Medical Literature

QUESTION:

Dear Doctor,

I have almost all the symptoms of GAD (especially my mind never shutting off) along with depression and irritable bowel syndrome.  I have read over all of your FAQs and looked at any that talked about GAD, Paxil, or Celexa.  In many you seem to say that Paxil is not good for GAD; but in one of your most recent, you recommend Paxil for it.

Is Paxil good or bad for GAD if I also start on BuSpar?  Would Celexa be a better option (along with BuSpar)?

Prozac and Effexor make me too nervous.  I just got off of Effexor.    I am just now realizing that my problems could be more from GAD than depression.  I am also seeing a counselor.  I am going to my regular doctor in a week and I need to know what you suggest.  She hasn’t done a very good job in diagnosing me, but I can’t afford a Psychiatrist.  I have a few of the symptoms of OCPD, but I don’t think I have it.  If I did, would your treatment for me be any different?

Thank you in advance for your reply.

ANSWER:

I do not recommend Paxil for the generalized anxiety disorder, particularly the cognitive component.  This is especially true if it runs in your family, making it the genetic type of GAD.

Paxil helps some patients with the somatic generalized anxiety disorder, but I suspect it’s “subclinical” panic disorder, or relief of anxiety symptoms, by relieving depression and/or social anxiety disorder.

If Prozac made you nervous, all SSRI’s will make you nervous including Paxil and Celexa.  Once you’re on the full dose of BuSpar (usually 15mg twice daily) for a week, you will likely be able to take Prozac or another SSRI without it making you too nervous.  Sometimes starting with a low dose first can make that process easier.

OCPD responds beautifully to 60-80mg of Prozac, usually 80mg daily.  Things stop feeling like they’re a “big deal.”  I go into this at length in “Biological Unhappiness.”

Why Do I Feel Worse On Ritalin, Zoloft And Buspar?

QUESTION:

Dr. Heller,

I wrote you last week with a question concerning my problems with figuring out the chemical imbalance I am having.  I would like to say that I have taken the advice you gave me in adding the BuSpar again.  I have just started it yesterday at only half the dosage of a whole pill in the morning because I take .25 Xanax at night before bed.  I think it is 7.5 mg.  of BuSpar.  Furthermore, I did not take my Zoloft today at all.  I also have cut the dosage of Ritalin to just 5 mg.  upon waking.

Today, (Christmas Day) I felt the most focused and calm I have felt in a long while.  My mind hardly raced at all either.  I told you that I have been diagnosed OCD.  Well, in reality, it is only suspicion.  I have only been officially diagnosed as ADHD, and GAD, with a heavy emphasis on the social aspect of anxiety.  Sorry if I confused things.  I just assumed I am OCD because a few doctors have said so, but I suspect that this Zoloft is making my mind race so fast and clouding it up so bad that I am obsessing a lot more.

Since the start of the Ritalin, I have not obsessed nearly to the extent I was before.  So here is my 2-part question:On the Zoloft, I am very perfectionistic.  I always feel like something is on my clothes, or in my hair, etc.  So I will keep checking it to make sure.  Would this likely be just an increase in the GAD and ADHD from the Zoloft causing me to do these things, or some other problem? The second part to the question: Could it be possible that my serotonin levels are fine, and maybe even a bit high in places like you said, and my dopamine levels and norepinephrine levels are low causing the hyperactivity and GAD problems?  I can only figure this because of my response to these meds.  I am scheduling an appointment with my G.P.  in a few days, and I was thinking of recommending Effexor XR to replace the Zoloft.  I know this is serotonin based too, but it seems that it is good for GAD, from what I hear and read.

I would appreciate any response to these questions sir.

ANSWER:

You likely have overactive serotonin 1 (GAD) and serotonin 2 (PTSD) receptors.  Ritalin and Zoloft worsen the anxiety of the GAD, sometimes of PTSD.  BuSpar lowers the overactivity of serotonin 1, but in many patients makes PTSD worse.  The medication I use for people like you is to add Remeron – which lowers the serotonin 2 overactivity.  The combination you’re on plus Remeron could be extremely effective.

From what you wrote, I suspect the OCD and/or OCPD are likely present as well – worsened by your current combination of medications.  It is common for people to have multiple diagnoses.

