"Take Your Pills: Xanax." A Doctor's Perspective
Updated: Dec 4, 2022
The new Netflix documentary looks at anxiety. Anxiety, at one level, is an emotion. The emotional center of the brain, called the amygdala, gets activated like an alarm going off to get us ready to prepare to take action to protect ourselves. Activation of the fight, flight, or freeze nervous system, known as the sympathetic system, gets activated. This can be very unsettling when there is no commensurate identifiable threat and when the frequency and intensity become overwhelming. The documentary properly identifies that this mismatch is a real problem deserving of real answers and, in the end, discusses non-benzodiazepine strategies. It spends much time calling into serious question whether using benzodiazepines, especially daily use for the treatment of anxiety, is appropriate. At the end I compare this to the first version, Take Your Pills which looked at ADHD.
Real experiences of life with Chronic anxiety symptoms
Scott Stossel, the author of Age of Anxiety, shared his struggles. He had tried a lot of treatments, including antidepressants as well as Xanax. His research revealed multiple factors that influence the development of chronic symptoms, including genetics and the environment.
A woman in the documentary shared the possible impact of her environmental exposure to bullying as a child, and sexual assault in the military may have impacted her development of chronic anxiety symptoms. She enrolled in fashion school after the military but struggled in multiple ways. She was given Xanax, which offered a reprieve. Many who do have chronic anxiety have been through adverse childhood events known as ACEs at much higher rates than those who have not gone through those experiences.
Not everyone, however, who has had adverse stress experiences, whether as a child or adult, develops chronic anxiety symptoms. What wasn't discussed in the documentary was the connection between anxiety disorders like Post Traumatic Stress Disorder and General Anxiety Disorder, and ADHD. I will write more about that later.
Another woman shared her struggles living through the pandemic, losing her job, moving in with her boyfriend, and discovering his infidelity, which escalated to impairing anxiety symptoms, causing her to move home. She had such difficulty sleeping that she feared going to bed. Her therapist discussed Xanax as an option, which she decided to take.
Is anxiety real?
The documentary rightly identifies these symptoms as real. There are different environmental causes that were discussed that may play a role, including the disconnection from people, nature, and the hyper connection of the modern technological world fans the flames. Covid 19 was the perfect storm to heighten the already heightened in the decades before.
Those who are struggling with fibromyalgia often have been told that their symptoms are not real. There is much overlap in these diagnoses.
History of Anxiety and Treatments
Historically, chronic anxiety was called by different names, from melancholia to neurasthenia. Others included hysteria. When you look at Neurasthenia symptoms with modern understanding, you will recognize overlap with the central pain processing disorders of problems like irritable bowel syndrome, migraines, and fibromyalgia. This wasn't mentioned in the episode.
Symptoms of General Anxiety Disorder include:
Feeling restless, wound-up, or on edge.
Being easily fatigued.
Having difficulty concentrating.
Having headaches, muscle aches, stomachaches, or unexplained pains.
Difficulty controlling feelings of worry.
Having sleep problems, such as difficulty falling or staying asleep.
A quick look at the symptoms shows a complete overlap with ADHD and fibromyalgia.
Matt shared his anxiety story.
He was told that he could pray away his anxiety. He recalls being "loud and nervous, had tantrums frequently, and had to have everything perfect." He took figure skating but then struggled with obesity which caused him to quit. He started to wonder about his sexuality as well in his teen years. From what he mentioned, he was diagnosed with ADHD and treated with Adderall briefly but didn't continue it. We don't get to hear any more mention of that in the rest of the documentary. He also had a lot of insomnia that was disabling. His doctor prescribed Xanax for him, and he slept very deeply.
The story resonates with those of many of my patients with ADHD and fibromyalgia.
Scott Stossel correctly identifies the medical bifurcation of how medical problems are viewed. If you have a medical problem like glaucoma or diabetes, treatment is not viewed as a moral failure anxiety sometimes is looked at.
History of benzodiazepines
In the 1950s, benzodiazepines were discovered and were considered a big upgrade from barbituates. By the 1970s, they were one of the most commonly prescribed meds. As time passed, the recognition of benzodiazepine's side effects was limited.
Heavy marketing of Xanax and 9/11 increased general anxiety and prescriptions.
Everyday challenges of parenting and working full-time work increased stress for many. When other stressors, like parenting a teenager, caring for an ailing parent, and menopause, were shared in the documentary by a woman who had developed anxiety.
