. Kathleen DesMaisons

8. Getting the Best Treatment For OCD
   Guest: Dr. Gerald Tarlow

9. Help For Agoraphobia
   Guests: Dr. Paul Foxman

10. Managing Your Anxiety
    Guest: Dr. David Carbonell

11. Obsessive Compulsive Disorder OCD Medications and Therapy
    Guest: Dr. Alan Peck

12. Obsessive Compulsive Disorder: How to Help Patients with OCD
    Guest: Dr. James Claiborn

13. OCD and Cognitive-Behavioral Therapy
    Guest: Dr. Michael Gallo

14. OCD: Getting Control of Your Obsessions and Compulsions
    Guest: Dr. Lee Baer

15. Power Over Panic
    Guest: Bronwyn Fox

16. PTSD Diagnosis and Treatment
    Guest: Dr. Darien Fenn

17. Social Phobia, Social Anxiety
    Guest: Luann Linquist

18. Thought Field Therapy
    Guests: Dr. Frank Patton and Phyllis

19. What To Do About the Obsessions Part of OCD
    Guest: Dr. Michael Jenike

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Dr. Gerald Tarlow joined us to discuss different treatments for OCD (Obsessive-Compulsive Disorder), such as behavior therapy, exposure and response prevention, and OCD medications (like SSRI's). He discussed how facing your fears through therapy can abolish your compulsions and significantly reduce your obsessive thoughts, thus alleviating your feelings of shame and guilt.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. I'm glad you had the opportunity to join us and I hope your day went well. Our topic tonight is "Getting The Best Treatment For OCD, Obsessive-Compulsive Disorder." Our guest is Gerald Tarlow, Ph.D., of the UCLA OCD Day-Treatment Program. He is also director of Center for Anxiety Management. We'll be discussing therapy, meds, and hospitalization to treat OCD. Dr. Tarlow will also be taking your personal questions.

Good evening, Dr. Tarlow, and welcome to HealthyPlace.com. Thank you for joining us tonight. What would you say defines the "best treatment for OCD?"

Dr. Tarlow: The best treatment for OCD could be behavior therapy, OCD medications, or a combination of the two.

David: Some people may live in or near Los Angeles and may have access to a great treatment program, like the one at the UCLA Medical Center. However, many people don't. How does one find excellent treatment for Obsessive-Compulsive Disorder in their community?

Dr. Tarlow: It is difficult to find good, experienced behavior therapists. I would suggest that people contact the OC Foundation in CT.

David: When you use the term "good, experienced behavior therapists," what do you mean by that? What should people be looking for when selecting a behavior therapist?

Dr. Tarlow: It is important that the therapist have experience treating OCD patients using the techniques of exposure and response prevention.

David: Don't all therapists have that type of training?

Dr. Tarlow: No. In fact, very few have been trained in these techniques.

David: I want to address some OCD treatment issues. Many people with Obsessive-Compulsive Disorder suffer from shame and guilt because of the symptoms associated with the disorder. That, alone, may prevent them from seeking the treatment they need. They experience tremendous amounts of guilt, not only for their unsavory thoughts but also for what it implies about their character. How do you remove the shame and guilt pervasive among OCD sufferers?

Dr. Tarlow: It is important for people with OCD to talk to other people who have had similar problems. The attention that OCD has received in the media (e.g. talk shows) has also been helpful in getting people into treatment.

David: I think some people with OCD have expectations of what will happen when they take OCD medications, like Prozac, Paxil, Zoloft, Luvox and combine that with therapy. From emails I receive, many are expecting to be cured. Is that reasonable?

Dr. Tarlow: I don't like to use the word "cure." The problem can be controlled and people can lead very productive lives.

David: So are you saying the obsessions and compulsions never really go away completely?

Dr. Tarlow: Since obsessive thoughts are experienced by about 90% of the population, I would say it is difficult for them to go away completely. However, the frequency and intensity of the thoughts can be greatly reduced and the compulsions can be eliminated.

David: I know that each person is different, but roughly how long does it take, using medications and therapy, to experience a significant improvement in your daily life if you have mild to moderate OCD? Then, extreme OCD?

Dr. Tarlow: For mild to moderate OCD you could expect treatment to last 3-6 months. For more severe OCD it may take several years to really get the problem under control. However, with the intensive treatment programs, similar to the one at UCLA, we can reduce the symptoms significantly in a short period of time (3-6 weeks).

David: Is there any reason you can think of for someone to be afraid of therapy for OCD? Will it initially be a scary process?

Dr. Tarlow: Behavior therapy involves facing the fears. This may produce a great deal of anxiety for many patients. However, we can make the process easier by starting with mild fears and working up to more difficult ones.

David: One other question before we start with the audience questions. When is it time to consider hospitalization for OCD, whether it be inpatient or outpatient? And what is the difference in the treatment program between the two types of hospitalizations?

Dr. Tarlow: Very few people need to be hospitalized for OCD. Most of the intensive treatment programs are usually 2-6 hours per day. It is important that patients learn to confront the fears in their home environment, not just in the hospital.

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David: Here is the first audience question:

nutrine: Hello to the moderator and Dr. Tarlow. I'm an OCD patient from India!!! How severe can the obsessive thoughts be and how likely are they to be cured?

Dr. Tarlow: Obsessive thoughts can be very severe. They can occupy one's entire day. They are treatable no matter how severe they are.

OCBuddy: I am wondering if Dr. Tarlow has any experience or thoughts about the use of 5-HTP, an amino acid, for treating the depression that often comes with OCD?

Dr. Tarlow: Sorry, no experience at all with that.

reishi9154: Hello to everybody here tonight. I'm an OCDer from Maine. My question is, where do intrusive violent thoughts come from and what is the likelihood that they will be acted out?

Dr. Tarlow: Intrusive, violent thoughts are actually very similar to all other OCD thoughts. The thoughts are, of course, produced in the brain and are often triggered by a specific scene or situation. If they are truly obsessive thoughts they will not be acted out.

slowsun: Why do you think that some people have thoughts of scrupulosity and others have other thoughts or fear of hurting someone. Is it mainly related to the person's experiences in life or something else?

Dr. Tarlow: I do believe that an individual's obsessions are related to their own life experiences. The obsessions could be related to what you see or what you read about.

missbliss53: What is the best medication for OCD?

Dr. Tarlow: I am a psychologist, so I don't prescribe medications. However, from my experience it appears that the SSRI medications are all about equally effective in treating OCD.

David: Missbliss, the general literature available suggests that SSRI's like Prozac, Zoloft, Luvox, and Paxil are helpful. But you should contact your doctor or a psychiatrist for more info on that.

Here's the next audience question:

ruffledfeatheredloon: Is it possible to get better without taking medicine?

Dr. Tarlow: Absolutely. Behavior therapy has been shown to be as, or more, effective in many research studies.

seb: Is there research going on right now so that we can hope for a complete cure some day?

Dr. Tarlow: I think the treatment is very effective right now. I would guess that there may be new medications that might come along that are even better.

kimo23: How can behavior therapy help someone who only has obsessions and no compulsions?

Dr. Tarlow: First of all, many people with obsessions often engage in mental rituals to alleviate the anxiety from the obsessions. Behavior therapy also involves utilizing a technique called imaginal exposure which is very helpful for obsessions.

David: What is imaginal exposure?

Dr. Tarlow: Imaginal exposure involves having the patient imagine their worst fears actually happening. The patient is then asked to continue imagining these fears until they no longer produce anxiety.

David: On the subject of "imaginal therapy," here's one audience comment:

Nerak: Oh My God, that sounds like it would be a very scary thing to do!!

Dr. Tarlow: Again, the behavior therapy is not fun. It is work and it does produce anxiety. I like to compare it to bad tasting medicine. You know it is good for you, but it does taste bad.

David: Earlier, we addressed the guilt and shame involved with OCD. Here's a question on how to deal with your family:

nutrine: It's difficult for me to express the severe obsessive thoughts to my family and my psychiatrist. How can I go about with the process?

Dr. Tarlow: It may be helpful to start with some of the thoughts that are less severe. If you can see that these thoughts are helped by the therapy, you may be more open to talking about the more severe thoughts.

holly43: My daughter says she has no fears of anything happening but just wants to do everything perfectly. How do you handle this?

Dr. Tarlow: Many people have done their compulsions for so long they are no longer connected to the original obsessive thoughts. For people like this we try to use exposure to doing things imperfectly without allowing the person to correct the situation.

David: For those in the audience, if you've been in therapy for OCD, maybe you could send me a brief comment on how that is going or how it worked out for you. I'll post the comments as we go along.

Does age make a difference in the level of responsiveness to behavioral therapy?

Dr. Tarlow: Generally not. However, some older patients have more difficulty with the treatment.

David: Why is that?

Dr. Tarlow: They have had the obsessions and compulsions for a long time and have learned to live their life around them. They avoid a lot of things. Also, they may not be able to identify the thoughts as obsessions.

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David: Here's a response to a question from Holly earlier tonight.

reishi9154: In response to holly's question, I had something like that where there was nothing I was really afraid of but I had to plan the next day for hours before I went to bed, otherwise I wouldn't be able to go to sleep or I'd wake up panicked. I just wanted to 'make sure' it would be a good day.

David: And here are some audience comments on "therapy experiences" for OCD:

slowsun: I am combining therapy with medication (Luvox) and have made great strides from where I started. I still hope to improve even more though. Most of my obsessions are fears of having the obsessive thoughts.

reishi9154: Therapy is working decently for me. I find it helps to have someone who understands my problems and fears, and she generally has helpful things to say. Medicine also complements that very nicely.

