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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for symptoms of anxiety

Answered by
Dr.
Dr. Bonnie Berger-Durnbaugh

General & Family Physician

Practicing since :1991

Answered : 3130 Questions

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Posted on Mon, 24 Oct 2016 in Medicines and Side Effects
Question: Hello Doctor,
on XXXXXXX 16 2016 went to hospital ER, 3 days for shaking hands and feet, dizzy, felt like pass out, hot prickly heat on face, almost nauseous, balance, vertigo, shaky hands and legs, felt like pass out, claustrophobic feeling? first time used zanex and seemed to work, was calmed down no shaking next morning in hospital, did brain scan with contrast all good and heart stress test with nuclear, all good, bloods all good, 160 pounds and 6 ft .. I did light weight work out every day and walk for 3 miles 3 mph, eat healthy diet no meat, for last 10 years, also did colonoscopy all good last year, have constant lower left pain in stomach very slight, pain increases when work out or when nervous. stopped working out july and pain went away 95%.then had major severe pain lower left stomach after severe panic in july 2016 and stomach pain caused nausea were I could not eat and lost 8 pounds in week, after pain went away in 3 weeks, I was able to gain the 8 pounds back as I am 160 again now. july 2016 after hospital and pain was almost gone, july had episode and pain came back from a panic attach. another time standing waitring for car wash and in shade 110 vegas heat, I felt the heat prickels on my face, and the almpost passout feeling, went inside to A/C and in few mins was back to normal, no pill, drank water as well. last week I went to business meeting dinner, basically first time out since july hospital, took my .0625 (1/4 of .25) zanex prior to meeting, and at restaurant while waiting for my party to arrive, I got extreme dry mouth, when they arrived, I could not swallow, heart rate up, hands shake, very nervous, felt like knife in throat, could not look at waitress to order water, felt room was closing in on me, felt claustrophobic, had to run out of restaurant, took another .0625 zanex, by the time I was home I felt better., slept 15 hours next day due to taking 3 zanex slices, I try to manage on 2 slices of .0625 per day, and at home that works for me so far it seems, I have problems in stores, and sometimes while driving I might get claustrophobic , typically I feel weak in the legs, sea sick kind of feeling in stores,, vertigo perhaps, not spins but in grocery story I feel like I will fall over, sometimes feel like I will pass out, i cant look up and down on shelves at items, must shop fast and get out, I left the grocery store several times in line as could not wait for check out line, last episode I did not feel like pass out, perhaps more claustrophobic, first time with the dry throat and could not swallow, next day the throat was fine, home alone I normally feel ok.. at hospital doctors thought it was exercise related, was not dehydrated, I asked if any of my pills can create dehydration symptoms?
but it happens with various triggers. Heat, claustrophobic, in stores, etc.. I started working out again, very light work outs in my apartment starting sept 15 2016, 10 pound weights running in place, etc. no issues, get heart rate up to 125 +-
my question are;
can the panic be something other than panic?
how can I control the panic to socialize?
to go to work? meet people? to date?
I have been in my apartment since XXXXXXX almost every day, july and august I had food deliveries as I could not go to store.
I don't want to be addicted to zanex,
let me know your thoughts, please.
XXXX
doctor
Answered by Dr. Bonnie Berger-Durnbaugh 1 hour later
Brief Answer:
Recommend an SSRI medication.

Detailed Answer:
Hello XXXXXXX

I am sorry you are suffering with this.

Xanax (alprazolam) is helpful for immediate control of anxiety symptoms, but doesn't really lessen the frequency of these unless it is taken around the clock, and that isn't ideal.

Given how many situations trigger your symptoms, I suggest it is time to consider an overall anxiety reducer such as an SSRI class medication. Lexapro (escitalopram) is a medication in this class and can help control anxiety and panic. It is taken daily. It takes a couple of weeks to kick in and about 1 month for maximum benefits. It is not addictive or dependency forming, but once a person is on it for awhile, needs to be tapered to discontinue it. It is good for social anxiety and panic. You can use the Xanax in addition to it until you start to get benefit from it.

You asked if there could be other reasons for your symptoms other than panic. I think it would be reasonable to do a few blood tests. Thyroid disorder can cause panic and anxiety symptoms, so a TSH and thyroxine level would be good. Also a CBC with differential to check for anemia (low hemoglobin) and Vitamin B12 level also. And fasting blood sugar (to check for hypoglycemia).

Also consider talking with a psychologist (there are many types of counselors, but psychologists are best trained) to talk about coping strategies too.

I hope this helps and you are done with this suffering in the near future.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Bonnie Berger-Durnbaugh 27 minutes later
Thank you Doctor,
very well said I might add.
another family doc prescribed the Zoloft, and I started that pill did not take the zanex thought I was ok, went to store and that's the major eposidode I described in my above out line, stomach went in vibrations, nauseous, near passout, the result lasted for weeks, could not go out at all, by august I started to feel better again. not perfect but better from the bad episode.
so yes I want to start the zolfoft again, know I need to keep the zanex for first month, I go to doc next week to discuss.
could these symptoms and triggers be a neurological problem? (ms/etc)?

