10/5/04:   I started having anxiety and panic attacks in my early to mid twenties. I was working for a hospital, and one day at work it seemed as though a light switch went off somewhere inside my brain. My heart began to race, the room was swimming, and I felt like if I didn’t get out of the situation I would die. I also experienced an unreal, dream-like sensation. People around me, even myself, didn’t really feel real (derealization). It was very fearful to me, and while it felt like I was experiencing those symptoms for an eternity, in reality it couldn’t have been more than a minute or two.

This is the direction that the next five years of my life would take. Not only was I experiencing panic attacks, but also chronic anxiety, social anxiety, OCD (short for Obsessive Compulsive Disorder), and Trichotillomania (compulsive hair pulling).

I diagnosed the OCD myself after having gone to the employee counseling center at my work. I was terrified, crying, confused, and didn’t understand what was happening to me. I happened to pick up a brochure in the waiting lounge, with the title “What Is OCD?”, or something close to that, and it described everything I was feeling. I couldn’t believe it. This monster actually had a name.

By no means did this discovery alone mean that I was better. When the counselor was finally able to see me, I sheepishly told her – after much crying – that I believed I had the OCD this brochure was talking about. She was patient and understanding, and referred me to a psychiatrist who specialized in treating anxiety disorders.

This was the first time I had ever been to a psychiatrist, except for once when I was in the fifth grade, right after my parents divorced. I was extremely embarrassed of my OCD, and because of my embarrassment - and shame - was not helpful or even talkative. I couldn’t communicate my experience to my doctor. He had to pull teeth just to get the tiniest bit of information out of me. He was able to confirm through a couple of tests that I did have OCD.

He also prescribed Prozac for me, but I don’t remember the dosage or that it did much good for me.

Around this time, I also met my future husband. A wonderful, loving, beautiful man. I was reluctant to share the more scary symptoms with him, but I did share my diagnosis of OCD, and he was accepting. When we became engaged, we relocated to a city an hour away, and so I discontinued both the counseling and the medication.

Life didn’t get any easier for me after we moved. After our marriage, the OCD and anxiety gradually built in intensity, until I was literally coming home from work and crying to my husband. I would cry to him about the scary thoughts I was having, and he would tell me it’s alright, that I didn’t need to be afraid.

Work was hell for me during this time. Anything social was difficult for me because I was feeling such shame for my thoughts. I would have the scariest, most abhorrent thoughts, and couldn’t seem to divert my mind to something different. My self-esteem was very, very low. I was being held captive by my own brain.

I started up counseling again, and this time my therapist was a woman. I liked her, but her specialty was not anxiety disorders. She recommended I start on an anti-depressant. Off to the Doctors I went. It was not difficult getting prescribed an anti-depressant, probably because I was in tears the entire time of my appointment! If anyone needed an anti-depressant, it was certainly me.

For the next two years I was taking 40 mg a day of Paxil. When I was prescribed Paxil by my doctor, I was warned about taking alcohol with the medication, and that I would need a liver test at least once a year. Other than that, I really didn’t have to worry.

I also discontinued therapy a second time because of insurance reasons, but also because I was feeling better due to the medication. My problems really seemed to disappear with the medication, and I was sooo thankful not to have to continue therapy. Therapy was difficult, partly because I didn’t feel as though I had a steady compass in which to guide me. I don’t mean to say that my therapist was not helpful, but I just didn’t understand that much about my problem, nor did she, or how therapy could help me.

For two years I continued on Paxil, 40 mg a day. For the most part, I felt much, much better. I felt more confident, and wasn’t terrified in social situations. My OCD also went away. The only drawback I could find was that the medication tended to make my period irregular. In fact, I started having my period almost constantly towards the end of the two years. My doctor confirmed – after searching her pocket-size book which listed medication side effects – that prolonged use of Paxil could lead to abnormal bleeding. I guess I was the first patient she’d seen who experienced this side effect.

This was one of the reasons which led me to discontinue Paxil. My husband also encouraged me to come off the medication, but for different reasons. He and I planned to start a family at some point, and we both thought it was better if I come off the medication before getting pregnant. My husband was also convinced that I was “over” any trouble that I was feeling before, and didn’t need to take Paxil any longer. Deep down I felt that was wishful thinking and incredibly optimistic, but I also strongly wanted to believe that I was better. And, not knowing how I would feel off Paxil – better, worse, or the same- I decided to give it a try.