David: Here's the link to the HealthyPlace.com OCD Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this.

Here's the next audience question:

Gattica: Are there life events which trigger OCD or is it independent of this and biochemical and would arise anyhow?

Dr. Tarlow: People often experience OCD in response to stress. It may be that many people are predisposed genetically toward OCD and it comes out initially during a stressful life event.

galia: What is the % of people who got well from the day program? How much does it cost and can program graduates be contacted for details?

Dr. Tarlow: 96% of the patients in our program reduce their OCD symptoms by at least 25% in the first six weeks and 50% of our patients reduce their symptoms by at least 50% during the first six weeks. The program costs approximately $320 per day. It would be possible to contact some ex-patients to get their feedback.

David: Are there similar programs that you know of in other parts of the U.S.? If so, where?

Dr. Tarlow: Rogers Memorial Hospital in Wisconsin has a day treatment program and a residential program. Mass General in Boston also has both programs. The Mayo clinic just started a day treatment program for OCD.

LeslieJ: Those of us with Bipolar Disorder, like myself, experience problems with obsessive thinking/ruminating only when we are in one particular cycle--such as hypomania or mania. Have you any experience with treating this with behavior therapy? Also, is it possible to take medications for OCD, such as Prozac, only during that cycle and have it be effective?

Dr. Tarlow: If you are currently experiencing the symptoms it would be possible to use behavior therapy. Again, I am not a psychiatrist. However, I have not heard of people taking the medications only during a particular cycle.

deeeni: Dr. Tarlow, I've been repeating the same sentence in my head for a month. It has to do with me dying. I suffer from bipolar disorder and the voice started when I was going through a rapid and mixed cycle. I still have the same sentence at the same time everyday. Is this some complication of bipolar or OCD?

Dr. Tarlow: It could be an OCD symptom triggered by the time of day.

David: Regarding an earlier question on whether OCD is caused by situational events or is biochemical in nature, here's an audience comment:

reishi9154: In response to Gattica's question, I feel that in many ways OCD is a control thing and that my personal OCD could have arisen in response to situations when I was younger where I felt very ill-at-ease with myself and surroundings. I think my OCD compulsions were a result of that and were meant to take control of my surroundings and better my life, but they backfired. I think that you can be predisposed to the disorder genetically but there is something environmentally that has to happen to really kick it

David: Besides depression, do you see many patients with OCD and other psychological disorders? I'm wondering how common that is?

Dr. Tarlow: It is common to have other problems along with the OCD. Many patients have another anxiety disorder, such as generalized anxiety. Other patients have eating disorders, impulse control disorders, substance abuse problems and even psychotic problems.

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David: I would imagine that makes treatment all the more difficult and complicated. Is that true?

Dr. Tarlow: Yes, it is important to determine which problem should be treated first.

ruffledfeatheredloon: Someone said OCD is caused by tightness in the brain and that you should learn to relax your brain. They said especially the part between your eyes. How can you do that? I don't understand.

Dr. Tarlow: I wish it was that simple. I don't think there is any research evidence that shows that technique will help people with OCD.

David: Earlier, someone sent in a question about which books might be helpful in understanding OCD and also deals with self-help issues. Are there any books that you would recommend, Dr. Tarlow?

Dr. Tarlow: Getting Control, by Lee Baer, is an excellent self-help book. There are others by Edna Foa and Gail Steketee that are also very good.

firespark3: Do you have any tips for people with trichotillomania?

Dr. Tarlow: Trichotillomania can best be treated with a technique called habit reversal. It is different from OCD treatment. It involves learning to break the conditioned, or learned habit.

David: And how is that accomplished?

Dr. Tarlow: It involves a series of techniques including relaxation training, self-monitoring, learning to use a competing response and several more.

David: There is one last thing I'd like to touch on. What help is available for family members of OCD sufferers?

Dr. Tarlow: There is an excellent book by Herb Gravitz that should be read by family members. There are also family support groups available. Finally, I would encourage family members to go to the therapy sessions with the patient, learn what the therapy involves and how to help out.

David: What can family members do to help the OCD patient?

Dr. Tarlow: They need to know what the patient's assignments are. They should not do compulsions for the patient. They should not get angry at the patient.

David: I know the last thing might be pretty difficult -- not getting angry at the patient. I'm sure that's where therapy for family members would be a help.

Dr. Tarlow: Yes.

David: Thank you, Dr. Tarlow, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful.

Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Dr. Tarlow: It was my pleasure. Thank you for having me.

David: Good night, everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Carolyn Dickman, Education Director of the Midwest Center for Stress and Anxiety.

David: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. I hope everyone's day has gone well. Our conference tonight is on "Attacking Anxiety and Depression". Our guest was going to be Lucinda Bassett. However, Lucinda contacted me and said she had a personal emergency, and we are lucky because Carolyn Dickman, who works with Lucinda, and actually went through her Attacking Anxiety program, is with us tonight. Her story is very interesting and what she was able to accomplish in treating her severe panic attacks and anxiety (Panic Disorder) will hopefully inspire many of you tonight.

As a youngster, our guest, Carolyn Dickman, was an anxious child. By 13 years of age, she graduated to panic attacks. At the time, no one spoke of panic and anxiety (back in the 1950's). She didn't discover what she suffered with until she was 40. That was 27 long years of not knowing what was wrong.

Intermittently, throughout those years, Carolyn was house bound, travel and vehicle avoidant, prone to bouts of anger and severe depression. She hid it all, even self-medicating with alcohol. It was a secret that "I was dying-or so I thought." It took a long time, but finally Carolyn found some tools that worked for her and she'll be sharing those with us later this evening.

Good Evening, Carolyn and welcome to HealthyPlace.com. We appreciate you being here tonight. Even today, there are many people who haven't identified their symptoms as Panic Disorder and who are scared out of their wits by what is happening to them. What was it like for you growing up?

Carolyn: I thought I was the only person on earth with the horrible scary thoughts and feelings of dying every day. The body symptoms lead me to doctors. No one could give me a name for whatever "it" was. I always felt out of touch with family and classmates, feeling something was "wrong" with me.

David: How did you discover that "something," was Panic Disorder?

Carolyn: I had a TV in the kitchen and I was watching it, and I saw Lucinda Bassett talking about body symptoms. I thought, oh dear, she has been sitting on my left shoulder for the past 30 years.

David: Before we get too far into that part of it, I'm wondering what it was like for you, personally and socially, dealing with panic and anxiety, during those early years, teens-20's?

Carolyn: As a teen, I was a great date because I couldn't eat, so I was very inexpensive. I couldn't stay away from home too long, so my parents loved that. I did most things teens and college students do, but with great fear. Fear defined my life and my decisions. I was never at peace, I always questioned my decisions. I was a perfectionist and analytic. People with anxiety disorders, panic disorders, are very clever at designing a life around their disabilities.

David: So, during that time, how did you deal with various situations?

Carolyn: Frankly, I gutted my way through some. I lied my way out of the things I couldn't do, like, go on vacation. "No, too busy." I cried a lot! Prayed a lot! Now, my goal is to help others, so they don't have to go through the pain I did because of ignorance. I have used what happened to motivate me, and hopefully, I can inspire others. If I can overcome this living hell, so can you.

David: We'll be talking more about Carolyn's road to recovery from panic and anxiety disorders. But first, some audience questions:

blusky: Do you believe that anxiety attacks, and the fears that come with it, are a learned behavior?

Carolyn: Yes. I believe it is reasonable to think that some of us were born with a goosey limbic system. However, from my experience we learn our fears and our responses to life. I have a dear friend who was once afraid of elevators. She survived encephalitis, but it wiped out her memory banks and she now loves elevators. I am not suggesting we go in for a sweep, but I truly believe we can replace our mis-beliefs. I have "learned" to fly, travel, do public speaking, the list goes on.

karen5: How long did it take you to control your panic episodes.

Carolyn: As you know, I went through Lucinda Bassett's Attacking Anxiety Program. There are 15 lessons, one per week. The second lesson is on controlling and stopping panic. There must be some justice in the world, because after that lesson, I've never had another panic attack. Now, not all of our participants can say that, some take a bit longer. The key is attaining basic beginning physical comfort, determining no physical illness, and most vital, learning why there is nothing to fear and then losing the fear. Recovery is like an onion with many layers.

irish_iz: Do you know what, if anything, started your panic attacks when you were a teenager. For instance, abuse, dysfunction, etc.

Carolyn: Short answer of what I went through: dry alcoholic, perfectionist, painfully poor, authoritarian, verbal abuse. My sensitivity was high; when the nuns talked about Jesus on the cross, I felt the nails :) There were also many many stressors like moving, illness, etc. It was a rain barrel effect: it doesn't matter if the rain comes from a storm or a shower, if we don't manage the level to evaporate some, one drop will send it overflowing. At 13, I had come to the brim and over, and from then on, it rained :).

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David: Here are a few audience comments on what Carolyn's been saying - then more questions:

SuzieQ: So very true. We all seem to be subject to the hypersensitive, "feeling other's pain"! She is telling our life stories as well : ).

Meg1: Carolyn, you are an inspiration. I identify with your story. Well told.

imahoot: Has anxiety or fear ever kept you bedridden for weeks on end?

Carolyn: For those interested, I write and edit a newsletter, call for a free copy 1-800-944-9428.

