The No SSRI way to alleviating test anxiety. Can you help me with it?
March 25, 2008 10:09 AM   Subscribe

The Green is my last hope. Need help with extreme test anxiety. The medical establishment has (surprise, surprise) failed me.

I've made the decision to sit for the July bar exam but my previous experience with it has left me anxious to the point that my heart is racing when all I'm doing is studying. I just started a new job and have a gradiated health insurance plan that is essentially crap until I've been here for six months.

Yesterday, I went to the walk-in clinic/health center that I've been using for the past year. They are basically there, as far as I can tell, to make money. The PA there gave me Paxil. (I had previously been on Prozac, which worked fine until it didn't.) I didn't have too many problems on the Prozac (which I took for mild anxiety/dysthmia ... and had previously tried Zoloft, Cymbalta and some others without success) but I have read here and on other forums that Paxil seems to be the most likely of all the SSRIs to cause weight gain/sexual dysfunction. Well, I'm a three-times a week trip to the gym and a couple of happy meals away from being Jenny Craig's next poster girl. I have to work hard to maintain my weight .... and I have a damn good lover. I'm not willing to part with either of those things.

I called today and was told by the snarky triage nurse that all SSRIs have potential for weight gain. I wasn't in the same room so I couldn't spit at her but I was told that if I wanted a different prescription, I'd have to come back in (and, of course, pay the $75 fee to see the PA for six minutes.)

So, questions: Anyone have experience using hypnosis CDs/DVDs for text anxiety? Can you recommend one? Got any other tips? I've given up (OK, cut back) on the caffeine, drank the last of the Cab on Saturday and dusted off the jogging shoes. My primary problem outside of the racing heart is insomnia and that disconnected feeling (which I hate.)

Also, if anyone happens to know of a kind, decent doctor anywhere in Phoenix, I'd appreciate a contact. Thanks.
posted by notjustfoxybrown to Health & Fitness (22 answers total) 8 users marked this as a favorite
That's a lot of questions. I think one helpful thing you can do for the test anxiety is to practice taking the test. Can you get hold of some old copies? If so, practice under the same conditions that you would actually be taking the test under. No extra bathroom breaks, no getting up to go have a meal, etc. The more familiar the circumstances seem, the less anxious you will be.

This strategy worked for me when I took my oral qualifying exam in my PhD program. I had two practice tests with my friends asking me the questions in the weeks before my actual test, and it was really useful. I was much more comfortable taking the actual test than I would have been otherwise.
posted by number9dream at 10:15 AM on March 25, 2008

Maybe look into beta blockers? Professional musicians use them to conquer stage fright, which may be similar to your test / performance anxiety.
posted by jenkinsEar at 10:19 AM on March 25, 2008

I hope this doesn't seem too simplistic, as I don't want to minimize what you are going through. But one thing that worked for me in the anxiety area was to seriously pick up the amount of exercise that I do during the day. The more I work out, the less anxious I am about pretty much anything. I used to think that I suffered from mild depression, but I stopped thinking this once I started working out more intensely.

You said that you are already working out, so maybe this isn't the answer for you. But maybe increasing the amount that you do work out is as a possible variable. There has been some research recently saying that exercise may be as effective, if not more so, than medication.

I also noticed that my level of anxiety has a direct correlation to the amount of sugar that I eat. When I indulge too much, and then I spend a few days making sure that I eat no sugar at all, the change in my emotional state is striking. Also, like you, I cut back on caffeine. I actually eliminated it 100%, and it's been HUGE for me. That and exercise pretty much cured my insomnia (I struggled with it for years), and I'm sure you know how much a good night's sleep is connected to feelings of well-being. If you can get the insomnia thing worked out, I think you'll find that much of how you feel about life is connected to this one thing alone.

So, for myself, I discovered that it's primarily biologically connected to diet and exercise (and a good night's sleep). The better I am in each of these categories, the better I feel.

