Managing Anxiety and Autonomic Dysfunction: Medication and Lifestyle Tips

Could you please provide more context or specify the medication you are inquiring about?

Hello, Doctor.
Last October, I underwent autonomic nervous system testing at a health check-up center and was diagnosed with moderate autonomic dysfunction.
I suspect this may be related to recent stress and interrupted sleep, accompanied by symptoms of irritability.
In February, March, and April of this year (with symptoms worsening over time), I occasionally experienced sudden dizziness, head pressure, rapid breathing, and increased heart rate.
At one point, my heart rate reached 140 beats per minute and wouldn't stop for an hour.
I consulted a cardiologist, and tests for thyroid function, an electrocardiogram, and X-rays showed no issues.
The cardiologist suggested that it might be caused by autonomic dysfunction and prescribed Propranolol: 10 mg in the morning and 10 mg at night, and Alprazolam: 0.25 mg in the morning and 0.25 mg at night.
After a week, I told the doctor, "The first two days after starting the medication, the symptoms were still severe, sometimes occurring every ten hours." The doctor said I could take Alprazolam an additional time at noon and as needed.
However, I found online that this medication has a short half-life (meaning it acts quickly but doesn't last long), and it was mentioned that medications with shorter half-lives can lead to addiction and withdrawal effects with prolonged use or higher doses.
Therefore, I continued taking it only twice a day, 0.25 mg each time.

On the other hand, after a week, I saw a psychiatrist who said my autonomic dysfunction was due to anxiety.
He prescribed an SSRI (Escitalopram: 5 mg every night).
I also practiced abdominal breathing regularly.
After that, I experienced fewer episodes occurring every ten hours.
However, when I am outside and encounter noise, poor air quality, clutter, crowded places, hunger, fatigue, or poor sleep the night before, I am very prone to sudden episodes of increased heart rate, rapid breathing, thirst, palpitations, gastrointestinal discomfort, blurred vision, head pressure, and cold extremities within 15 minutes.
In severe cases, I experience tremors, extreme anxiety, and severe dizziness, almost losing the ability to move, necessitating an immediate return home.

I have been taking Alprazolam for five weeks now.
In the first three weeks, I took 0.25 mg in the morning and 0.25 mg at night.
In the fourth and fifth weeks, I reduced it to 0.17 mg in the morning and then 0.17 mg around 2 PM or close to bedtime.
After this reduction, my anxiety increased slightly, but I could manage it with mindfulness and abdominal breathing.
However, if I go out and encounter the aforementioned situations, I can easily experience severe discomfort, prompting me to take an additional 0.25 mg.
Currently, I am abroad and unable to consult my original doctor in Taiwan, so I would like to ask the following questions:
1.
Given my situation, should I avoid reducing the dose of Alprazolam? Would it be better to continue taking 0.25 mg twice daily?
2.
For short-acting medications like Alprazolam, can I wait until I need it to take it? If so, should I still gradually reduce the dose (considering I have been taking 0.35 mg to 0.75 mg daily for a month)?
3.
I have been taking Escitalopram for three weeks at 5 mg every night.
I read online that it takes at least two weeks to see effects, but in the past week, I experienced two episodes of severe discomfort while out, requiring me to return home immediately.
Although I feel uncomfortable at home, it is not as severe.
Given my symptoms, should I increase the Escitalopram dosage to 10 mg daily, or should I continue with 5 mg for a while longer?
4.
Sometimes my symptoms worsen when I go out, but I know that staying home can negatively affect my mental state, so I force myself to go out.
Is this approach harmful? Should I stay home to rest instead?
5.
I know that walking can help with autonomic nervous system recovery, but once when I felt slightly unwell and started walking home, I felt close to fainting before I reached home.
How should I gauge the intensity of walking rehabilitation?
I would greatly appreciate your advice on these questions.
Thank you.