The documentary shared the hormonal differences between women and social acceptance of discussing their fears and anxieties. Men, however, are not brought up to discuss their feelings.
One of the therapists in the documentary recognized this. Asking the right questions is important. People who have been through high-stress childhood or adult events are often unaware of their experiences and have been normalized in the fabric of their minds. One of her clients did not recognize that being shot was considered an adverse stress experience.
Increased Awareness of Anxiety
In the documentary, they rightly identify that initial treatment with a benzodiazepine often leads to long-term daily use. A panic attack often is the driver of getting a prescription.
Other medications, instead known as SSRIs, can be quite helpful. There is more awareness of mental health through celebrities sharing their struggles.
Problems with Benzodiazepines
A woman struggling with flight anxiety was given Xanax making the flight so much easier. Unfortunately, she decided to take it daily, which interfered with her ability to function. The side effects of benzos are many. It can suppress part of the brain involved with anxiety but has the collateral damage of impairing general cognitive functioning. It interferes with memories, dementia risk is increased, and tolerance is a real problem as well. One of the psychiatrists in the film compared benzodiazepines "to alcohol in a pill." Scott shared his struggles with his dependence and withdrawal symptoms. The half-lives, known as the duration of action, vary among benzodiazepines. The consequences of stopping benzo withdrawal can include suicide, heart racing, palpitations, nausea, vomiting, and insomnia.
Many with anxiety have a family history of addictions. With this insight into their genetic susceptibility, many people will use unhealthy but socially acceptable coping strategies instead of alcohol abuse, for example. Often this includes excessive food consumption, which can lead to obesity, as was in Matt's story. The increased risk of dementia that was brought up earlier may not be caused by Xanax. Instead, Xanax may be a marker for those with anxiety and worse eating habits. It is hard to tease out the impact of each variable as there are so many confounding factors to consider. More effective non-medication options are discussed later.
John shared his regret about starting Xanax. He had a history of involvement in outdoor high-risk adrenaline-like sports when he was younger and wondered how he got diagnosed with anxiety. He thought that he should have been more resilient from developing anxiety. However, the drive to get the dopamine rush in these physically demanding sports is common in those with fibromyalgia or ADHD. The problems arise when the time spent in these activities diminishes, and the demand to perform non-adrenaline activities of everyday college and work life takes over.
John was escalated to a high dose. His life seemed to stabilize for a while, so his dose was dropped 1/3. He developed sound and smell sensitivity, heart palpitations, burning sensations of the skin in his arms, myalgias, brain fog, and physical fatigue. He saw many specialists, including rheumatologists, cardiologists, neurologists, and others, to get answers. His primary doctor finally referred him to the Mayo Clinic, and he was diagnosed with autoimmune encephalitis. He was given weeks of IV infusion, and not only didn't he improve, but he also got worse. Along the journey, he asked if his medications were causing it but was assured it was not. He was switched from Xanax to Valium. One morning, he had intense symptoms of sound sensitivity, burning skin sensations, and chest pain. He couldn't handle it and drove very fast and erratically and contemplated going to a hill and jumping off of it. He, fortunately, thought of his family and didn't follow through.
He did research and discovered he was likely having problems due to benzodiazepines. He found the Ashton Withdrawal method and Dr. Ashton's identification of the dangers of benzos and the safe withdrawal. He continues to work on a slow wean that has been going on for a couple of years. He has reached the level of micro pipetting his benzo dose in slight daily decreases.
In the 1990s, advertising of depression and anxiety medications started and has since then become mainstream into the normal fabric of society.
The documentary said doctors became like workers on an assembly line, seeing patients quickly. The medical model of prescribing a pill without other treatment options is much easier and faster than spending 45 minutes discussing complex explanations and lifestyle interventions. The documentary brings up patient surveys as a potential problem in dealing with benzodiazepine use. A point brought up is the fear that if a doctor doesn't continue to prescribe Xanax, they may get a poor rating. One poor rating can significantly impact patient satisfaction scores, which has a big financial impact. The consumer mentality of medicine is commonly accepted in place of more paternalism of the past.
The documentary recognizes there is an appropriate use of benzodiazepines. A comparison to opioids is made, one for physical pain and one for more emotional pain. Interestingly, opioids have a strong action on emotional pain. Both have appropriate uses, but very careful consideration and duration of use are needed for both medications.