That said, obviously people need more than this at times, so feel free to apply or disregard as appropriate.
posted by SpacemanStix at 10:22 AM on March 25, 2008 [1 favorite]

Taking the Anxiety Out of Taking Tests: A Step-By-Step Guide is a self-help book that uses Cognitive Behavioural Therapy (CBT) techniques to lower test anxiety. Also, here’s a link to a one page PDF that summarizes the usual CBT techniques for combating test anxiety.

In the linked PDF, it says to, “Use imaging. Imagine yourself in a test situation. Look over the test. You feel calm and focused. You do not permit intrusive thoughts to enter your head. You pay attention to the test questions and answer to the best of your ability. You finish the test and feel good about your effort.” The only thing I would add is to actually do this (not just visualize) with practice exams. Create a realistic test environment (at a desk under time pressure) and practice doing an actual test. Pay attention to your anxiety. And keep doing this over and over until you learn to tolerate (and eventually become desensitized) your anxious feelings.
posted by Jasper Friendly Bear at 10:29 AM on March 25, 2008

I have a diagnosis of panic disorder with agoraphobia. I also had extreme test anxiety in school. Klonopin has been the single most effective remedy for my anxiety. The second most effective remedy is giving myself permission to fail. I'm not sure how the bar works, but I'm pretty sure you can retake it if you don't pass. You may be out some time or money, but you won't die if you fail. I have never done badly on an exam for which I was both highly prepared and also unattached to the results.
posted by desjardins at 10:33 AM on March 25, 2008

I take Paxil for anxiety and have experienced neither weight gain nor sexual dysfunction. I actually lost weight while on it (because of changes in my workout routine, not because of the drug).

I started taking it after having crazy, unrelenting panic attacks during my first round of 1L law exams. No problems since then. And taking Paxil has shown me the degree to which anxiety had been having a negative impact on my life, exam time or no.

I guess what I'm saying is that Paxil works for me without side effects, so it might work for you, too. I would suggest using it. Keep in mind however that you won't feel the full effects until you've been taking it for a few weeks.

I also find that yoga helps, which I hate to admit because I totally despise yoga.
posted by the littlest brussels sprout at 10:34 AM on March 25, 2008 [1 favorite]

Seconding jenkinsEar. In college, my friends whose parents were doctors always broke out the beta blockers before taking their exams. They're common as hell (and consequently cheap), since high blood pressure runs rampant through society. IANAD, but you should be able to scrounge some atenolol, for exmaple, from sympathetic hypertensive friends. It'll damp down your adrenaline and keep the pulse steady. Not that I would advocate such a thing, but, you know, people do it. I'm told.
posted by mumkin at 10:57 AM on March 25, 2008

Try the Paxil and see if you like it. You can always taper off of it if you don't like it or if the side effects outweigh the benefits for you. But you have it, and you've already paid for it, so you may as well try it out before dismissing it on the basis of other people's statistical experiences with it.
posted by decathecting at 11:19 AM on March 25, 2008

This isn't a pharmacological solution, but when preparing to take the MCAT the single most effective thing I found was a meditation class. As a rule, I'm extremely anxious during testing, and 6 mos. of this class helped me actively modulate my breathing/thinking etc. If you're in a good-sized city, you may be able to find a similar class free/cheap at a yoga studio or somesuch. As a caveat, the first half-dozen classes, I found it excruciating to sit still for so long, but eventually it clicked.
posted by BundleOfHers at 11:29 AM on March 25, 2008 [2 favorites]

I wouldn't necessarily count out all SSRI's off the bat. Almost all of them say that they may or may not cause weight gain or weight loss, and it truly is different for everyone.

