Talking to my doctor about anxiety
August 18, 2015 6:34 AM   Subscribe

I think it's finally time for me to talk to my doctor about anxiety. I'm looking for advice on what I should be telling him, and what I should be expecting in terms of treatment options.

I've been dealing with anxiety for a long time. It's usually at what I would consider a low level, but it's pretty constant, and every couple of years external stressors can make it flare up more significantly. Previous examples would be when I was in my final year of grad school, and when I went through a period of unemployment. Right now things are getting stressful at work.

Leaving aside the more acute 'episodes', I've come to realize that even the low-level anxiety affects my life. I have trouble forming relationships, I get stressed out in social situations, I arguably drink too much, and I feel like it's preventing me from performing as well as I could at work -- I get "analysis paralysis", and I procrastinate, and I'm always expecting my manager/director to call me out and be pissed off at me.

All that said, I generally manage well enough day to day, and eventually power through the tougher times. I force myself to get out and try to meet people and be social, and objectively speaking I'm a pretty good performer at work.

Is this just what everyone deals with? Or is there some medication that will make me realize how much I've been missing all my life? My preference would be for a pharmacological intervention over therapy, FWIW. What will my doctor want to know? Is there a particular way I should frame the conversation? Thanks.
posted by sevenyearlurk to Health & Fitness (22 answers total) 19 users marked this as a favorite
I would frame the conversation in terms of how your anxiety is negatively affecting your daily life. What thing(s) are you no longer able to do or enjoy because of your anxiety? What inappropriate coping mechanisms are you using? (So basically, be sure to mention your work performance and the fact that you are self-medicating with alcohol, and any other salient details.)

Feel better soon!


My preference would be for a pharmacological intervention over therapy, FWIW.

I think that's a fine preference to have, but I would be cautious about expressing it to your doctor in these terms - you don't want to be labelled a drug seeker (I'm sure you're not, but it's all about perception). Being open to therapy at least in theory might be helpful.

posted by schroedingersgirl at 6:42 AM on August 18, 2015 [4 favorites]

"Along with more acute 'episodes' every few years, I've come to realize that even the low-level anxiety affects my life. I have trouble forming relationships, I get stressed out in social situations, I arguably drink too much, and I feel like it's preventing me from performing as well as I could at work -- I get 'analysis paralysis', and I procrastinate, and I'm always expecting my manager/director to call me out and be pissed off at me."

That's a perfectly good way of phrasing things to your doctor. "I have anxiety that's interfering with my work and social functioning, and I'd like to try to medication of some sort" is the approach that likely makes the most sense. If it were me, I wouldn't try to downplay it, mainly because (as a therapist) I've seen so many people write off their own very very high anxiety as "normal" or "not that bad" when it's actually making them miserable, and if it's been bad over several years and is affecting multiple areas of your life, your anxiety certainly is worth treating in some manner.

I am not a prescribing physician or psychopharmocologist, but there seem to be two main types of medication for treating anxiety, SSRIs/SNRIs (which are generally thought of as anti-depressants, and would be taken daily) and various types of benzos (which are more immediate acting and would likely be prescribed as-needed for panic situations). Benzos can be habit-forming if taken very regularly, so SSRIs/SNRIs are usually prescribed first, though often with benzos prescribed on an as-needed basis as back-up or for very acute panic/anxiety. (There are a few other options, like Buspar, but from what I've seen those are usually only prescribed if other medications haven't worked or can't be taken.)

Some general practitioners are more comfortable than others with prescribing psychotropic medications. If your doctor balks, you can ask for a referral to a psychiatrist, who would have more training and experience in treating anxiety. (And most psychiatrists don't provide therapy, so a referral to a psychiatrist is not the same as a referral for therapy.)
posted by jaguar at 6:52 AM on August 18, 2015 [4 favorites]

You should tell your doctor exactly what you wrote in your first two [more inside] paragraphs. If you are talking about your regular GP, they may suggest a referral to a psychologist/psychiatrist, which is not a bad idea, and does not necessarily mean therapy.
posted by Rock Steady at 6:53 AM on August 18, 2015 [1 favorite]

I just went back on anxiety meds a month ago, for similar reasons to yours. Not immobilizing or anything, just constant low-level anxiety. I framed it to my doctor in terms of this article (I have hypermobility and the article explains an interesting connection between hypermobility and an excessive fight-or-flight response). I've tried meditation and therapy and they're helpful with various other things but haven't done a thing for the day-to-day anxiety, so I went back on something that worked for me in the past. Feel free to memail me if you want more information.
posted by SeedStitch at 6:53 AM on August 18, 2015 [1 favorite]

My preference would be for a pharmacological intervention over therapy, FWIW.