Also around this time -for reasons unknown to me- my husband did a search on the Internet for Paxil. What he found were myriads of websites advertising lawsuits against the makers of Paxil, and the horror stories from people who were withdrawing from the drug. When he told me about what he had found, I was in disbelief. It was hard for me to accept that something which had worked so well for me, and which my family doctor had prescribed for me, really had such harmful side effects. I was never warned of any withdrawal effects. I listened to him, but didn’t really follow up for myself. I guess I thought there was a chance it wasn’t as bad as he said it was.

I finally made an appointment to see my doctor, and her plan was to wean me off the medication over a period of one month. I went from 40mg to 30mg in the matter of one week or less. The withdrawal effects were pure torture. That first weekend, my body actually felt like it was dying. I do not know how to explain it any more simply than that. I was dizzy and nauseated to the extreme, and noises around me were amplified. Car horns sounded like they were within inches from my ear. Any sharp or loud noise was absolute torture to my ears. I also experienced the Paxil “zaps”. I could barely stand up, and was close to going to the emergency room because I was so frightened! My emotions were also an up and down rollercoaster. I felt extremely irritable, almost angry, and also very sad and weepy. I made the bad judgement of telling my mother-in-law, a nurse, about what I was going through. She told me I should be weaning much more slowly than I was, and she also told me to drink electrolytes. This advice was helpful. She also said she worked with nurses who took about 10mg or so just to help them relax. However, when she found out the dosage I was on, she said that there was really something wrong with me, and I needed to see a psychiatrist if I needed that high a dosage. This hurt me a lot, even though I didn’t express it to her. I did however make a mental note not to share this kind of information with her ever again.

Following this advice, I weaned from the medication at a slower dose. It was very tough, but by June 1st I was completely off (having started weaning in mid-April). I did fine for the next month –no anxiety-- but by mid-July I started feeling a terrible depression. I would cry nearly all the time, and felt completely hopeless about life. I have never experienced this kind of depression in my life, and had a very sneaking suspicion that it was the Paxil (or going off) which caused it.  Following the depression, came the extremely debilitating episode of anxiety. It got so bad that I nearly couldn’t even go into work. I was highly anxious in any and all social situations, especially at work. Friends that I previously had made, I no longer felt I could talk to, the anxiety was so bad. My concentration and focus had also gone down the toilet. I would go to work, but my mind was so focused on how anxious I was feeling, that my work suffered. I had absolutely no concentration for anything but how anxious I was feeling. Each day I dreaded going to work – and I mean dread. If I opened my mouth to talk what came out was a shaky, frightened quivering voice. It was the worst feeling I have ever experienced in my life. It also became a major issue between my husband and I. I desperately needed help, but my husband thought I could will myself into feeling different. He also forbade me to go back on Paxil, which he thought was harmful to me. He attributed my anxiety to lack of confidence and social skills. He gave me books to read like “The Power of Positive Thinking”. Intuitively, I knew this strategy would not be helpful, but I gave his plan a try in order to keep the peace.

Being desperate for relief, I turned to any type of alternative therapy I could think of. This included herbs and hypnotherapy. Hypnotherapy was the most ineffective strategy I took. It may have even been harmful. Basically, the hypnotherapist spoke into a tape during our sessions and had me imagine a warm, safe place, such as a beach or reflecting pool. It absolutely had no effect on me, and in fact my anxiety worsened as I continued with this therapy (about a month). When I described some of my anxious and OCD feelings to the hypnotherapist, he commented that he was sure that somewhere inside me there was a “nice” person. He totally misunderstood my problem.

I also started going to an anxiety support group, received acupuncture (did not help except that it was very relaxing and my acupuncturist was a very nice lady from China), started an exercise regime and also started taking herbals. The support group was not very comfortable. I was the only female in the group, and most people were there for mild anxiety (and I stress, mild). I found a lady over the Internet who claimed to have cured people with OCD through an herbal regiment. That was a very expensive and also ineffective strategy for me, but it gave me alot of hope when I began because she claimed to have cured herself of OCD. Unfortunately, it had no benefit for me.