I have suffered from severe anxiety for years, and have tried a number of medications. Paxil is one of the more notorious SSRI's with regards to ones that are likely to make you gain weight. There are others that are less likely to have weight & sexual side effects - the one I tried with the best results (seriously made me a new person in terms of being able to manage my anxiety) was Celexa. Also note that sometimes if you experience side effects, there are ways around them ... for me, my doctor prescribed Wellbutrin as well, which tends to balance out any weight gain or sexual side effects. This seems to be a very common thing to do. I'm not saying this will work for you ... but I wouldn't let fear of weight gain prevent you from trying something that will help you get to a place where you can really work on building habits to control your anxiety forever. I found it impossible to really work on CBT skills or build other habits when I was constantly in a state of panic.

Another reason not to let fear of weight gain prevent you from trying an SSRI ... I gained quite a bit of weight on Paxil. I tapered off of it after a year, so that my last dose was right before Thanksgiving. Between the end November 2007 and the end of January, I lost 20 lbs (holiday pig outs and winter laziness and all!). So, even if you do have a weight gain, you can lose it again.

Aside from that, I highly recommend working on some CBT techniques and making sure you are getting exercise in - those things have made the biggest impact in handling my anxiety.
posted by tastybrains at 12:18 PM on March 25, 2008

This whole business of pushing SSRIs for whatever ails mentally is just wrong. They were initially meant for moderate to severe depression and then became a staple for even mild depression and now more and more these drugs are being prescribed for anxiety. I am no big advocate for benzodiazepines either - but those are the anti-anxiety drugs -- not SSRIs. If you need anxiety relief in the short-term - talk to a doctor about true anti-anxiety drugs. The claim that SSRIs are somehow better because they are not "addictive' is simply not true. They simply have another name for it: "Discontinuance Syndrome," and it can be hell.

I second the suggestions from SpacemanStix and also would encourage you to look into self-hypnosis recordings.

Having lived with extreme anxiety, my heart goes out to you. I hope that something can help alleviate the symptoms and soon. I got in a position where the anxiety and depression was mild compared to the life-wrecking cycle of psychopharmacological cocktails (which have their place) but can easily spiral out-of-control as doctors move from one to the other and to this and to that; without regard to the damage the chemical soup was inflicting on my brain. Most general doctors haven't a clue as to how these drugs work and pushing SSRIs for anxiety is an example.

Good luck to you. Believe me when I say I can feel your pain. Just remember, one way or another, things WILL get better. Hang in there and good luck with your tests!
posted by Gerard Sorme at 12:26 PM on March 25, 2008

Thanks for all the tips and advice (the ones hopefully to come) -- both pro and con psychopharmalogical solutions.

I am actually open to a different SSRI, it's just that I don't want to keep paying $75 for them to find one that suits me ... and I only want to stay on it until the test is over.
posted by notjustfoxybrown at 12:37 PM on March 25, 2008

I think there are some excellent suggestions here already, but just to add something else to consider, I have situational anxiety, too, and find that GABA or 5HTP (my preferred option) can be just the thing to take the edge off and allow me to function as I need to.

Better yet, as far as I'm concerned, they're inexpensive, available locally or on the internet without a prescription, and aren't habit-forming. There is debate about their efficacy, primarily due to questions regarding crossing the blood-brain barrier, but to me it was worth the few bucks to discover whether they worked for me. YMMV, and I'd try before relying on them for anything I considered important.
posted by notashroom at 1:58 PM on March 25, 2008

I have also heard that beta blockers are good for test stress. You might want to bounce that idea off your MD.
posted by Carbolic at 2:46 PM on March 25, 2008

An astonishingly large number of classical musicians use beta blockers like propranolol to beat down performance anxiety. Best description of its effect might be that it knocks the peak off of the fight-or-flight response. The typical dose for this sort of use is much lower than its standard dosing for angina or hypertension -- in the 5-20mg range. Its action is somewhat different from Klonopin (and, possibly, complementary), which as I understand it calms constant anxiety (as opposed to the panic reactions that beta blockers tend to fight).

I try really hard not take drugs for performance anxiety, and have (mostly) succeeded. Beyond the usual techniques (eg, becoming a Yoga master, visualization, etc), the best trick I've ever found is from A Soprano on Her Head by Eloise Ristad.