To imahoot, yes my children would come home from school and ask why my eyes were red. I often said I had a cold. I wondered how my history affected them, and at one time in the recent past I apologized for all the missed athletic events, plays etc. My oldest (30+) said, "But Mom, you forget, we got to see you get better." Maybe I didn't do such a bad job to have such a sweet child.

David: What about the depression that couples the panic and anxiety? Were you affected by that?

Carolyn: Yes, as time went by, I became increasingly depressed. I didn't want to live anymore by the time I was 40. I regularly asked God to take me, but He knew better. Depression naturally comes to people who constantly stress out because we deplete seretonin. Then add the horrible inner self talk "I'm no good. I can't do anything right." No wonder we become depressed! Every thought brings with it it's own biology/chemistry.

Here is a great true story: my daughter took her dog to the car wash this winter. Everytime the arm of the washer hit the dog's side of the car, the dog stood up and shook itself off! The dog was wet in her mind! We do that too. Now, if we can make ourselves miserable, I believe with the right skills we can also help ourselves to happiness!

David: I think you have an interesting story and many people here tonight can identify with what you are saying. There are many people here tonight who feel exactly like you did. How did you cope with the depression?

irish_iz: Carolyn, wonderful analogy about the dog at car wash.

Carolyn: I didn't! I didn't really have any skills because I didn't catch any growing up. I thought I was a realist but now I know I was a fatalist! I would stop eating, stay awake most of the night, cry all the time, hide it with drinks - which wasn't terribly bright, as we know alcohol is a depressant! But I had a rationale for that too. I figured if we give hyper children a stimulant to settle them down, perhaps a depressant would pick me up. Oh brother! I don't think there is any thing worse than depression.

David: For people in the audience tonight, I'd like to know what the hardest part of living with panic, anxiety is like. I'll post the responses as we go along.

I want to get to a few more audience questions, then we'll talk about what you had to do to control the severe panic and anxiety that took over your life.

lizann: Carolyn, I find that I am always analyzing what other people must be thinking about me and I think that creates a great deal of anxiety. Do you experience that, and if so, have you found any particular techniques that are effective in combating it?

Carolyn: I am proud of the work I have been able to do in the workbook and on the tapes. Because of my experience with depression, we update the Attacking Anxiety program every 6-18 months. We stay up-to-date.

lizann: I find this to be evident in most sufferers, we are so into control, and at the same time feel so out of control inside, that we try to control the universe. We wish to appear in perfect order at all times, and we scan for this constantly.

Yes, I have experienced the same and it creates lot's of anxiety. I don't do this as much anymore. I know I am a good and worthy person. I know that what others think of me is NONE of my Business :) We can learn how to think differently, and I am so glad I learned how to understand. Now, I had to have someone teach me because I didn't know how.

David: Here are some of the audience responses to "what is the worst part of living with panic/anxiety?":

luvwinky: The hardest part is - relationships.

wallie2: Staying alone, for me. I have lots of trouble staying in my apartment. I am always staying at relatives.

sparrow1: The hardest part of living with panic is not being understood by my family and friends. They say things like "just get over it."

Roach: The hardest thing about anxiety was the agoraphobia and staying alone. Any ideas?

Sissy: For me, the constant bewilderment and fear of what will happen next?

imahoot: The excruciating fear that lingers within your system, and not being able to function outside home!

Chatyg47: I clean constantly, day and night. My house has to be perfect because I care too much about what others think of me. I have to use medication. I haven't slept without medication in 15 years.

Carolyn: We are searchers. Do you know what searchers do? They find! You are all going to find your answers alone, but first we must have comfort tools breathing techniques, thinking skills, distracting skills.

sweet1: My friends and family think I'm like this just because I need attention.

Carolyn: Attention...isn't that a hoot? The last thing we want is attention for this. We want attention for our skills and accomplishments.

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David: For those who have asked, here is the link to The Midwest Center for Stress and Anxiety.

Carolyn, I want to get into the treatment aspect of your panic and anxiety. Can you go into that for us? What did you do, specifically, to deal with your panic?

Carolyn: What would you like to do if this condition were not holding you back? Focus on a plan. Deal with the panic following my advices given in the previous comments, and adding the following: see your doctor. If your haven't already done so, test for diabetes, thyroid etc. Learn all you can about the "flight or fright syndrome". The worse thing that can happen from a panic attack is depression.

Here are some first quick fix steps:

First: Look at the sensations! Don't run! Face your sensations and say: "I know what you are, I am in charge".

Second: Allow them to be there. Don't run!

Third: breathe! in through the nose for 2 seconds, out through the mouth for 4 seconds (no holding breath). Simultaneously, count, mentally only "one - one thousand, two - one thousand, " as inhale as exhale" one-one thousand (through) four one -thousand". Do not count verbally, and make the count in a rhythm. Do this for 60 seconds. Watch your watch.

Fourth: Move into some comforting inner dialogue:

"There is no danger, there is no emergency. I am slowing my breathing, my thinking. I am here. I am a great problem solver. There is no danger, there is no emergency."

Fifth: Proceed into a bit of distraction, clean something, do yoga, crochet, rock dance, you get the idea.

Finally let a little time pass. Panic always goes away. Focus on real answers, lasting answers. You are all so very capable, I promise.

David: Just to recount here: the best ways to handle your panic are:

1) acknowledge it, don't run away from it;

2) remind yourself that you are in charge of your emotions and feelings;

3) breath in through your nose and out through your mouth in a rhythm. Then, finally, remind yourself in a positive way that everything will be okay and that you are okay.

How difficult was it for you to master this and then, has it become a part of "who you are?"

Carolyn: People ask me if I still listen to tapes that come with the program and I tell them: "no, I am the program." I really live the things I was taught. They are a part of me but that can't happen without practice. I like to use the analogy of: if your doctor writes you a prescription for medications and you just read it, you don't get the benefit :).

I hope you will call our information number: 1-800-ANXIETY. We have a free brochure and cassette to send to anyone who asks. I believe in recovery for all. It is not difficult, it's much easier than the way I was trying to live!! It takes at least 2 weeks of practice to become fairly smooth, and of course, the more the better. I never think about my 2-4 breathing anymore, it is now a semi-automatic skill.

Here is a great resource for information: Lucinda's book From Panic To Power.

David: Here are some audience questions, Carolyn:

Violet 1: Hi Carolyn, it's so nice to meet you and hear your story. I have Lucinda's program and done it. My last fear I am trying to get through is being afraid of driving on highways. I am stuck with that, do you have any ideas or hints? I have her driving tape as well and am petrified to listen to it.

Carolyn: Violet1: I scripted and recorded the Driving with Comfort tape. Please! don't be afraid. I would never scare you! Promise me you will listen to just 5 minutes of it tomorrow and write to me and let me know what you think. Driving, like most of our fears, can be best addressed by breaking it into small pieces. Just sit in your car! Make friends with it, play the radio, clean it, polish it, drive it in and out of the garage. Who cares what the neighbors think!!! Good practice for those who care too much too :).

Gradual patient practice is the key with comforting inner dialogue. Play my tape in the car!

Amber13: Carolyn, I have been doing so well for a long time, but in the last few months or so, I have not been handling it too well. I know we get growth spurts, but I can't seem to be positive once again, and I did go through Lucinda's tapes, over-and-over.

Carolyn: There is always a reason for growth spurts. Try to make a list of what has been of concern lately. If your spider plants are not having babies and that concerns you, put it on the list. Once all is in front of our faces, it is easier to be compassionate. Then, the healing must begin.

Your situation sounds like a rain barrel situation, and a gradual healing process must take place. You know the skills helped you before, please give yourself a break and do what works. Remember, if we always do what we've always done.....we always get what we always "got." Sorry English majors.

Warbucks Good evening. Are you familiar with depersonalization? And what are your thoughts on it?

Carolyn: I am familiar with the term and the diagnosis. Sometimes we allow words to scare us when there is no need. Anxiety sufferers are often on overload and "checking off line" for a time is actually self-protective and not a "diagnosis". If you have concerns regarding this as a "disorder," please check with your doctor.

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hydrangea: Since recovery comes to those that use a combination of tools such as CBT (cognitive behavioral therapy), anti-anxiety medications, support network, and faith, can you determine which was the most vital aid for you in your recovery?

Carolyn: Wow! Good question. I think learning how to comfort myself with positive, truthful inner dialogue was my most vital aid. Then learning the relaxation response was a close second. We can't do anything without the Lord. My favorite knock - knock joke is in the Bible paraphrased; Knock and the door shall be opened to you, ask and you shall receive. I see Jesus opening the door, smiling, gesturing for me to come in, and I stand there and keep knocking. We sometimes forget, we must step up and step in. We are the lock and we are the key. He gives us the grace. We must use it!

David: For those of you interested in Lucinda Bassett's program, here is the link to her site The Midwest Center for Stress and Anxiety.

Lisa5: I thought that if I told anyone they would lock me up in jail. I had a scary thought of suffocating my son with a pillow, while he slept. I love my son and would never hurt him, that is why the thought scared me so much.

Carolyn: Lisa5, I can't tell you how many times young moms have shared this same thought. You are not your thoughts! You are your actions! We tend to have scary thoughts about the things we love the most. Does that make sense?

David: Here are some responses from earlier this evening on " what is the more difficult thing when it comes to living with your panic and anxiety," then more questions.

tlugow: The most difficult thing? The embarrassment!!!

SuzieQ: Overcoming the negative habits of analytical thinking, worrying, the intensity, the perfectionism, and adopting a "so what" attitude were the most difficult traits of my panic disorder to overcome.

bladegirl: Not even being able to find doctors who can help you! That is hard. I am an agoraphobic, partially housebound for 2 years. Will recovery take longer because of this?