Xiao Bi, 40~49 year old female. Ask Date: 2016/05/24

Dr. Wu Enliang reply Psychiatry

1.
In my situation, should I not reduce the dosage of Alprazolam, and would it be better to continue taking 0.25 mg twice daily? A: Alprazolam is best used for the short term, but since you are still experiencing anxiety symptoms, you might try taking 0.25 mg twice daily to see if it provides more comfort.
2.
For short-acting medications like Alprazolam, can I take them only when needed? If so, should I still gradually reduce the dosage (considering I have been taking 0.35 mg to 0.75 mg daily for a month)? A: Taking it only when needed is the ideal approach to avoid long-term dependence.
Gradually reducing the dosage is preferable; otherwise, some individuals may experience increased anxiety with sudden reductions.
3.
I have been taking Escitalopram for three weeks at 5 mg every night.
I read online that it takes at least two weeks to see effects, but I experienced significant discomfort twice last week while out, which made me want to return home immediately.
Although I feel uncomfortable at home, it is not severe.
Given my symptoms, should I increase the Escitalopram dosage to 10 mg daily, or should I continue with 5 mg for a while longer? A: Generally, a minimum of 10 mg daily is needed for effectiveness.
It is advisable to discuss with a psychiatrist (your doctor abroad is also acceptable) whether to adjust the medication.
4.
Sometimes my symptoms worsen when I go out, but I know that staying at home can worsen my mental state, so I force myself to go out.
Is this a bad approach? Should I stay home to rest? A: Do not force yourself to go out.
If you must go out, consider taking Alprazolam beforehand.
5.
I know that walking helps with autonomic nervous system recovery, but once when I started feeling a bit uncomfortable and walked home, I felt close to fainting before I even got home.
How should I gauge the intensity of my walking rehabilitation? A: Do not push yourself to exercise; rest when you feel tired.
In summary, your anxiety and panic disorder, or what you refer to as autonomic nervous system dysregulation, have not yet resolved, so it is recommended to adjust your medication and discuss this with your doctor.

Reply Date: 2016/05/24

More Info

Managing anxiety and autonomic dysfunction can be a complex process, especially when it involves medication and lifestyle adjustments. Your situation, characterized by symptoms of autonomic dysfunction and anxiety, is not uncommon, and it's commendable that you're seeking to understand how to manage it effectively.

1. Medication Management: Regarding your use of Alprazolam, it's important to recognize that while this medication can provide quick relief from anxiety symptoms, it is a short-acting benzodiazepine. Your concern about potential dependence is valid, as long-term use can lead to tolerance and withdrawal symptoms. If you find that reducing the dose increases your anxiety, it may be beneficial to maintain your current regimen of 0.25 mg twice daily for now. However, if you feel comfortable, you could consider using it on an as-needed basis, especially during high-stress situations. Just ensure that you are cautious about how often you use it, as frequent use can lead to dependence.

2. Escitalopram (Lexapro): This SSRI typically takes several weeks to show its full effects, often around 4 to 6 weeks. Since you have been on 5 mg for three weeks, it may be premature to increase the dose to 10 mg just yet. If you experience significant discomfort, it’s reasonable to discuss this with a healthcare provider when possible. They may suggest maintaining the current dose for a bit longer to assess its effectiveness before making any changes.

3. Lifestyle Adjustments: Engaging in activities that promote relaxation and reduce stress is crucial. You mentioned practicing abdominal breathing, which is excellent. Additionally, incorporating regular physical activity, like walking, can help regulate your autonomic nervous system. However, it's essential to listen to your body. If you feel faint or overly fatigued, it may be a sign to slow down or take a break. Gradually increase your walking duration and intensity as your body allows.

4. Exposure to Stressors: While it's important to challenge yourself and not isolate, be mindful of your limits. Gradually exposing yourself to situations that trigger anxiety can help desensitize you over time, but ensure that you have coping strategies in place. If you find that certain environments are overwhelming, it’s okay to step back and take a break. Balance is key; pushing yourself too hard can lead to setbacks.

5. Monitoring Symptoms: Keep a journal of your symptoms, noting when they occur and any potential triggers. This can help you identify patterns and discuss them with your healthcare provider when you have the opportunity. Understanding your triggers can empower you to manage your anxiety more effectively.

6. Professional Guidance: Since you are currently abroad and unable to consult your original physician, consider seeking a local healthcare provider who understands anxiety and autonomic dysfunction. They can provide tailored advice and possibly adjust your treatment plan based on your current needs.

7. Self-Care Practices: Incorporate self-care practices into your daily routine. This could include mindfulness meditation, yoga, or other relaxation techniques that can help manage anxiety and improve your overall well-being.

In summary, managing anxiety and autonomic dysfunction requires a multifaceted approach that includes medication, lifestyle changes, and self-awareness. It's crucial to communicate openly with healthcare providers about your experiences and concerns, as they can help guide you through this process. Remember that recovery is often gradual, and it's okay to seek help when needed.

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