It might be effective to reframe away from medication/therapy as either/or. Think of it as like having a chronically injured leg; painkillers will help a lot while you're doing the physio to get your leg functional again.

A lot of the time anxiety has root causes that can be addressed and lessen the need for medications. (The need may never go away completely of course). For me personally, what medication gave me was the space necessary to allow the work of therapy to have an effect. This isn't some moralizing nonsense--if you need meds you need meds, period. What I'm saying is that it may be more effective in the long term to dig up what triggers your anxiety and tackle that head on; as jaguar points out some anti-anxiety medications are habit-forming, and getting off benzodiazepenes (basically drugs that end in -am; diazepam, clonazepam, etc. Ativan, Valium, Klonopin) can be actually dangerous to your health.

Beyond that, your best bet is to a) print out this question and take it with you, b) (write out if you need to) discuss how your anxiety is affecting your quality of life.

Best of luck! Good for you for addressing something that is causing you distress.
posted by feckless fecal fear mongering at 7:19 AM on August 18, 2015 [1 favorite]

I go to both a therapist & psych for anxiety. Like previous replies, I would frame it as you did here.

When I go to my psych (visits are ~15 minutes), we discuss just what you mentioned: how the anxiety is impacting my life and what I am doing to cope with it. You didn't mention any physical symptoms (ie sleeping patterns, shakiness, etc) but your doc will probably be interested to know about those.

To a degree, this is what everyone deals with. However, some people's brains are wired to deal with it more effectively than others. And sometimes the brain need a little help to get things balanced correctly. Don't feel like you're "off" for needing to deal with it pharmacologically.

In my experience, there is not any medication that will make you realize how much you've been missing all your life. What there is is medication that that will help you more effectively cope and/or manage. Don't expect a light switch. It's more of a dimmer switch... and just like a dimmer switch, it may take some adjusting to get it just right.
posted by imbri at 7:32 AM on August 18, 2015 [5 favorites]

You're getting good advice here about how to frame the conversation, so let me address your "what to expect in terms of treatment options" instead.

First, you probably are going to get asked about whether you are open to therapy. I hear you if it's not your thing - for me, medication is a much more important component of my treatment than therapy although I do both - but I would suggest at least staying open to the possibility that after you see where medication gets you, you may be open to looking at other treatment modalities too. Partly because I genuinely think it's a good thing to stay open to, and partly because I think it's going to get you a better response from your doctor.

Second, in my experience, the first line medical treatment is an SSRI, probably in combination with a short-term benzo prescription to be taken for the first month or two while the longer-term medication is building up in your system. You'll probably have frequent checks for at least the first few months, to see how side effects are going, assess your dosage, etc. Once you're at a stable medication and dosage you're looking at more like quarterly visits, 15 minutes or so apiece, to talk through side effects, efficacy, any concerns you're having, etc. Short term side effects are to be expected but if they're intolerable or last more than a few weeks you absolutely can and should call your doctor - there are a lot of medications out there and no reason to suffer through one that is a bad fit for you.

Third, I can't tell you what you'll experience. But for me, medication hasn't done a ton for my day-to-day level of anxiety. It has made a world of difference in the acute episodes. For the general "existing in the world gives me agita and I don't know how to function like a person" stuff, I would not say the medication has helped a ton. But it has maybe helped a bit - I've been able to do a few things since starting on the meds that I'd been putting off because thinking about them stressed me out way too much. Most of what it's done for me is gotten rid of the constant fear that I was *about* to burst into a major panic episode, and with that gone, I've been able to focus on other stuff (mindfulness, meditation, and self-administered CBT for me, might be exercise or support groups or other things for you) that has helped with the day-to-day stuff.
posted by Stacey at 7:39 AM on August 18, 2015 [1 favorite]

There are doctors who will prescribe anti-anxiety agents (usually benzodiazepams) when you just say the word anxiety. There are others who will want to talk to you more to try to figure out if maybe an anti-depressant is more appropriate, whether you actually could achieve symptom reduction by changing your diet, getting your thyroid tested, taking more exercise, etc. And there are others who don't feel comfortable prescribing psychiatric meds at all without getting a psychiatric consult. Your personal doctor will fall in that spectrum somewhere, so go ahead and explain what's bothering you and let her/him know you'd like to try medication.