Carolyn: bladegirl, no! The right skills produce results! It didn't' take as long as I thought it would, nor was it as hard as I thought to change. It is not always easy, but lots easier than I anticipated.

7: Can I ask if we, as parents, know that we've got a overly sensitive child, what (if anything) can we do to possibly help them to avoid getting a panic disorder?

Carolyn: We have a Sensitive Child tape. I also recommend learning great coping skills that, as parents, we can teach modeling! Model what is helpful to the child, self-respect leads to self-esteem. Help them discover talents and nourish them.

David: Some more audience comments on "the toughest part of living with panic and anxiety":

lizann: I get so tired of the fear that comes up seemingly for no reason.

irish_iz: The hardest, if I had to pick one would be "the isolation"

hydrangea: Limitations, invisible boundaries, guilt, frustration.

deeger: The self-imposed imprisonment, the guilt over missing events, the lack of self-esteem and confidence.

Flicka: I want to know why certain fears just stay. Even after the program, I still hate elevators. Can you help?

Carolyn: Fear stays because we nurture it. Break your "practice" of elevators into very small sessions. Go with a friend, just touch the elevator door and breathe the 2-4 breathing, accompanying it with self-talk. Then step in and step out, compliment yourself and celebrate. One floor, two floors, give yourself a litany of positive comforting inner dialogue. Research elevator safety. Take small steps. This is very important, and so is consistent practice. Have a schedule on a calendar for practice sessions.

I feel limited here because of necessity of short answers, but I hope the tiny hints are a start.

Roach: How can we concentrate on breathing on one thing, when it causes some of us to have anxiety attacks.

Carolyn: Ah! I too, had breathing fears, but with consistent practice along with relaxation skills, this too, can became manageable, and actually more than just manageable. Positive dialogue makes a huge impact on this.

Tracy C: Does it take some people more than once to go through the Attacking Anxiety program, and why?

Carolyn: I went through the program 3! times not because I am deficient, but because I noticed that I felt better each time.

I think it takes a long time to change life-long habits! How many times did you practice riding your two-wheeler before you became proficient? The first time through is for education! The second time is for the heart. It makes sense that you want to live the skills. The third time is for the gut: now you are the program.

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hydrangea: I just want to share that, after I finished the Attacking Anxiety program, I had some concerns and Carolyn, you wrote me back a letter that I will never forget. At the time, I was pretty much housebound, and you told me to take it one light pole at a time as you did. And today, by gosh I collect poles as I pass so many of them. THANK YOU!

Carolyn: Thank you to hydrangea.

Henney Penney: I have all the physical symptoms of an anxiety disorder (insomnia, feeling wired, etc.) but I don't have any anxious thoughts or feelings that I am aware of. Have you heard of this version of Anxiety Disorder? And do you know how I can approach it?

Carolyn: I can't imagine! Unless your symptoms are from thyroid disease or some such. The science behind cognitive behavioral therapy (CBT) is that there is always a thought that proceeds a feeling. Therefore, what we think determines things like the reaction of fear, anger, etc.

Las Lisa: I have horrid night terrors (nightmares). Recently, I have had panic attacks when I want to go to sleep and they have progressively gotten worse. I have tried to sleep in different rooms of the house but the panic attacks continue. I literally pass out from the panic. Is there anything I can do to help alleviate this?

Carolyn: I believe the first step is a visit to your doctor. If you over-breathe to the extent of passing out, using the 2-4 breathing technique will not allow that to happen. But please, rule out any other condition.

Why the fear of sleep? That is a question that I would explore. What started the fear? How can we set up a reality based on the change in this fearful thought process? I will send you some information on this if you write to me as I know our time is limited here.

David: It is getting late and I want to thank Carolyn for joining us tonight and sharing her story and answering everyone's questions. And thank you to everyone in the audience for participating tonight.

Once more, here's the link to the Midwest Center for Stress and Anxiety and this is the toll-free number: 1-800-511-6896. You can also visit our panic-anxiety community for more information on the subject.

Carolyn: Thank you, hope to hear that it was pain-free to all.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Evelyn Goodman Psy.D., MFT, our guest speaker, is an anxiety disorder treatment specialist. She has worked with several anxiety treatment programs. The discussion centers around what to do when you experience an anxiety disorder relapse.

David Roberts: HealthyPlace.com moderator

The people in blue are audience members.

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David: Good evening everyone. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Before we start, I would like to invite everyone to visit our Anxiety Community home page and sign up for the mail list on the side of the page, so you can keep up with events like this.

Our topic tonight is "Anxiety Disorder Relapses". Our guest is Evelyn Goodman, Ph.D. Dr. Goodman is in private practice in Los Angeles, California and specializes in treating anxiety disorders and panic attacks. She has worked with several anxiety treatment programs. Dr. Goodman has presented workshops on anxiety treatment at conferences given by the Anxiety Disorders Association of America.

Good Evening, Dr. Goodman, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. So that everyone knows what we're talking about, can you please define a "relapse" for us?

Dr. Goodman: A relapse is another word for a setback. It happens when people work to recover from their anxiety disorders - 2 steps forward and one back.

David: Is there a defined period of time a person must be "recovered" before the return of anxiety symptoms qualifies as a relapse?

Dr. Goodman: No. It can happen anytime, during the recovery process, or even years later.

David: What is it that causes a person to have an anxiety disorder relapse?

Dr. Goodman: There are several possible reasons. It should be understood as a natural process - we don't make progress in a linear fashion. Most people experience a return of anxiety symptoms at some time. For some people, it's because their only coping skill was medication. For others, it's because they are under stress again and not coping with it effectively.

David: So, are you saying that people who have an anxiety disorder should "expect" to have a relapse, or two, or three, along the way... even after they've apparently recovered?

Dr. Goodman: Yes. However it's important to understand why their anxiety symptoms have returned, so they can continue on with their recovery process.

David: What are the most important steps someone should take, in dealing with an anxiety disorder relapse?

Dr. Goodman: The very first step is understanding what is going on, that they are feeling more stressed or anxious again. If the person has had the right kind of treatment, preferably cognitive-behavioral therapy, they can go back to what they've learned in the past and reapply those skills.

David: My guess would be that one of the most troubling aspects for the anxiety patient is dealing with the feeling of hopelessness -- "here we go again" -- type feeling.

Dr. Goodman: Yes. And that can lead to depression. Very often, with anxiety disorders and panic attacks, the person is feeling scared of their anxiety again. It's important to not scare oneself because that's how the vicious cycle of anxiety/panic work. One might see it as an opportunity to grow, to learn something about themselves, to remember to reapply what they had learned that helped them progress before.

David: One of the most frequent questions we get at these conferences, no matter what the disorder, is: "will this ever finally end". From what you are saying, I gather the answer is "no". That there will be periods of no, or fewer, or lower intensity symptoms, but you have to be prepared for a relapse. Is that true?

Dr. Goodman: Not necessarily. It's important that one accept that they have a sensitive nervous system, one that is highly reactive to different situations and stimuli. But that doesn't mean that a person cannot recover from having an anxiety disorder. It does take time and commitment to the recovery process. Actually, stress management must become a lifestyle. Recovery work takes lots of motivation.

David: We have a lot of audience questions, Dr. Goodman. Let's get to them:

shellmail: Can you give an example of stress management?

Dr. Goodman: Making time for daily relaxation practice, setting limits on your time and commitments, making sure you are expressing your feelings and needs, getting enough rest, to name a few areas.

DottieCom1: When you've had panic disorder for 35 years, you've had lots of time to build up fear of the fear (fear of panic). Does this make it easier to go into setbacks? It seems it takes very little.

Dr. Goodman: I've worked with lots of people who have had this problem for many years. Commitment to changing one's attitude about anxiety and panic is very important.

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emmielue: Is the fear of the panic a learned response?

Dr. Goodman: Yes, I believe it is. And it can be unlearned as well.

Panicker32: Does a person necessarily have to be under stress to relapse?

Dr. Goodman: No. Sometimes, people believe they are better and over the problem, so they go back to old habits and ways of coping that aren't helpful.

Wolfe396ss: I have been dealing with panic for about a year now. Even though I work on getting out and stuff, I would like to know if this is going to get better and go away? I just really want to know if there is recovery for this? And how long does it take?

Dr. Goodman: Yes, there is. There are several good anxiety treatment programs that are very effective for most people and research has proven their effectiveness. The length of time varies from person to person.

GreenYellow4Ever: What is your view on cognitive-behavioral therapy for treatment of panic disorders?

Dr. Goodman: I think it's the best method of treatment for most people. I always start with cognitive-behavioral strategies. Sometimes understanding how our histories play a role is also important. Many ineffective beliefs and attitudes are rooted in our past. So it's often helpful to really understand ourselves in a complete way, not just focus on the symptoms.

David: I also want to mention here, you can read the transcript from several excellent conferences we've had on recovery from anxiety and panic disorders.

lld7777: I am on 25 mg Zoloft and have minimal anxiety, but have side-effects. I would like to go off medications and use another form of treatment. I've tried breathing exercises, but it didn't work. I'm afraid that if I go off Zoloft, I'll have the anxiety again. What measures can I take to avoid having it come back if I go off?

Dr. Goodman: The best answer I can give you, is to work with an anxiety specialist, so that you will know what this problem is about for you. Medication is only a partial solution.

David: What do you think about the idea of "self-help" recovery? Can a person recover from an anxiety disorder on their own, without seeing a therapist?