After literally feeling like I should be institutionalized, spending weekends apart from my husband with my mother and sister (who I finally shared my OCD and anxiety trials with, and who were supportive of my taking medication), my husband was finally pressured into approving my going back on Paxil. It put an extreme amount of stress on our marriage, but finally he caved in late September, after pressure from my family and seeing me in such awful mental health. Looking back it seems unhealthy that I abdicated so much responsibility to him for my well-being, but he did not make it easy for me to return to the medication.

I also changed doctors at this time. I took advice from my mother to quit seeing the part-time family practictioner, and go to an internal medicine doctor. My new doctor belonged to a very reputable hospital and I had a lot of confidence in her. She listened to every concern I had, and answered all of my questions in a very educated manner. She explained why Paxil had such harmful withdrawal effects, and how it worked. She said that in her experience Paxil was the best medication for OCD, but given my withdrawal experience with this drug, she decided to put me on Paxil CR (controlled release) instead. She explained why this would be better for me, and that she would wean me off of it very slowly (from three to six months) when I decided to go off. She also made sure I would get counseling or therapy for the OCD and anxiety. I wasn’t looking forward to going through this process again, because it was so much work finding a new therapist and explaining my history to yet another person who may or may not refer me to someone else, and who may or may not be helpful. But I knew what I had to do, so I called several people on her list of recommendations, one of whom was a therapist who specialized in anxiety disorders, Dr. Stephen Pravel.

I became convinced that Dr. Pravel was the right therapist to help me, since his background was in anxiety disorders. I decided to give him a try. The first session (which was also my third wedding anniversary) was me crying the entire time, and telling him about everything which was making me feel anxious. Crazy, non-sensical things which were totally scary and felt out of my control. I told him everything over the course of a few sessions. He had me take a few tests to gauge what exactly I was experiencing. OCD, panic attacks, and social anxiety were all part of the problem. Over the course of the next few weeks, he gave me literature on OCD and anxiety, and gave me some books for recommended reading. In our therapy sessions, he had me give him specific examples of what OCD thoughts I was having, and then we would calculate the likelihood of those thoughts actually occurring. He also had me discuss my family history with him, which I did, and I was surprised to learn (over many sessions) how much of my current problems were rooted in issues which had taken place in my childhood. The fact is that I came from an abusive home. My father abused my mother, sisters and I, and then pending a divorce in the fifth grade, left without saying goodbye. I also had some very complicated issues with my mother, who was emotionally very manipulating and over-controlling to the point that I left home at age 20 in order to gain some autonomy. I was away from home for five years, without any contact with anyone from my family, not even my sisters or my grandmother. I also made the mistake of falling in with people who were just as abusive as the home environment that I had left, and so the cycle continued. 

I had never effectively dealt with these issues before meeting Dr. Pravel. Carrying around so much baggage for so many years was bound to affect me in some way. From Dr. Pravel I learned that not only are there biological influences at work (my OCD is strongly biological, since I’ve had it in different forms since I was a young child, and my mother and both of my sisters also have it), but also strong environmental and family issues which helped to shape my current problems. For instance, one of the themes which Dr. Pravel has helped me to uncover is guilt. I have a strong inclination towards guilt --towards feeling bad-- and this theme manifests itself and helps feed my OCD and anxiety. This has been a very helpful and important insight for me, since feelings of guilt have literally crippled me all these years. Therapy with Dr. Pravel will be ongoing for me, at least for now. Because of Dr. Pravel’s help, I have literally taken back power for myself, and now see my anxiety and OCD in a totally different light. Before I felt defeated and shamed by my anxiety, OCD, and my past, but through our sessions he has helped me to take back my life.

My husband and I plan on starting a family, so three months ago I started weaning off the medication under my doctors supervision. As of today, I have been Paxil (CR)-free for five days. This experience was much better than the last. I was only on Paxil CR for six months before I tapered off, and I withdrew very, very slowly. With the exception of when I lowered doses, I barely noticed the withdrawal effects.

In all honesty, Paxil (minus the withdrawal effects) has been very helpful to me. Without it, I do not know where I would be today. However, finding Dr. Pravel has also been as beneficial to me as taking Paxil. With his insights and experience, he has helped to change the way I respond to my OCD and anxiety, which in the end helps me to manage it with much greater confidence and control. Instead of shrinking away in fear of my illness, I now know how to respond so that it doesn’t snowball out of control.