The documentary shared the common use of Xanax in the lyrics of more than 50 music artists. Many were able to get these from friends or online dealers. The documentary shared that, unfortunately, fake Xanax imported from drug cartels onto the street has been increasingly prevalent; some of the fake tablets are laced with fentanyl which can be deadly.
The documentary shared that benzos with opioids can be very deadly, acting like anesthesia by putting them into a deep stupor with respiratory depression.
Some music artists are bringing to the attention the struggles of Xanax addiction and the need to live without daily benzo use.
However, not everyone who uses a benzodiazepine has major negative impacts. One woman shared the has been on 1 Mg of Xanax a day, is working to help her anxiety, and has not had any dose escalation. However, many experience anxiety when they stop taking them.
How to treat anxiety?
The documentary briefly mentions lifestyle management with the importance of
exercise, good sleep, Yoga, and meditation, to help create a calm biological state.
SSRIs reduce anxiety, but the impact is not immediate like Xanax. They may work by helping the brain build stronger connections over weeks.
The documentary briefly mentions the possible benefits of marijuana use. Cognitive therapy can help by reframing how one looks at their thoughts.
Social connection is very powerful. Loneliness affects mental and physical health. Infidelity can be devastating. Connection with others is one of the best things we can do.
Normal responses to abnormal environments in the world we live in. Unfortunately, we often have limited control of our environment.
Doing physical things is so important. You can lose yourself in the activity and get out of your thoughts. One example in the documentary was volunteer work caring for horses. The fresh air and physical contact with horses can be very therapeutic. Doing hands-on creative activities can be done as well. It might be art, crafts, or flower arranging.
One of the psychiatrists shared that "the problem with using Xanax every time you get anxious is you are not building up the calluses to tolerate more anxiety." "If you are squelching the anxiety with Xanax, you are not learning ways of coping on your own, which are opportunity costs for the next time you have to face it."
A woman shared she uses Xanax 1-2 times a month only for high anxiety despite her best attempts at self-management with diet, exercise, sleep, and volunteering spiral to an out-of-control level. Scott shared that he uses Lexapro and cut benzo use to very infrequent.
One of the psychiatrists said, "The only way out is through it."
"Getting through an episode of anxiety can build resiliency. However, nonmedication strategies don't always work. Benzodiazepines give the experience that one can quickly get away from anxiety with a pill. Our job is not to remove all the pain and suffering but to diminish it."
A Deeper Look
Anxiety has more than one meaning. It can refer to a symptom or a condition called general anxiety disorder or others like Post Traumatic Stress Disorder. Other conditions commonly occur with anxiety in a bidirectional relationship, including Major Depression, Fibromyalgia, and ADHD, for example. Deciding which of these to treat first can be challenging for the doctor. The first step in evaluation is identifying all the conditions present, starting with a thorough history, review of systems, physical exam, and appropriate tests like a complete blood count, thyroid panel, and metabolic panel. There may be other tests to consider like a cholesterol panel to assess for cardiovascular risk. Sometimes a stress test must be done depending on the history and laboratory findings. If there are symptoms of chest pain with exertion, evaluation for heart disease would be needed.
The documentary brought attention to anxiety alone. Focusing only anxiety can miss the other conditions. For example, if someone has ADHD, they often will feel anxious and overwhelmed but not necessarily depressed, more often frustrated.
There is a problem when diagnosing anxiety that sometimes occurs, known as anchoring. Anchoring is the tendency to stick with initial impressions even as new information becomes available. Anchoring could be reduced if clinicians consider probabilities and clinical judgment when diagnosing common clinical conditions. This can occur when other possible explanations for the symptoms are not considered.
For those living with chronic anxiety and are still struggling despite seeing many doctors, it is important to consider there may coexisting conditions or other conditions that better explain what they are going through. Examples include coexisting fibromyalgia, ADHD, restless leg syndrome, and depression. As I discussed earlier, many with anxiety symptoms have ADHD as the primary diagnosis, which is missed in 90% of adults. This failed recognition can majorly affect an individual at many levels, including health and social determinants.
This version of Take Your Medicine did a much better look at anxiety than the first version directed at ADHD. The first one was poorly done and only increased the stigma of ADHD. There is more that could be said in a part 2, but there was limited time. The producers achieved the likely desired attention to cause doctors and other providers caring for those with anxiety to exhibit caution and carefully consider the appropriate use of benzodiazepines to treat anxiety conditions. I would add the need to carefully consider other disorders that coexist or may better explain the condition.
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