Dr. Goodman: I have met some people who have. They've used a self-help program and did the work. They were highly motivated and stuck with it.

(ö¥ö): How can one overcome the awareness during sleep that's associated with anxiety? The feeling where one is half asleep, and is aware of his surroundings, but cannot move?

Dr. Goodman: Sometimes this happens. I don't really know the physiology behind it.

cj52: Do you believe that anti-anxiety medications are needed at some point?

Dr. Goodman: For some people, anti-anxiety medications are very helpful. Initially, it helps to lower the general anxiety level, which may make it easier to do the necessary recovery work.

amfreeas: What would you suggest, because I live in rural Australia, about finding information on the management of panic attacks? All I have at the moment is medications to help.

Dr. Goodman: On my website, www.anxietyrecovery.com , I have a page of wonderful self-help links that I hope will be useful for you.

David: We also had Bronwyn Fox from Australia as an earlier guest. Check the transcripts to her conference Power Over Panic.

Dr. Goodman, when one suffers an anxiety disorder relapse, are the anxiety symptoms generally more intense than during the initial onset of the anxiety disorder?

Dr. Goodman: Generally not. It usually is less severe than before; however, any return of symptoms can feel very distressing.

oktout: What do you do about obsessive thoughts?

Dr. Goodman: Stop them.

David: Easy to say :) How do you do that?

Dr. Goodman: I know. It takes perseverance. When you are aware you are obsessing, say STOP, and then refocus your awareness to something else that holds your attention. Usually something that is calming or funny or joyous.

David: For those in the audience: I'd be interested to know what you've found helpful in dealing with a relapse? Send me your comments, I'll post them as we go along. Please keep them relatively short.

Amber13: I was doing so well, until about 6 months ago. I did have a lot of changes in my life, but am also in the menopause stage. Do you believe that menopause can make one more anxious?

Dr. Goodman: Hormonal fluctuations have been known to generate anxiety in women who are prone to it. It's a good idea to talk with your gynecologist about this. However, life changes can be very stressful, even when you have wanted those changes to occur. People with sensitive nervous systems are affected by changes in their environment, good or bad.

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backfire: I have terrible anxiety before my periods. Is this common?

Dr. Goodman: Yes. And stress management becomes even more important.

David: Here are a few audience responses on what you've found helpful in dealing with a relapse?

zulie: I have found that not beating yourself up during a relapse is very helpful.

TeriMUL: I found that when I quit taking Prozac, the panic came back within 4 months. I will probably be on an antidepressant for the rest of my life, and I'm ok with that.

DottieCom1: Remember you've come through this many times before.

David: One of the common themes here, Dr. Goodman, is to remain hopeful that you will get through this.

Dr. Goodman: Definitely. Anxiety disorders are highly treatable; people do recover.

David: And to be accepting of your situation.

Dr. Goodman: Acceptance is an important precondition of change.

David: Here are a few more audience comments:

zulie: Be in touch with others who have the same problems, so that you won't feel alone.

Ang58: I am in the recovery stages of panic disorder and agoraphobia, which I have done basically alone, but I just can't seem to kick the fear of there being something seriously wrong with me. This causes me to have anxiety and panic symptoms. Any suggestions?

Dr. Goodman: What do you believe is really wrong with you?

Ang58: I guess I really fear that I have caused myself to have heart trouble or something like that.

Dr. Goodman: It's a good idea to have a medical evaluation so you know the reality.

Ang58: I have just become so in-tune with every little twinge my body makes:)

Dr. Goodman: Yes. This is very typical and part of the problem. You might try distracting your mind from your body and all the nuances. Realize that focusing on your anxiety symptoms and being afraid of them is keeping the anxiety cycle alive.

David: How important is it for a person to get professional treatment immediately after suffering a relapse? Would it be true, that the longer you wait, the harder it is to recover?

Dr. Goodman: I think it depends, but in general I believe in treatment sooner than later, so that the anxiety/panic cycle doesn't take hold so strongly.

angggelina: I've had Panic Disorder/Anxiety for 30 years. I've been housebound since 1981. I live in a small town with one mental health clinic. I've seen every anxiety "specialist" there. I'm listed as severe/chronic and left to my own devices now. I'm on Medicaid and I can't afford private counseling. I've tried practicing on my own with a support person, but it's too inconsistent. What can I do to get better?

Dr. Goodman: Have you tried any of the self-help strategies that have been described on anxiety websites?

David: There are also anxiety tape programs available. As Dr. Goodman stated, having a skilled therapist is helpful, but if you can't access one, you might try the tapes.

Steffane: When I have a panic attack now, I am starting to take the attitude of "this is another normal thing my body is going through just like stubbing my toe." It doesn't seem to make them any less severe or shorter, but I find myself able to tolerate them better. Am I approaching this right, or am I just making them ultimately something part of my life?

Dr. Goodman: This is a good question. Taking the fear component out of having a panic attack is an important first step. Now you need to go to the next step learning to reduce your anxiety symptoms when they happen.

David: Here are a few more responses from the audience regarding what you've found helpful in dealing with a relapse?

blair: You know that you are not going "crazy" and that it will pass.

amfreeas: Being in rural Australia, using these special chat sites, and talking to others with the same problems, have dropped my concerns and my prima donna thinking dramatically!!

David: Thank you, Dr. Goodman, for being our guest tonight and for sharing your suggestions and insights with us. Also, thank you to the audience for coming and participating.

Dr. Goodman: Thank you for inviting me David. Have a good night everyone.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Carol Watkins is a board-certified psychiatrist. She has written numerous articles on the treatment of anxiety disorders in children and adults, and maintains a website on anxiety issues.

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good evening everyone. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Anxiety and OCD Medications." Our guest is psychiatrist, Carol Watkins, who is board certified in adult and child psychiatry. She is a clinical assistant professor of psychiatry at the University of Maryland and maintains a private practice in Baltimore, Maryland. She is the author of many published psychiatric papers and a frequent lecturer at workshops and seminars. Dr. Watkins has also written numerous articles on the treatment of anxiety disorders in children and adults, and maintains an active online resource site dealing with anxiety, that you can locate here.

Good evening, Dr. Watkins and welcome to HealthyPlace.com. We appreciate you being our guest tonight. We get a lot of email that goes something like this: "I've tried 3-5 different medications for my anxiety or OCD and nothing seems to work." Why is it that psychiatric medications work for some but not for others?

Dr. Watkins: Each person is different, both in personality and in their individual biochemistry. Some people have different rates of metabolism based on differences in their liver metabolism. On the personality side, people have different attitudes and expectations of medication.

David: What is a reasonable expectation when it comes to the performance of an anti-anxiety medication?

Dr. Watkins: A certain percentage of individuals of each ethnic group may have different enzymes that metabolize a particular medication. It depends on the subtype of anxiety. For OCD, you might expect a 50-70% positive response with medication. Higher, if combined with the appropriate psychotherapy.

David: And for an anxiety disorder or panic attacks, what can one expect?

Dr. Watkins: For panic attacks, I would expect a similar response rate. I often start with smaller medication doses for panic than for Obsessive-Compulsive Disorder. For generalized anxiety, I expect a lower medication response and emphasize therapy in addition to the medication.

David: If you are suffering from an anxiety disorder, would you recommend medications as a first line of treatment, or would you say to the patient, try therapy first and if that doesn't work, then we'll talk about anti-anxiety medications?

Dr. Watkins: It depends on the situation. For adults, I discuss both options. If the symptoms are mild, I am more likely to go with therapy first. If severe, I often recommend starting with medication and therapy simultaneously. For children, I am more likely to recommend a course of therapy first. However, in some cases, if the anxiety symptoms are pervasive, or if the child refuses therapy, I might start medication right away.

David: I know you are a psychiatrist, but I'm wondering what your thoughts are about a person going to see their family doctor and having that doctor dispense medications for their anxiety disorder versus seeing a psychiatrist to be treated?

Dr. Watkins: In some cases, there are primary care physicians who know the patient well, maybe for decades. The physician might know and treat the family too. If the doctor has the time and expertise, then it is OK. If the doctor is busy and can only allot a few minutes, it is better to refer. If the person does not respond well to the first treatment, then a referral is also a good idea. I deal with some primary care physicians who know me and have a good sense of when to refer on to a psychiatrist.

David: We have a lot of questions, Dr. Watkins, and then we'll continue with our conversation.

Sharon1: How do you feel about Serzone as a treatment for panic disorder?

Dr. Watkins: I prefer to start with an SSRI, such as Zoloft (Sertraline) or Luvox (Fluvoxamine) and reserve Serzone if the person has side effects on an SSRI.

sadsurfer: What do you think of alternative medicine, such as acupuncture or massage therapy alone to reduce anxiety if one wishes to come off medication?

Dr. Watkins: Some people get good results with acupuncture. One should also realize that many people get good results with cognitive behavioral therapy or hypnosis without using medications at all.

David: So are you saying that hypnosis and acupuncture are legitimate treatments for anxiety disorders?

Dr. Watkins: I believe that hypnosis, cognitive behavioral therapy and some other forms of therapy are legitimate. I am not an acupuncturist, but I have seen some good results. I do get concerned when some acupuncturists go on to prescribe herbal preparations without checking with me to make sure that they are not interacting with my medications. This can be dangerous.

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auburn53: Can hypnosis work by using tapes or do you think you need to have it done in an office?

Dr. Watkins: Some people get good results with the tapes. I prefer to do it in my office to see what technique works best and then make the person a custom tape. It is best though if the person can do self-hypnosis without a tape. More portable.

ninas: Hi David. Is there any way to wean off Clonazepam? Why are my panic attacks cyclical?