JULY 2016

WBC 12.6 k/uL
3.8-10.8
RBC 4.71 Million/uL
4.20-5.80
Hgb 14.8 g/dl
13.2-17.1
Hct 44.7 %
38.5-50.0
MCV 94.8 fL
80.0-100.0
MCH 31.3 pg
27.0-33.0
MCHC 33.0 g/dl
32.0-36.0
RDW 13.7 %
11.0-15.0
Plt 270 k/uL
140-400
MPV 9.6 fL
7.5-11.5
Absolute Neutrophils 8543 Cells/uL
1500-7800
Absolute Lymphocytes 2810 Cells/uL
850-3900
Absolute Monocytes 743 Cells/uL
200-950
Absolute Eosinophils 441 Cells/uL
15-500
Absolute Basophils 63 Cells/uL
0-200
SEGS 67.8 %

Lymphocytes 22.3 %

MONOS 5.9 %

EOS 3.5 %

BASOS 0.5 %

Vitamin D, 25-Hydroxy 71 ng/ml
30-100

GLU 81 mg/dl
65-99
BUN 13 mg/dl
7-25
Creatinine 0.98 mg/dl
0.70-1.33
BUN/Creat Ratio 13.3 calc
6.0-22.0
CA 9.7 mg/dl
8.6-10.3
Protein, Total 8.4 g/dl
6.1-8.1
Albumin 4.8 g/dl
3.6-5.1
Globulin 3.6 g/dl
1.9-3.7
A/G Ratio 1.3 calc
1.0-2.5
Bilirubin, Total 0.7 mg/dl
0.2-1.2
Alkaline Phosphatase 84 iu/l
40-115
AST (SGOT) 27 iu/l
10-35
ALT (SGPT) 32 iu/l
9-46
Sodium 140 mmol/L
135-146
Potassium 3.8 mmol/L
3.5-5.3
Chloride 101 mmol/L
98-110
CO2 28 mmol/L
19-30
eGFR XXXXXXX XXXXXXX 98 mL/min/1.7
>59
eGFR Non-AFR. XXXXXXX 85 mL/min/1.7
>59

TSH 2.64 mIU/l
0.40-4.
Hemoglobin A1c 5.4 %T.Hgb
0.0-5.6

FREE T4 FREET4 1.3 ng/dl
0.8-1.8
CHOL 151 mg/dl
125-200
Triglycerides 140 mg/dl
0-150
HDL 35 mg/dl
40-199
CHOL/HDLC Ratio 4.31
0.0-5.00
LDL (Calculated) 88 mg/dl
0-130
NON-HDL Cholesterol 116 mg/dl
0-159
Color YELLOW
YELLOW
Appearance CLEAR
CLEAR
SPGR 1.004
1.001-1.035
UPH 7.0
5.0-8.0
Glucose NEGATIVE
NEGATIVE
Bilirubin NEGATIVE
NEGATIVE
Ketones NEGATIVE
NEGATIVE
Occult Blood TRACE
NEGATIVE
Protein NEGATIVE
NEGATIVE
Nitrite NEGATIVE
NEGATIVE
Leukocyte Esterase NEGATIVE
NEGATIVE
WBC 0-5 /HPF
0-5
RBC 0-2 /HPF
0-2
Squamous Epithelial Cells 0-5 /HPF
0-5
Bacteria NONE SEEN /HPF
NONE
PSA 0.9 ng/ml
0.0-4.0

Thanks Doc.
XXXX

doctor
Answered by Dr. Bonnie Berger-Durnbaugh 20 minutes later
Brief Answer:
Thoughts on this:

Detailed Answer:
I generally prefer Lexapro to other SSRIs because of fewer side effects.

And when people are sensitive to medications, it's best to "start low and go slow", i.e. start at a lower dose and increase gradually. It may take longer to reach a therapeutic state, but side effects are minimized.

I don't think your symptoms are consistent with any neurological disorders. But working with a psychologist for dealing with particular situations that trigger the symptoms would be good.

Thanks for sending the lab work. The things I was looking for look ok. Only other thing I'd check would be Vitamin B12 as you don't eat meat.