Remember, these are among the most prescribed medications in the world, so *someone's* prescribing them. They make patients happy and doctors like happy patients. Be aware that the medical field is shifting its view about these drugs somewhat. They are addictive and you'll likely find that you need to increase your dose over time to get the same effect. And that when you want to get off them, you need medical guidance around tapering the dose.

I also would encourage you not to think about this as *either* pharmacology or psychology. You can do *both* and your life will be enriched for it. Anxiety is among the most treatable conditions using CBT type models (including Acceptance and Commitment therapy, my personal favorite). There are many many good self-help books around on the subject (my favorite) if you want to play around with this on your own. Alternatively ask your doctor or your friends for recommendations for therapists and give it a try.
posted by jasper411 at 8:05 AM on August 18, 2015 [1 favorite]

I first asked my doctor about medication for anxiety several years ago. He told me to try therapy first. I ignored that for several years. During that time I started practicing meditation, which helped a fair amount, and about a year ago started seeing a therapist. That has also a fair amount. I was still experiencing anxiety and panic attacks though, so I went back to my doctor and told him the things I was doing to help my anxiety, that I was still having panic attacks, and that I was interested in some medical options. He gave me a prescription for Zoloft and its made a really big difference. My panic attacks are pretty much gone, though I still have some low level anxiety that I'm trying to reduce through meditation and therapy. YMMV, but for my doctor, it was important that I look into non-drug options first. I also agree that you should frame the conversation in terms of how anxiety is negatively impacting your life.
posted by bajema at 8:13 AM on August 18, 2015 [1 favorite]

Tell him your symptoms, just as you've described them here. IME he will probably offer you a drug in the first instance anyway, without your specifically prompting for it. (Unless you have really good insurance or deep pockets.) It is likely (ime) to be an SSRI or SNRI.

I suggest doing some reading on the various likely options in advance, and/or asking directly about any side effects. And if you're prescribed something, insisting on follow-ups / monitoring. That doesn't always happen and it's important. And keeping a daily log of your symptoms as you go, because it can be hard to pick out what's drug-related and what's anxiety-related when you just reflect on or remember things without that kind of data.

Don't neglect to mention your drinking, though, even though you might not feel great about it. One, because it can help your doc work things out, and two, because some drugs are more liver-intensive than others and it may help him make a more informed judgement.

Does everyone deal with this? I think many, many people experience some amount of situational anxiety when they're adjusting to a new role or new, unfamiliar responsibilities (grad school, new job). Does it cause everyone the same distress? Probably not. Constant, low-level anxiety and social anxiety that impacts the development of relationships are less common. (I mean they're common, just less common than grad school stress.)

I agree that you should reconsider your take on therapy. The tools you currently use to cope with stress (e.g. drinking, procrastination - which is really a maladaptive way of managing anxiety) are clearly not working for you, and no drug is going to help with that on its own. Drugs also won't teach you how to be proactive about e.g. managing your workload (or communicating with bosses or colleagues to manage expectations) or help you re-evaluate your decision-making processes - all those techniques, which can be learned, could help prevent at least some of this stress from happening in the first place.
posted by cotton dress sock at 8:27 AM on August 18, 2015 [1 favorite]

I should have mentioned: Many people find that SSRIs and SNRIs actually increase their anxiety for two to four weeks, until their bodies adjust to the medication (which is why many healthcare providers also prescribe some sort of benzo, at least at first, to calm the extra anxiety). In my personal experience, increased anxiety is often a sign that the medication will work long-term, assuming the anxiety does decrease after two to four weeks.