Dr. Watkins: If you go off the Clonazepam (Klonopin), do it gradually and with medical supervision. It may take a few months if you are on a large dose. Substitute something else like another class of medication or a form of psychotherapy to get you through.

David: What side effects can one expect if they suddenly decide to withdraw from some of these medications?

Dr. Watkins: Don't suddenly go off a Benzodiazepine (Klonopin (Clonazepam), Valium (Diazepam), Xanax (Alprazolam), Ativan (Lorazepam) etc.). You could get seizures or maybe just feel jittery and anxious. A slow taper is a good idea especially if you have medical conditions or are on other medications.

LISA R: I've been given Topamax for Panic Disorder; however, I've yet to find anyone taking this medication for Panic Disorder. Is this a commonly prescribed medication?

Dr. Watkins: I have never used it for Panic. I have heard of it as an adjunct for Bipolar Disorder.

GreenYellow4Ever: What benefit do you see in making a combo of anti-depressant and anti-anxiety medication?

Dr. Watkins: I prefer to use an SSRI medication such as Zoloft or a medication such as Effexor XR (Venlafaxine). If the person needs something immediate, I will start a Benzodiazepine until the SSRI kicks in. I may also add a benzodiazepine (Klonopin, Xanax etc.) in cases where the first-line drugs do not work completely.

madi: I just had my Prozac dosage raised and it seems like I am going through side-effects again. Is that possible? It seems like the OCD symptoms are worse because I feel so hyper.

Dr. Watkins: Some people can get a restless feeling, called Akathesia from SSRI medications such as Prozac. I have seen it more in Prozac because it is a little more stimulating than some of the other medications in its class. You might talk to your doctor about a switch to another SSRI medication, or you might back off the dose. Sometimes a low dose of a beta blocker (Propranolol, Atenolol) can block the jittery feeling.

Kerri20: What happens when someone can not take medication due to bad side-effects or even allergic reactions, but therapy is just not enough?

Dr. Watkins: Sometimes, you might start back on medication at a very low dose. I see a lot of people who are sensitive to medications. I use a lot of liquid SSRI medications. Then I go up slowly. I once tasted several of them for the benefit of my pediatric patients. Taste matters to that group. Liquid Paxil tastes best. I haven't tried liquid Zoloft yet. If the jitters bother you, a beta blocker, or a Benzodiazepine might help.

vcarmody:Q: Please speak to significance of Clomipramine at 25mg on a twelve year old child. How significant a dose in suggesting severity of OCD?

Dr. Watkins: I don't always see a correlation between dosage requirements and severity of the disorder. I measure it based on improvement and side effects. Often that would be a low dose, but I don't know if the child is a slow metabolizer.

flowerchild: What is a good medication for panic disorder for someone who is sensitive to meds?

Dr. Watkins: It would depend on the nature of the sensitivity. I sometimes use Zoloft in low doses for adults. In children, I often start with Luvox.

ponder8n: I've read that Benzos can become addictive very quickly. Any comments?

Dr. Watkins: Not always. I am probably more stingy with Benzodiazepines than some of my colleagues. If a person has a tendency toward addiction, I am more cautious of the Benzos. However, I have some people on them who do not display the psychological characteristics of addictions. It depends on how and why you prescribe the Benzodiazepines. If you use them cautiously and do not continuously bump up the dose, they can work well.

David: Some of the medications, like Prozac, that are being mentioned are for depression. And some members of our audience would like you to talk about the connection between anxiety, OCD and depression.

Dr. Watkins: Medications like Prozac and the other SSRIs do help with depression and anxiety and OCD. These disorders are separate entities and may be inherited separately. However, anxious individuals are more likely to get depressed and vice-versa. Often people who have had an anxiety disorder (especially untreated) for a long time, go on to develop depression. In children, I sometimes see anxiety earlier than depression but not always.

Dugan: Dr. Watkins, I am currently taking Celexa, Buspar and am coming off of Paxil because of weight gain. Does this combination of medications have a good success rate for Obsessive-Compulsive Disorder?

Dr. Watkins: Yes, they can work well for OCD symptoms, but you can get weight gain on Celexa (Citalopram) too. Exercise helps with the weight and improves anxiety symptoms too.

madi: Do vitamins have any effects when mixed with OCD medications such as Prozac?

Dr. Watkins: I have not seen any controlled studies (compared to placebo with carefully selected subjects) that show a consistent effect. A balanced diet, at least three meals a day and regular exercise do help.

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hobster: If you were treating a patient who is housebound, with some form of OCD with an eating problem, would you recommend medication, cognitive behavioral therapy, or would you recommend Seroxat?

Dr. Watkins: I do not know what Seroxat is. I would recommend CBT and an SSRI. I might also start a Behzodiazepine. Housebound patients may need a couple of home visits from the doctor or a treatment outreach person until they can get into the clinic. For treatment-resistant anxiety I may augment an SSRI with Lithium, Depakote, or I may use a beta blocker such as Propranolol. MAO Inhibitors such as Parnate and Nardil can be quite effective, but you need to be on a special diet and they can lead to weight gain. They are probably underused. I don't combine the MAOI with other medications in most cases.

David: Just to clarify hobster's question before, Seroxat is the UK name for Paxil.

Kerri20: I did cognitive behavioral therapy and exposure therapy for about three weeks and I found it was working great. I noticed I went down hill after stopping therapy. I guess I want to know what is the average length of time that someone would be in therapy to get the best out of it, or to keep it up, so to speak.

Dr. Watkins: You can have relapses after stopping either therapy or medication. The time frame varies. I usually recommend follow up therapy sessions as "boosters." When I stop the active phase of treatment, I have the patient and often a significant other write down the early warning symptoms. We make plans for what we will do if it starts to come back (anxiety disorder relapses). We write these down and everyone has a copy. Same process for coming off medications.

Cortny9: I am nine years old and I take Zoloft. It has helped me a lot. But my mom and I would like to know if there are long term side-effects?

Dr. Watkins: Paxil is a good SSRI to use for a patient with OCD. We don't have a lot of long term data on Paxil in children. However, physicians are supposed to send in reports of problems with medications. I haven't seen severe long-term side-effect reports.

Brin: Should a nine-year-old be on Zoloft?

Dr. Watkins: Zoloft can be used in children that age with OCD. Each case is individual. I look at a variety of treatment options in a child with OCD. There is a great book, "Blink, Blink, Clop Clop, Why Do We Do Things We Can't Stop?" that explains OCD to children.

David: You can visit the HealthyPlace.com psychiatric medications area, if you are looking for information on a particular medication.

tracy565: Do people with panic disorder need to be on medication all their lives?

Dr. Watkins: Not necessarily. Some people learn techniques to deal with the symptoms. I will taper it in some people and have them step up their therapy while we do the taper.

sgroove63: I've been on Serzone for anxiety and anorexia and bulimia for about a month (up to 200mg). I have had strange side effects. I'm dizzy, spacey, silly, and have a lack of coordination. How serious are these? My psychiatrist also started me on a small dose of Celexa a week ago, I think in anticipation that the Serzone won't work for me. What do you think?

Dr. Watkins: I have had several people who have had those types of symptoms on Serzone. Often, they are the same people who have trouble on Prozac. Celexa might be a good substitute for the Serzone. Ask your doctor if she is planning a substitution or if she intends to keep you on both. You need to use caution if you combine the two.

David: Why, what can happen?

Dr. Watkins: Sometimes, when you use two different medications that act on Serotonin, you can get a buildup of the Serotonin. This can occasionally lead to Serotonin Syndrome, one might get a bit disoriented.

Dr. Watkins: St. Johns Wort, combined with some medications can cause serotonin syndrome too.

Jitterbug: I have recently found that I have severe OCD and I don't like medication. However, I took the advice of my therapist and went on Zoloft. I then heard about Luvox and I was wondering which medication is better for OCD. I am having the hardest time functioning everyday. I'm feeling depressed and need something to help.

Dr. Watkins: Is your therapist also your psychiatrist? I am not keen on non-medical therapists recommending medication, unless the therapist is in very close contact with your psychiatrist. One is not necessarily better than the other. Luvox can interact with some other medications, so I tend to use it more by itself. I like it with children. Celexa may be less likely to interact if you are on a lot of different medications.

btlbaily: I have been on Zoloft for about six months. If I decide to get pregnant, is it recommended to discontinue the medication? And, if so, how long does it take to "wean" yourself off the medication?

Dr. Watkins: Some women do take Zoloft and Prozac during pregnancy, without problems. You need to discuss this with both your psychiatrist and your OB/GYN prior to conception. You should have your medications prescribed by a psychiatrist who is familiar with this sort of thing and who is willing to keep in touch with your OB. You need to go over the risks and benefits of taking the medication and the risks and benefits of going off medication.

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pavanne: What is your opinion of using Buspar instead of Zanax and the like?

Dr. Watkins: BuSpar is less likely to be addictive. However, it takes longer to kick in. If I need something to work really fast, I would go with a Benzodiazepine. However, I like to consider SSRI medications first.

David: Roughly, how long does it take for a medication to be effective?

