Anxiety, depression, panic and phobia in one case history

What follows is a case history of a complex anxiety disorder. Like many disorders, the case does not  fit neatly into any single category. It involves somatization (bodily effects of a psychological disorder) and depression, probably both secondary effects of the anxiety. It shows that treatments must be tailored to individuals, not just to some general diagnosis. His successful treatment relied almost entirely on medication; in other cases cognitive-behavioral therapy has been equally successful, and does not require a lifetime of medication. "Earl" (a pseudonym) wrote his own case history. He reports that he had two brief anxiety attacks prior to the events described here; in addition, he was, and still is, phobic about flying.

ANXIETY: ADVENTURES IN TREATMENT

My problem began with a bloody bowel movement.  I thought little of it until it repeated the next week, and then began to reoccur every few days, along with rectal pain.  It never occurred to me that I might merely be suffering from hemorrhoids. I was convinced I had some terrible disease. I became progressively more anxious.  I finally made an appointment for a sigmoidoscopy.  As the day approached, I became more and more anxious and unable to sleep.  For several days prior to the appointment, I got only 2 hours sleep each night.

The examination showed that I had only a case of hemorrhoids, not a horrible disease.  I should have gone home and gone to sleep, but I was so relieved I wanted to stay up and celebrate.  I stayed up and my anxiety began to return (no doubt because of sleep deprivation).  I awoke at 5:00 AM the next morning with the most powerful anxiety I have ever experienced.  At 8:00 AM I went to the emergency room, and met the psychiatrist who eventually "saved my life."  He gave me Mellaril (generic name: thioridazine hydrochloride), one of the less potent "major tranquilizers," and sent me home.  I slept for 2 hours, and awoke more anxious than before.  I went back to the emergency room and was given four Librium an hour for about 4 hours. It was decided that I should stay in the emergency room over night and be given intravenous Valium.  However, I fell asleep just before this was necessary. I slept the night through, and was discharged the next morning.

For the next several months, I had to continue on Librium. It was almost 4 months before I could sleep through the night without waking for an hour or more around 3:00 AM.  I continued working during this period.  Just as my sleep was improving, I started moving my bowels two, three, or four times a day.  And between bowel movements I constantly felt like I needed to have another bowel movement.  I went to a gastroenterologist and was diagnosed as having functional bowel disorder, another way of saying that my bowels weren't working right but they had no idea why. The bowel movements increased in frequency to 8 to 12 a day, and the urges in between became more intense.  It was total agony.

The next year was spent seeing gastroenterologists, internists, psychologists, and psychiatrists, all to no avail. The anxiety and functional bowel disorder turned into a positive feedback loop - the worse my anxiety got, the worse my bowels got; the worse my bowels got, the worse my anxiety got. I had now continued working for about 1½ years.  I was given every known tranquilizer, and every tricyclic antidepressant - the psychiatrist having concluded that my anxiety was so intense that some kind of atypical depression must be at work. I refused to take monoamine oxidase (MAO) inhibitors because they can have fatal interactions with several foods; I was afraid I might eat one of the foods, either accidentally or on purpose. Nothing helped.  That spring, I felt that a dark cloud was descending upon me, and in about a month I had developed a full-fledged case of agoraphobia.  However, I only experienced panic attacks on two occasions outside of the house.

At the end of that summer, I was unable to return to work.  I finally decided to kill myself by starving to death.  For 3 days I sat in a chair, refusing all food.  On the fourth day, I awakened with no anxiety, no bowel disorder, and 15 lbs heavier than when I went to bed!  I had been extremely dehydrated, and rehydrated during my period of starvation.

I thought I was cured, but both the anxiety and the bowel disorder gradually returned. During this period I read a book about a symposium held in Europe on beta blockers and anxiety.  Most of the studies evaluated the first of the tetracyclic antidepressants, maprotiline, which was not available yet in the USA.  At that time my psychiatrist sent me to a research institute to try a number of experimental drugs.  None helped.

Then maprotiline was made legal in the USA.  My psychiatrist called and told me, and wrote a prescription.  Because I had responded so poorly to tricyclic antidepressants, he started me with 12.5 mg, intending to work up to a therapeutic dose of 125-150 mg.  I had little hope that it would work. Yet I woke the next morning feeling like a different person, and even went fishing off the pier.  I continued to take one 30 mg Serax (a short-acting benzodiazepine, generic name oxazepam) in the morning, and two Dalmanes (another fast-acting benzodiazepine, generic name flurazepam) before bedtime, along with ½ a maprotiline (about 12.5 mg.), and I have never changed the regimen. None of the doses have ever been increased. I made a rapid return to normalcy over the summer, and went back to work. I have had no side effects from the drugs so far as I know. This may sound like a strange drug regimen, but it works for me and I'm not about to change it. I'm convinced that the hardest part of treating anxiety disorders with medication is finding a drug or combination of drugs that fits the individual. Standard regimens just didn't work for me.

The functional bowel disorder never went away, but through a combination of milk of magnesia and mineral oil, I am able to confine my elimination to mornings and generally feel fine in the afternoons, evenings, and all night long. The anxiety has not returned. Looking back on everything that happened, I think that if I had been able to head off my anxiety as I was waiting for a sigmoidoscopy, my problems would never have been serious. But once the anxiety demon got out of the box, it was almost impossible to get it back in.