The third and final important part of my recovery has been turning to religion. In my case, Christianity. Drawing closer to God and his teachings has helped me to develop a center, confidence in the future, and has provided a steady roadmap for me. There is an abundance of Christian literature, and each book I read makes me hungry to read the next. I can't begin to describe the value in developing a spiritual life. It's helped to fill a huge hole within me and to give my life purpose.

I do not know what the future holds, as far as any debilitating anxiety and OCD returning, but I plan on moving forward with my life and taking with me everything I have learned about my disorder and myself.

                                                             -- SARA

CLINICAL SUMMARY

As Sara states in her story, her OCD is of both biological and psychological origin. The fact that her mother and sisters also have OCD is strongly suggestive of a biological - a genetic - involvement. The persistent irrational thoughts and behaviors that characterize OCD are the result of the brains difficulty making transition. In other words, it is like a car whose transmission sticks in one gear. The brain gets one idea and can't let it go, or shift gears. While the average person can check a faucet or door lock and see it is secured, the person with OCD cannot let it go. Their brain is stuck in gear - it doesn't just automatically shift into the next gear - or thought. Part of Cognitive Therapy is helping the person learn to manually shift gears, since their brain at times is like a manual instead of an automatic transmission. Sara would become so anxious and agitated over her awful thoughts, that her anxiety would then cause her to stay stuck in gear even longer. The more anxious she'd become over her thoughts and impulses, and the more she thought she may act on those feelings, the more she'd have these thoughts and impulses. Part of Sara's therapy was coming to recognize that vicious cycle, and learn how to become less agitated over her thoughts. She was able to learn that her thoughts were not her fault: "It's not me, it's my OCD". As a result, she was able to be less anxious when those thoughts would come to her, and less anxiety led to fewer thoughts.

Sara also experienced extreme shame and guilt over her obsessive thoughts, causing her to become anxious in the company of others when she was experiencing those thoughts. Her shame, guilt and social anxiety would become even worse if the people she was with were the people she was having inappropriate thoughts about, which was often. She would therefore be anxious about looking anxious to these people, which only made her more anxious - another vicious cycle. In therapy she was able to understand the need to recognize that other people were not reading her mind, and could not know what she was thinking. This helped her feel less fearful of discovery, especially the fear of being discovered to be a "bad person". She was not bad, she had OCD, something she was not to blame for. She was able to learn to relax and allow the thoughts to come into her head, understand that nobody knew of her thought, and allow the thought to pass through. This increased her sense of self-control and therefore self-confidence and self-esteem. As a result, her panic attacks in these social situations started to diminish, making her feel even better and more in control. Her vicious cycle was turning into a positive or virtuous cycle.

Through Insight Therapy, Sara was able to come to understand that in addition to biological influences, there were strong childhood psychological issues involved in her OCD and anxiety disorders. Since she was a young child, Sara had the type of personality inclined to be compliant, compared to rebellious. She wanted to please her parents, to make them happy and feel their love and approval. Unfortunately, Sara's mother was extremely controlling, moralistic and had difficulty allowing her children grow up and develop lives separate from her. Sara's normal urge to do just that was met with stiff resistance. This made Sara feel she was bad, and caused her to develop a powerful guilty conscience. Normal thoughts, urges and desires were therefore "bad", and this became her internal landscape: a bad person who thought bad things and wanted to do bad things. Sara's father was a very abusive, tempermental man who only reinforced Sara's sense of being bad. In addition: mom's disapproval and fathers abusiveness also made Sara feel insecure and afraid, leading to the development of anxiety disorders in adulthood.

By learning about all of these influences, Sara has been able to involve her adult brain in reconsidering the beliefs and feelings she developed as a child. She has been able to come to realize she had to struggle to achieve normal development given all these negative factors. She had to fight to overcome fear induced by her father, and struggle to achieve independence that was thwarted by her mother. She has managed to become a very successful, independent grown up woman who is happily married to a very caring man. She now wants to complete her life by having a child. She has demonstrated the ability to overcome odds and develop a fulfilling and complete life. Good work Sara.

                                                 --  Dr. Stephen Pravel