Dr. Watkins: A Benzodiazepine can be effective in a matter of minutes or hours. An SSRI such as Zoloft or Prozac may take longer (a week to six weeks). BuSpar takes several weeks. A beta blocker may take effect fast, but mostly just covers the external manifestations of anxiety, such as tremor and palpitations. People with stage fright sometimes take a small dose of a beta blocker before a performance to block the tremulousness. If they can control that external part, they may be able to manage the internal feelings.

murkyangel: I've tried over ten medications: Serezone, Welbutrin, Effexor, Trazadone, Buspar, Remeron, Depakote, Zanax, and am currently on 450mg Welbutrin (again), 1mg Risperdal, and usually 10mg valium a day. It's better than no meds, but not really taking away the anxiety during the day (I take the valium at night). Anyway, what else do you suggest? And yes, I've tried therapy and groups and all that other stuff). I'm at my end in all of this and I don't know what to try next. I've tried many combinations of those medications that I listed.

Dr. Watkins: It is difficult to say. It would depend on the subtype of anxiety. It would also be useful to find out what relatives have taken and what helped them. A MAOI such as Parnate or Nardil might be a consideration. You would need to discuss this with your psychiatrist and get counseling about the MAOI diet. No beer, aged cheese and several other things.

terrjohn: Does a person have to be weaned off of Paxil? My doctor just changed my meds.

Dr. Watkins: Some people who stop Paxil suddenly, feel like they have the flu. It feels uncomfortable for some people. Same for Effexor.

terrjohn: How well does Wellbutrin work compared to Paxil for panic and anxiety disorder?

Dr. Watkins: I think that Paxil would generally be a better choice. Wellbutrin is a great medication for some depression and can also help ADHD, but is not as good for panic. I have occasionally seen it make panic worse. I might add Wellbutrin to an SSRI if the person's anxiety was better, but he or she was still depressed and lethargic. I might also add it to help with sexual dysfunction associated with an SSRI.

Veralyn: I am on Paxil and I was on Prozac a few years ago. I have both depression and anxiety with it. What is the difference between Paxil and Prozac?

Dr. Watkins: They are both selective serotonin reuptake inhibitors. (SSRIs). They have the effect of increasing the availability of serotonin between nerve synapses. Prozac tends to be more stimulating and lasts longer. Paxil is likely to be more sedating and wears off quicker. When you stop Prozac, it stays in your system for weeks or more and gradually goes out. Paxil goes out faster. That is why you may need to taper Paxil but not Prozac. A few people get sleepy on Prozac and are more alert on Paxil but they are in the minority.

David: Thank you, Dr. Watkins, for being our guest tonight and for sharing this information with us. We will see you tomorrow night to talk about "Bipolar and Depression Medications". Dr. Watkin's website is here.

And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have very large Anxiety and OCD communities here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others, http://www.healthyplace.com.

Here's the link to the HealthyPlace.com Anxiety Community. Thank you for coming tonight.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Samantha Schutz, our guest, is the author of I Don't Want To Be Crazy" a poetry memoir documenting her personal battle with an anxiety disorder and the incapacitating panic attacks that first struck during college.

Natalie is the HealthyPlace.com moderator

The people in blue are audience members

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Natalie: Good evening. I'm Natalie, your moderator for tonight's Anxiety Disorders chat conference. I want to welcome everyone to the HealthyPlace.com website. Tonight's conference topic is "An Inside Look At Anxiety." Our guest is Samantha Schutz.

Ms. Schutz is an editor of children's books. She is also the author of a recently released book: "I Don't Want To Be Crazy" a poetry memoir documenting her personal battle with an anxiety disorder and the incapacitating panic attacks that first struck during college.

Samantha, thank you for joining us tonight. You are now 28 years old and this book is based on your experiences with anxiety and panic during your college days; starting about 10 years ago. Before I get into those details, how are you doing today?

Samantha Schutz: I'm feeling pretty good. I haven't had a panic attack in a long time - months, really. Of course, I still get anxious and get flutters of panic, but they usually don't last very long. I'm also starting a new job in a few days. I'm a little nervous about it, but nervous in a normal way. In other words, it's not giving me panic attacks.

Natalie: Your book, "I Don't Want To Be Crazy" provides real insight into not only what it's like living with anxiety and panic, but also the personal struggle most people face in trying to get the right treatment for an anxiety disorder. The book is specially written for teens, 14 and up, along with their parents, but it's an excellent read no matter what your age. Samantha, why did you target this group?

Samantha Schutz: There were no books for teens about anxiety disorder. (There are of course, many self-help-type books on the subject, but they weren't engaging reads and they didn't make me feel any less alone.)

There are books for teens about drug abuse, depression, rape, suicide, OCD, cutting, learning disabilities, eating disorders...but there were no books about generalized anxiety disorder or panic disorder--ironic since anxiety often plays a major role in other disorders. In short, I wanted representation.

There was also a big part of me that was writing the book because I wished that I had had a book to comfort me and make me feel less alone.

Natalie: What were the first symptoms of anxiety that you experienced and what was going on in your life at that time?

Samantha Schutz: The first panic attack I ever had was after I smoked pot for the first time in high school. I really freaked out. I was pretty sure I was going to die. Or at least have to go to the hospital. I swore I would never smoke pot again . . . but eventually, I did. Sometimes when I would smoke, I would freak out. Sometimes I wouldn't. It never occurred to me that anything besides the pot was responsible for the anxiety.

The first panic attack I had when I wasn't high was right before I left for college. I was shopping for school supplies with my dad and all of a sudden I felt really strange. The ground felt soft. I felt really spacey and confused. It was like everything was moving too fast and too slow at once.

Natalie: As time went on, how did the symptoms progress?

Samantha Schutz: During my freshman year, my first panic attacks were scattered and seemingly without pattern. Although, I did have A LOT in class. But it wasn't long before the attacks picked up speed and I was having several a day. I often felt nervous, not in control of my body, and convinced that I was going to die. As their frequency increased, it became difficult to do normal things like go to class, the dining hall, or parties.

Natalie: What impact did the anxiety and panic attacks have on you?

Samantha Schutz: This is a really hard question. At the time it kept me a bit withdrawn. Not terribly so, but enough to hold me back socially. Luckily, by that time I already had a few very good friends. Academically, I was doing ok. My grades first semester were actually quite good. But mostly I attribute that to the fact that I purposely picked classes that I knew I would like. I knew that the transition from high school to college would be hard (for anyone) and I thought that it wouldn't be the best time to have to deal with hardcore requirements like math. Now, if you want to know what impact panic disorder has had on my life in the overall sense, well..... that's an even harder question. One that I am not even sure I can answer. Would I be the same person I am today? I doubt it. But what would I have been? These are HUGE questions.

Natalie: Your book is called "I Don't Want To Be Crazy". Did you think you were going crazy? Did it come to that?

Samantha Schutz: There was a very short amount of time where I thought that. It was freshman year right before I went into therapy and went on medication. I had no idea what was happening to me and the only explanation I could come up with was that I had gone crazy. At the time I had never even heard of anxiety disorder. No, I never thought that I actually went "crazy". But it was something I was very fearful of. I guess I envisioned "crazy" as something I would or could enter into and never come out of.

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Natalie: And how did your friends, others on campus and family members react to your behavior and illness?

Samantha Schutz: My friends were very supportive. They did what they could, but for the most part they had to just follow my lead. If I needed to leave wherever I was because I was having a panic attack, then we left. If I needed water, then someone got it for me. If I needed to stay up and talk, then there was someone who would stay up and talk to me. I had one friend in particular who was wonderful. She was always there for me. There was also another friend who was diagnosed with an anxiety disorder. Our relationship was interesting. We were really able to help each other, but there is some irony in that. She could calm me down, but not herself. And vice versa. I told a few teachers that I was having problems. The classes were really small and I was worried that they would notice how I was always leaving. I lied and said that I was claustrophobic. Any teacher I told was really understanding and sympathetic.

Natalie: Samantha, many people with psychological disorders, whether it's bipolar disorder, anxiety, depression, OCD or some other disorder, feel as if they are the only one on earth with this problem. Did you feel that way?

Samantha Schutz: Yes and no. Yes, because I couldn't imagine that someone knew the depths of what I was feeling. For me, the anxiety was in my head. No one could see it or hear it. It was mine alone to deal with. That added to it being a solitary experience. But I also knew I wasn't the only one. I had a friend who was going through the same thing.

Natalie: And, at what point did it become apparent that you weren't alone?

Samantha Schutz: I think when I realized that other people I knew were having the same types of problems.

Natalie: I can imagine that it was difficult for you - especially at a time when most kids are trying to figure out who they are and wanting to fit in and here you are standing out. What about depression? Did that set in too? And how bad did it get?

Samantha Schutz: I think once I went into therapy and on medication, some of those feelings went away. But for the most part, I don't think I was very depressed. But then again, this wouldn't be the first time that I appeared one way to outsiders and perceived myself as being another way.

Natalie: After I graduated from college I was REALLY depressed. I was having so many panic attacks and I felt broken and hopeless. I had no idea what I was doing with myself. I was back living in my parents' house. I hadn't found a job yet. Things felt very shaky.

Samantha Schutz: My anxiety and depression were at the worst they had probably ever been. I cut myself off from my friends and almost never went out at night on the weekends. I remember having very serious talks with my parents about going to the hospital. I didn't know what to do with myself. And neither did they. We decided not to . . . but my parents played a big part in getting me out of the house and then back to therapy. I was really grateful for that. I really needed someone to swoop in and take charge.

Natalie: So now we have a sense of how anxiety, panic and depression had a grip on you. I want to address diagnosis and treatment. How long did you suffer with the symptoms before seeking help? And was there any turning point where you said "I really need to deal with this?"

