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First off let's talk about SSRIs and then I'll come back here. SSRIs are helpful but
they're not, their performance is not stellar in treating PTSD. But what's interesting is
that when this research was started more than ten years ago trying to use SSRIs with ptsd,
the speculation was that it would reduce anxiety symptoms, reduce things like hyperarousal
and intrusive symptoms and it does to some degree. The surprise finding, sort of surprise
was that when people got benefit from SSRIs they also were spending less time in states
of being numbed out and disassociated. It's like, well wait a minute why does it cause
that? And the people who are experts on trauma said duh you know. Dissociation is a defense
against overwhelm, if you're not overwhelmed you don't dissociate as much. Well okay maybe
that makes sense. Combined treatments. There are case reports, not any studies I've seen
you know, like double blind placebo control studies. Case reports that people that are
taking high doses of SSRIs and having some improvement, adding Buspar to that sometimes
you can get more mileage out of that. Also adding atypical antipsychotics. Once again
people that don't have psychotic symptoms ok may actually get more mileage out of this
treatment for PTSD. And then if nothing else works, Air Sarsaparilla makes the weak strong.
I don't know if there's been any studies on this but I think we need to investigate
this as quickly as possible. Now breakthrough symptoms. Some people say with anxiety disorders,
sometimes they lose their effectiveness over time, there's tolerance development, for benzos
and SSRIs that sorta thing. There's not compelling evidence to suggest that tolerance develops
okay but clinically you're going to see a lot of people who are going to do well for
panic attacks or social anxiety or what have you and they may drop out of therapy and call
you three months later having the same attacks again, "are you still taking your medicine?"
"yes I am." "Could it be that I've developed a tolerance to the medication?" The vast majority
of the time it's stuff like this okay. Yeah they're taking the medicine but they're not
as you know compliant or religious about taking it as usual. Very very common once people
are not suffering they're not as motivated to take the medicine as
prescribed okay. Very common, substance use and abuse. One of the most common substances
here with anxiety disorders is caffeine. Okay a person has gradually got back to using more
and more caffeine and gets breakthrough symptoms, "oh I don't think my drugs are working any
more." well wait a minute, how much caffeine are you using? Well actually a lot you know.
I've seen that again and again and again. The obvious new stressors that come on the
scene. You think that that matters? well yeah absolutely. these drugs don't provide immunity
from anxiety, they deal with the current situation and there'll be new issues that come up and
finally sleep disturbance. Sleep disturbance can be caused by any number of things you
know, taking a second job or their bed partner develops restless leg syndrome or they develop
sleep apnea or what have you. So I think the kneejerk reaction a lot of times, I don't
mean to be overly critical of this but in primary care is "well let's increase the dosage
of medicine." Time out. let's really stop and take stock of a number of things that
may account for a lot of breakthrough symptoms before we even think about increasing the
dose okay. And I'd say probably 3 out of 4 times it's one of these things and you can
talk to a person for 15 minutes and that's what's causing i. That's why I think therapists
are in the best position because we have enough time to actually talk to our patients. Kind
of a radical idea especially compared to primary care medicine.