The trick: When you start to feel the anxiety coming on, pay attention to the physical symptoms. Pick one, and consciously try to make it worse. (For example, if you're getting shaky, shake your hands; if your stomach is clenching, intentionally clench it more.) For me, this is usually followed by a sensation of the anxiety totally melting away.

The theory here is that the worst part of performance anxiety isn't the physical symptoms, but the loss of control over your own body that they represent. Fighting the physical symptoms never works, and just makes clearer how little control you have -- so by making it worse, paradoxically, you're regaining a measure of control (even though it's in the wrong direction), which help your brain to break out of freakout mode.
posted by range at 3:31 PM on March 25, 2008 [1 favorite]

Seconding Beta-blockers!

I and several people I know have severe anxiety problems that require creative medication management, and for situational or performance anxiety that must be faced without any diminishment of mental faculties, the beta blockers are excellent. Instead of working on neurotransmitters, they help to control the physical effects of anxiety - rapid heartbeat and increased blood pressure. OF course, IANAD and YMMV.

The best part is that they are taken situationally and there is no need to wait several weeks for them to take effect. Lots of professional public speakers use them too.
posted by monopas at 3:42 PM on March 25, 2008

Whups! and after posting - I take 20 mg of propranolol for stressful situations (family gatherings, etc.), because benzos are too sedating for me.

re: range: Klonopin is a benzodiazepine (like Valium), and probably wouldn't be a good choice for wanting to do better on a test. Many people take it for sleep.
posted by monopas at 3:49 PM on March 25, 2008

Should have been clearer -- in some cases where someone is facing both the situational anxiety of the test itself and the much-longer-time-constant anxiety of dreading the test, feeling overwhelmed, etc., I've seen people successfully use Klonopin to deal with the day-to-day anxiety of studying (like the submitter, freaking out when cracking a book) and beta blockers for the situational anxiety of the test. In some extreme situations, too, "a little sedated" may be a better deal than "completely freaking out."

Everyone's different, though, and when you're talking about a one-shot, high stakes exam like the Bar, it'd be foolish to not test out the scenarios, especially when you have this much lead time. The only way you'll know how dulled or drugged you'll feel is to replicate the conditions as closely as you can, and that includes taking the pills (or doing the yoga, or listening to the hypnosis CD, or whatever you want to test) before taking the practice test.

I have friends who used to get so rattled in performance that they would take a beta-blocker every time they picked up their instrument at home, so that they could be confident that they really were going to perform like they practiced. (I think this borders on "totally insane," but it does show how far down this road you can go.)
posted by range at 4:28 PM on March 25, 2008

I take propranolol for another reason so found the comments about it in here very interesting. After a Pubmed search I thought it might be worth adding that there seems to have been a few studies done on propranolol in testing/stage fright situations. If you end up asking a doctor to prescribe propranolol for you to use for this purpose, being familiar with these studies may help.

A starting point:

I found more with search terms like "propranolol test anxiety", "propranolol anxiety", "propranolol stage fright", etc. Also you can hit "related articles" on the article linked above and get quite a few relevant studies that should not be too hard for a layperson to understand (at least by the standards of reading primary literature for medical research).
posted by david06 at 5:09 PM on March 25, 2008

In some extreme situations, too, "a little sedated" may be a better deal than "completely freaking out."

Yup. Before I was diagnosed and medicated, I'd get drunk before a test. I always, always did better on the drunken exams than on the sober ones, because I wasn't freaking out. The advantage of Klonopin or similar is that you don't get a hangover (and presumably it doesn't fuck up your liver). Don't, I repeat, DON'T mix it with alcohol, unless you think blackotus are fun.
posted by desjardins at 7:46 AM on March 26, 2008

blackouts, I mean.
posted by desjardins at 7:46 AM on March 26, 2008

Acupuncture has helped me a lot. Addressed the insomnia too. Ginsing calmed me down and fired up the brain.
posted by pointilist at 10:04 AM on March 26, 2008

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