You may want to work with a psychiatrist for medication management as they are more expert in prescribing these (may try anti anxiety medications that are not common to what family practice doctors use). But it would be reasonable to restart an SSRI plus Xanax. Another medication specific for anxiety is Buspirone, but it does take awhile to work too. It is not an SSRI, and does not help depression - is anxiety specific. It can be used in addition to an SSRI and Xanax too, if the SSRI plus Xanax does not help after a month.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Bonnie Berger-Durnbaugh 13 minutes later
Thank you Doc,
and again you are right, I am very sensitive to almost everything, over 5 mg crestor I get bad reaction in throat and pains in arms , the 5 mg amlodipine at full strength I cant stand up without major head rush, and of course the 5 mg zanex, omg 5mg I would sleep for a week at a time. lol
I have a physc appoint in two weeks as well. (insurance)

Do you have any idea why the heat is a trigger to my feeling like passing out/dizzy?

thanks for your help and fast response.


doctor
Answered by Dr. Bonnie Berger-Durnbaugh 33 minutes later
Brief Answer:
Thoughts

Detailed Answer:
About the heat triggering the symptoms: when panic attacks happen, there is a release of adrenaline and cortisol, and these cause the blood vessels in the head to dilate, and may cause facial flushing as the blood rushes in. It's possible that feeling real heat triggers a feeling of the panic symptoms and results in them. It's also possible that heat makes you feel more claustrophobic and a sense of urgency.

I see that you are on amlodipine and metoprolol. Something to consider having checked is "orthostatic blood pressures". These are blood pressure checks and pulse checks when a person is lying down, then seated, then standing. If the blood pressure drops and pulse goes up significantly when going from reclining to standing, it may be due to the blood pressure medications and these should be reevaluated.

About feeling like you were going to pass out in 110 heat - this may be due to really overheating (which can happen to anyone) and as you were standing, and with the blood vessels dilating naturally to allow for heat loss, it is understandable that you might feel like you would pass out. But again, get the orthostatic blood pressure/pulse checked to make sure you are not having problems like this from your meds.

One other thing to consider with the heat symptoms is to have your testosterone levels checked. Women get hot flashes when their hormones drop, and men can get these too. Not as common but it does happen.

You asked before if it is possible there is a neurological problem going on. None specifically that your symptoms reflect, but some people have more sensitive autonomic nervous systems (I am one of those!) and can pass out more easily, feel nauseated, car sick, etc.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Bonnie Berger-Durnbaugh 21 minutes later
actually I do test myself sitting laying and standing at home.
I take bp every am sitting to get daily benchmark.
typically 110/65 57 +-

most of the time
at 8 am no stress no work out
typical
105/65 55 beats laying
108/66 57 beats sitting
120/70 70 standing

right now (still a bit shaken from last night episode) plus only 1/8th zanex all day
125/65 66 laying
120/69 71 sitting
128/75 81 standing

I notice at home sometimes, when I feel shaky in legs, light headed, (could be poor circulation?) causing low beats per min standing, cooking, I check bp standing and sitting and I might be 69 beats per min standing and 65 beats sitting, I will do push ups to get beats up to 80+ standing,
is that a good idea?
also do you think Viagra is safe to take now with the panic?
doctor
Answered by Dr. Bonnie Berger-Durnbaugh 11 minutes later
Brief Answer:
Thoughts

Detailed Answer:
That your blood pressures increase with standing (rather than dropping blood pressure and increased pulse) is good.

The difference in pulse between 69 and 65 isn't significant - that's ok.

Rather than poor circulation, I suspect your blood pressure meds.

Do you take metoprolol for blood pressure of panic symptoms? (It will keep heart rate down).

And how long have you been on the metoprolol and amlodipine?

Right now I wouldn't take the Viagra just because it might complicate the symptoms that are going on. I don't know that it will cause more panic, but it does affect nitrogen oxide and so if you have symptoms from it, it might confuse whats going on with the light headedness.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
default
Follow up: Dr. Bonnie Berger-Durnbaugh 15 minutes later
metoprolol 5 years for high bp only- hospital for 210/110 bp was stressed from x wife.
the panic attack is new- never had panic that I knew of.....
I was introduced to Edarbi ( again cut the 50mg into 1/8ths) recommended by cardiologist 2015- as white coat in dr office still 166/80 2015 and home 120/75
first week took 50 mg edarbi I was 90/50 could barely stand
then cardiologist said sure cut the pill in 1/4s so that's how my slicing of pills started-- still head rush upon standing car, chair bed etc
then in hospital july 2016, doc said the amlodipine is better tolerated drug taken by millions and said to try it. same thing cut it in half and seems to be working fine no head rushes etc
doctor
Answered by Dr. Bonnie Berger-Durnbaugh 47 minutes later
Brief Answer:
Thoughts

Detailed Answer:
Ok - so you have been on the two blood pressure medications for awhile. I would expect the most severe orthostatic blood pressure symptoms to have already occurred shortly after starting them. So your light headedness may be from anxiety, but I'd still ask at the dr's office for them to check orthostatic BP and pulse.

Panic attacks can come out of the blue. Often there is some underlying stressor that we may or may not be conscious of. That Xanax helps when your symptoms happen makes me think the symptoms are more likely due to panic (claustrophobia, dry mouth, can be due to anxiety/panic).

The episode in Nevada, however, where you were standing in extreme heat and then felt better after coming in to cool off and drink water: that may be due to the heat rather than anxiety. It is not entirely out of the ordinary.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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