Samantha Schutz: I was in therapy and on medication within two months or so after getting to school my freshman year. The moment when I went for help was almost comical . . . at least it seems that way now. I was in Health Services (I went there a lot in college) and there was a poster on the wall that said something like "Having Panic Attacks?" I know that seems strange, but it's the truth. I can't even be sure I had even heard the phrase "panic attacks" before, but when I saw that poster, things made sense. That same day I made an appointment with the Counseling Center.

After my initial appointments with a therapist I was asked to make an appointment with the staff psychiatrist. It was easy. There was a path. And giving over a bit of control over to my therapist and psychiatrist was comforting after feeling so out of control with anxiety.

Natalie: How difficult was it to find help?

Samantha Schutz: As I said above, it really wasn't. But I don't think that that's the average response. I think people sit with things longer and let them fester. I am thankful that I possess two qualities: being forthcoming about my feelings and being proactive about my health. I believe that these qualities are a big part of the reason that I was able to ask for help.

Natalie: Did you have the support of your family? If so, in what way did they help? And was that important to you?

Samantha Schutz: Being forthcoming about my feelings and being proactive about my health. I believe that these qualities are a big part of the reason that I was able to ask for help. I told my parents about my anxiety disorder around Thanksgiving of my freshman year. I think finding out was a big shock for them. They probably thought I was off having the time of my life at school and when I told them what was really going on I think it really shocked them. They also didn't get to see my panic in action until I was home after my junior year. I think that not seeing me in the middle of "it" might have made it harder for them to understand what I was going through. But when I was having a hard time after my junior year and then again after I graduated my parents were there for me. They were very supportive and tried to get me whatever help they could. It was great having their support.

Natalie: So talk about the road back. Was recovering from panic disorder and depression easy, hard, extremely difficult? On the scale of difficulty, where did it lie for you? And what made it that way?

Samantha Schutz: I think recovery is a great way to describe what I have gone through in the last few years.

For the last few years, whenever I tried to talk about my experience with anxiety disorder, I ran into the same problem. I couldn't describe myself as having an anxiety disorder because I'd gone months without having a panic attack. And I couldn't say I had an anxiety disorder because I still felt its effects. Trying to find the right verb was more than just semantics.

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For many years, having an anxiety disorder shaped nearly every bit of my life- where I went, who I went with, how long I stayed. I do not believe that anxiety disorder can be flipped off like a switch, and accordingly, simply using past or present tense did not accurately reflect how I was feeling. The body has an unbelievable capacity to remember pain, and my body was not ready to forget what I had been through. It was only about a year ago that I settled on saying, "I am in recovery from anxiety disorder."

As far as recovery goes, my life is VERY different than it was when I was diagnosed with panic disorder ten years ago. Since that fall, I have seen more than a half dozen therapists and taken as many different medications. I've had two episodes where I nearly checked myself into a hospital. I have been to yoga and meditation classes, swung tennis rackets at pillows, practiced the art of breathing, tried hypnosis, and taken herbal remedies. I've done things that once seemed impossible- like going to crowded concerts or sitting with relative ease in a packed lecture hall. I've also gone many months at a time without panic attacks or medication. I don't know how to quantify how hard it was. . . but it sure wasn't easy. It was what it was. I dealt with things as they came.

Sometimes times things were good and I didn't have many panic attacks. Sometimes things were bad and I had several panic attacks a day. I just had to always remember that panic attacks always end and that bad days and bad weeks always end too.

Natalie: You tried different treatments, different medications. At some point, did you just want to give up? What motivated you to continue on with seeking treatment?

Samantha Schutz: I don't think I ever wanted to give up. There were sometimes when things looked pretty bleak . . . but I kept trying new meds and new therapists because I wanted to get better. That even though things are pretty bad, there is something they are getting out of feeling bad. There have been a few times that I have felt really depressed and I wanted to feel depressed. It was comforting. I think that at some point I decided I really wanted to get better and that was a sort of turning point for me and I started making more progress.

Natalie: One last question before we turn to some audience questions: You mentioned at the beginning that you are stable and better able to live your life. Are you ever afraid that the anxiety and panic attacks and depression will return? And how do you deal with them?

Samantha Schutz: Sure I do. I am still on medication and I wonder what will happen when I go off it. Have I learned tools to deal with my anxiety? Have I passed through that stage of my life? I don't know. I am really hopeful though.

At the end of my book there is a poem that says a lot about how I felt on this subject. Keep in mind that this poem reflects how I felt several years ago. I am in a house. I am in one room and my anxiety is in another. It's close. I can feel it. I can go to it. But I won't. It still felt like the anxiety was there. That it was close, but that all of the work I was doing (the meds, the therapy) was helping to keep it at bay. I don't feel like it's as close now. I don't feel like I could fall back into it as easily as I once did.

Natalie: Here's the first question from the audience

terrier7: Was there a line of demarcation that kind of separates who you were before the panic attacks/anxiety and afterward or was it a lot more gradual than that?

Samantha Schutz: There is no hard line. I can only wonder how things would have been. It's not like I was very outgoing before and then really shy afterward. I think it could take me a lifetime to figure out how things are different, but even then, is it important to know? And really... I will never know for sure what is different about me. I was diagnosed at such a critical time. I was 17. A lot was changing about me and developing anyway.

Natalie: Thanks Samantha, here are some more questions from the audience.

trish3455: I experienced many different symptoms of anxiety and I worry that maybe it's something serious and not anxiety. I have read many books and it seems I experience symptoms that are not common. Did you experience this?

Samantha Schutz: I know I thought that a lot too. There were times I thought I had some weird illness. There are so many different symptoms and so many different ways that people feel. The important thing is to NOT diagnose yourself. Let a doctor do that.

Debi2848: Does the panic/anxiety attacks embarrass you and you have to leave a family gathering for no reason and can't go back for fear of having a bad attack in front of people?

Samantha Schutz: I think that for a long time I just left where ever I was if I was having a panic attack. So I wasn't there long enough for many people to see what was going on for me. I don't think I felt very embarrassed by my anxiety. I did feel bad that I was putting my friends out and that they left all sorts of places because of me.

sthriving: I have had anxiety and panic attacks for about 7 years now. Things like driving, socializing, etc. I can now do without any hesitation, but I am still on Xanax. Do you think there is anything wrong with having to take medication to enjoy doing things?

Samantha Schutz: Hard question. I remember when I was first thinking about going on medication I was hesitant. The psychiatrist asked me if I would have trouble taking medication if I was diabetic. I said of course not. There have been times when I didn't want to go on meds. Others where I could not swallow the pill fast enough. It depended on how I was feeling. I am sort of in the same boat now. I have been on meds for a long time and am wondering if I should go off. I wonder if I need it? But then part of me wonders if I should stay on. If I am feeling good, why mess with it. But again, I am not a doctor.

It's different for everyone and of course your doctor should have some input into this decision. This does not sound like one decision you should or can make alone.

support2u: I have had anxiety all of my life and recently started having what I would call panic attacks and I start hyperventilating and breath holder. How would someone like me cope with this and how did you?

Samantha Schutz: There is a type of therapy called CBT: Cognitive Behavioral Therapy This therapy is all about teaching you specific ways to deal with specific problems. In CBT a patient might do a lot of breath work on learning how to breathe in a way that will help you calm down. I hope you are seeing a doctor. I know I sound like a broken record. But I can only speak from my own personal experience.

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Neeceey: Did you develop any specific phobias? I have a medication phobia among many others (bridges, crowds, elevators, etc.)

Natalie: Sort of. The thought of passing out scares me a lot! There were also a lot of places I avoided and things that I hated doing because I would have panic attacks. Having a medication phobia is rough. especially when medication is something that can help you.

3caramel: How did you manage to overcome your fears, I am unable to go to restaurants or go on trips and I don't know how to overcome that?

Samantha Schutz: I mentioned CBT before. That might be helpful. There is also something called Aversion Therapy. These therapies give you strategies to deal with your fears.

How did I get over mine? Some of them faded. Some of them are still there. I think what was most helpful was trying to go to places that freaked me out. If I went to a club (a place where I had had many attacks) and didn't have a panic attack, then that was a success. Then, the next time I would be nervous about going to a club, I would remember that I was ok the last time. I would try to build on that.

Natalie: Okay Samantha, the next questions are about your book. How long did it take to write your book?

Samantha Schutz: It took about 2 years from the time I decided to write it to the time I gave it to my editor. But I had many years worth of journals to use for inspiration.

Natalie: Here's the last question. Has your life changed after writing your book?

Samantha Schutz: In some ways it has. I get fan mail from adults and teens telling me how much they love my book and how much of an impact I have had on their lives. I've had people give my book to their kids or parents as a way of explaining what they are going through. It is amazing to know that I am having an impact on people. I also think that writing this book gave me a lot of distance from my experiences and a way to look back on it and make sense of it. I don't think it could be considered closure, but it has definitely helped.

Natalie: I am sorry but we've run out of time.

Samantha Schutz: Thanks for having me!

Natalie: Samantha, do you have any final words for us?

Samantha Schutz: The only thing I can say with certainty is that my commitment to therapy and my willingness to try new medications has made the most difference. I know that it seems hard and it is awful to have to go on and off meds trying to find the right one... but it is worth it. It is also worth it to try new therapists.... it's like a good friendship. Not everyone is the right fit. I am really lucky I am seeing an amazing therapist now and it makes all the difference.

Natalie: Thank you very much for being our guest tonight Samantha.

Samantha Schutz: My pleasure!

Natalie: Thank you everybody for coming. I hope you found the chat interesting and helpful.

Good night everyone.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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