I think that if people expect their anxiety to go up a bit, it doesn't feel like a huge deal, but many doctors don't seem to warn patients to expect that, and those patients can get into an anxiety spiral ("I feel worse! Why do I feel worse?!?! Something must really be wrong!"), especially if they were already anxious about trying medication. So, just something to be aware of if you are prescribed an SSRI or SNRI.
posted by jaguar at 8:40 AM on August 18, 2015 [2 favorites]

I recently did exactly this, for pretty much exactly the same reasons. I wasn't in a crisis state, I just got tired of being afraid so often. I actually made an appointment with psychiatry, but saw my GP earlier and asked her for a temporary prescription until I could get my (six month later) psych appointment. I told her I'd been having these periodic swings of anxiety that were sometimes uncorrelated with life stressors, and that it was beginning to affect my sleep. She put me on a low dose of Paxil. After getting used to it (be patient) and lowering my dose a little with my psychiatrist's oversight, I've stopped having that horrible pit in my stomach that screams WHAT ARE YOU FORGETTING TO WORRY ABOUT NOW. It's incredible what 10mg a day can do - I feel like I have balast. I sometimes get worried about something, but it's so much easier for me to swing back to balance again, and it doesn't linger. I can dismiss irrational thoughts as irrational, and they actually go away. I wish I had done this years and years ago. It worked well enough that I ended up deciding not to go to therapy in the end, and my psychiatrist was okay with that.
I wish you the best, and hope you find something that works as well for you.
posted by you're a kitty! at 9:47 AM on August 18, 2015 [2 favorites]

It sounds like you have a handle on this and people have given you good advice. I have taken benzos for anxiety (on an as-needed basis, not regularly) and just this year also started therapy (also as-needed, I had some acute stuff I was dealing with and now things are mostly harmonious again). I was surprised how much each had a part to play in helping me get to a better place. Like the benzos made me not nuttily overthinking everything but the therapy helped me think of areas in my life that were now in my power to improve now that I wasn't just stopped dead by anxiety.

So when talking to your doc, there are a few steps

- this is the problem (explain what happens, not just "I have anxiety)
- it's affecting my life negatively (sleep, work, relationships, social life)
- this is what I have tried (including self-medicating with alcohol) and these were the results
- I'd like to take this to the next step, let's talk

And yeah some docs will be like "Here is your Ativan goodbye" and some will talk about therapy and you can steer the conversation somewhat to what you think would work better for you. And you can try some things, be aware there may be a bit of a trial period to see what works and what doesn't work. The fact that a first attempts doesn't work doesn't mean that there is no solution, just might mean you need to move to plan B.

For me anxiety has been sleep-related, often, with some social anxiety. Benzos made me predictably able to sleep. Therapy has helped me unpack my elaborate and somewhat superstitious sleep rituals so that sleep isn't such a TRIAL for me (and a lonely trial) which has been helpful I wish you luck. If you get meds be aware that you may be afraid to take them at first. This is normal and there are other AskMes that talk about that aspect of it.
posted by jessamyn at 9:50 AM on August 18, 2015 [3 favorites]

I can dismiss irrational thoughts as irrational, and they actually go away. I wish I had done this years and years ago.

This! I didn't ask my psychiatrist for anxiety medication. I see him for my ADHD and mentioned in passing my anxiety attacks, which I'd been having for several years and the health anxiety (different but potentially related) with which I'd been cursed since I was 10. And he suggested I try Citalopram. I was skeptical and he said, "My patients tell me anxiety comes up to the porch but doesn't get through the door."

That's pretty much how it's been for me. Not 100% anxiety free but maybe 90% compared to how I used to be. The quality of my life has improved dramatically. I used to worry about dying. Every. Single. Day. Honestly, at some points I thought it would be easier to just die and get it over with. Of course, my anxiety is not your anxiety; my results will not be your results.

I was over 50 when my shrink made this life-enhancing suggestion. I had been in therapy, on and off, for many years and with some pretty talented therapists (to be fair, working on lots of stuff, not just anxiety). One of them, the best, specialises in Dialectical Behaviorial Therapy and worked with me specifically on my health anxiety.

Alas, that was only slightly helpful. Kind of in the way that an umbrella with lots of holes will give you some protection from the rain but not much. The medication I'm taking (in my case, 5 mg daily) is like having a really great umbrella that shields you from nearly all of the rain except for the few times the wind blows the drops sideways. I never expected to stop being fearful and afraid and worried nearly all the time.

In fact, I felt a tiny bit of the old fear this morning and then it just disappeared. Which reminded me, once again, of how powerful certain drugs can be for certain people. It's exhausting to white-knuckle your way through life, which is what I'd been doing.