Effexor may work in high doses.  Some physicians and patients get good results on high doses (300-600mg daily).  I haven’t seen many benefits; both side effects and withdrawal symptoms are of concern, and a problem for most patients.



 

2001 October Questions

 

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QUESTION:

Dear Dr. Heller,

Do you think they are any closer to coming up with a cure for GAD?

ANSWER:

The GAD is mostly a genetic disorder, especially the cognitive component (mind always going, persistent worry). BuSpar is a very effective medicine for the GAD, although many patients erroneously consider it ineffective because it doesn’t make all their anxiety disorders go away.  Other medications can help such as Paxil, Effexor and the benzodiazepines. There’s a great deal of work being done on genetics and I would expect that someday a cure will be developed.  This day is likely a long way off, however.  For now the best treatment is medications.

QUESTION:

Dear Dr. Heller,

What do they mean that there is no cure for GAD, but it is treatable?  Aren’t you cured if you can treat GAD?  I know someone who had GAD for 3 months and treated herself, without medication or therapy, within 3 months.  She has been cured for 4 years now and states that she can’t cause any anxiety anymore no matter how hard she tries.  She even had her dad pass away in her arms, and the anxiety disorder never came back.  I want to know if GAD could also be a neurotic disorder not just a psychotic.  No one in my family ever had any emotional disorders.  My mom worries a lot (but that’s like most parents), but she has no disorder.

Please Reply ASAP.

Thanks

ANSWER:

The vast majority of people with the GAD, particularly those with the cognitive component, have a genetic disorder where the 5HT1A receptor is overactive.  These people made great “cave guarders” thousands of years ago.  Cognitive GAD means having persistent worry or the mind never shutting off.

There are many causes of anxiety, and I suspect the person you knew didn’t have the GAD, but was experiencing situational anxiety.

The GAD is considered a neurotic disorder, not a psychotic disorder.

What Can Be Done For Sexual Dysfunction?

QUESTION:

Dear Dr. Heller, My wife is taking Celexa for generalized anxiety disorder.  Our sex life was slow before, but we could deal with it.  Now — It’s nothing!  She would try, but no go.  Then it would just turn me off, because of her state. My question: Is their anything we can do to get her, or our sex life, back in order?

ANSWER:

Celexa usually worsens the GAD (generalized anxiety disorder), which can cause a lack of sexual interest.  BuSpar is usually needed also. SSRI drugs like Celexa can cause a lack of orgasms.  If she doesn’t need an SSRI, other antidepressants are an option.  If she does, high doses of ginkgo (120-240mg daily) or the addition of Wellbutrin could make a huge difference.



 

2001 November Questions

 

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QUESTION:

Dear Dr. Heller,

I am a 25-year-old male.  I have a 3-part diagnosis.  ADHD, Obsessive-Compulsive Disorder, and GAD.  I am now on 50mg. Zoloft a day, and just today started Ritalin for my ADHD (just 10mg. a day).  I also take a .25mg. Xanax before bed to sleep well and slow any racing thoughts.

Would the fact that the Xanax is the only thing that slows my thought process suggest that possibly my anxiety is seizure oriented after all?  I know that they can use Klonopin and Xanax to prevent seizures.  Or, would you think that the Zoloft is causing my mind to race out of control and my GAD is being completely undertreated?  It seems like this to me.  Finally, would something like Neurontin be a good suggestion to my doctor as a treatment for GAD?

Any response would be greatly appreciated.  Thank you.

ANSWER:

The cognitive GAD (persistent worry, mind always going) is a genetic trait that was of enormous help to our ancestors tens of thousands of years ago.  These individuals were sensational cave guarders.

The GAD appears to involve an overactive serotonin 1-A receptor.  This causes an imbalance with the OCD, which likely involves low serotonin.  This high/low imbalance is likely causing you problems.  SSRI medications like Zoloft increase all the serotonins, stimulating the already overactive 1-A receptor and worsening the anxiety.  Xanax and Klonopin, like all Valium like benzodiazepines, reduce anxiety.  It’s unlikely that it’s a seizure in your case.  Neurontin is highly unlikely to help.  Ritalin will likely make the GAD worse.

BuSpar is the best medication for the GAD, and lowers that receptor so SSRI and psychostimulant medications can be taken without worsening the GAD.