Best of luck of finding an approach (meds, therapy, combo, whatever) that works for you.
posted by Bella Donna at 10:52 AM on August 18, 2015 [2 favorites]

Also, what Jessamyn said about being afraid to take the meds at first (thanks!). That's me, every single time.
posted by Bella Donna at 10:54 AM on August 18, 2015

My life has been completely changed by the medications I take for anxiety. I want to emphasize that it's NORMAL for an anxious person to feel deep anxiety about talking to a doctor or therapist about it, and about trying any kind of treatment. It's okay to write everything down and take the notes with you. You can even hand your notes to the doc, who can probably read faster than you can talk, anyway :-)

It would be great if we could look at a chart to find out which drug is best for a specific symptom. Unfortunately, it's impossible to predict how a given person is going to feel when taking a given drug. Even within one family, different people can have very different results. Try not to be swayed when you hear about someone's great or terrible experience with one drug or another.

All you can do is try. If a medication isn't right for you, you can stop taking it and move on to something else. Also, one thing I wish someone had told me when I was starting out: If a medication is working, you'll know. If you can't tell, then it's not working. By "working," I mean that the right drug will allow you to feel better while still feeling like yourself.
posted by wryly at 11:40 AM on August 18, 2015 [3 favorites]

I had a nervous breakdown earlier this year and went to see my dr because I wasn't eating or sleeping due to such a high level of anxiety (I was also having trouble breathing normally). Things we did after I described my physical and mental symptoms:

-Blood test to rule out thyroid issues
-Breathing test to rule out asthma or a problem with my lungs
-Referral to a great therapist that I am still seeing, got me to the top of the waiting list
-A small prescription of Xanax to get me through the initial rough patch
-Tried out an SSRI. It gave me horrible side effects. Went back and got another SSRI (incidentally, the one my mother is on). The second started helping and I'm now on a 6 month course.

Medication hasn't changed me significantly but it has made the difference in getting my eating and sleeping relatively back to normal. It's got me feeling more like me again rather than this raging ball of anxiety that was convinced, utterly convinced, that the sky was falling and my life was over

Best of luck
posted by raw sugar at 1:22 PM on August 18, 2015

Thank you all so much for your kind, thoughtful and encouraging responses. I appreciate the pushback on my reluctance to pursue non-drug therapy and I'll try to be more open to it. In part, my preference for medication is because pills will be almost entirely covered by my insurance whereas my coverage for psychological therapy isn't great. Plus I just feel like I need a biochemical intervention more than I need better coping strategies. But anyway, I feel a lot better about having this conversation with my doctor now and I'll see where that gets me.
posted by sevenyearlurk at 2:26 PM on August 18, 2015

Man, I feel you — therapy is expensive, and time-consuming. it's okay to make it a long-term plan if the medication doesn't work for you, or if you end up feeling like you'd prefer to go off the pharmacological options eventually or supplement them. Therapy is always going to be available, but I think the "therapy first, pills if that keeps failing" attitude is pretty destructive. There's enough of a stigma about chemical approaches to anxiety and depression as it is.
There's no reason you need to try therapy first; it is and should be your decision how you want to handle this medical condition, just as it would be if you were having knee problems and needed to decide between surgery and long-term physical therapy. Consult with your doctor, consider your options, decide how minimalist you want to be and how well you usually respond to medications. Consider real-life stuff like insurance coverage. If you do choose pills, definitely stay in touch with your doctor about side-effects and try different ones until you find one without big/annoying problems. But there's no reason therapy has to come first, or has to be the "better" option. It can be a good supplement, and for some people it works on its own, but it's not inherently more noble or anything.
posted by you're a kitty! at 4:37 PM on August 18, 2015

You may want to check if your employer has EAP. I didn't know until someone told me. This benefit usually allows you 8 free sessions per topic a year with a therapist.
posted by raw sugar at 5:53 PM on August 18, 2015 [1 favorite]

SSRIs etc are habit-forming, too. Generally: benzos like clonazepam short term while the SSRI is gearing up, for a month or so. Then benzo only as needed.

Good luck!
posted by persona au gratin at 2:19 AM on August 19, 2015

Let me also say, it's not either or. Take what I said above, and add therapy to it. You get immediate relief with the benzo, and longer term relief with the SSRI and therapy. Or that's the idea, anyway.
posted by persona au gratin at 2:22 AM on August 19, 2015

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