Depression and Social Anxiety Medication: A Student's Journey

Regarding medication for depression and social anxiety disorder?

Hello Dr.
Ding: I am a junior studying in Chiayi.
Since high school, I have noticed that I feel anxious in crowded places, and I become even more nervous when giving presentations, experiencing palpitations.
Sometimes, these emotions lead to feelings of sadness, wanting to cry, and overall low mood.
Therefore, in my sophomore year, I finally gathered the courage to see a psychiatrist, wondering if it might be a case of social anxiety disorder.
The psychiatrist did not provide a clear diagnosis but I saw the prescription indicating social phobia.
I have been taking 0.5 mg of Xanax and 12.5 mg of Cymbalta for over a year.
Initially, I took them once a day, and after a few weeks, I felt some improvement, as I felt drowsy and less preoccupied.
However, after a few months, the symptoms gradually returned, and I no longer felt drowsy.
The doctor then adjusted my medication to take Xanax twice a day and added 0.5 mg of Abilify.
As of now, I still cannot feel comfortable in crowds (although I feel much better if I am with someone I know), making it difficult for me to find suitable work (for example, data entry positions).
Recently, due to financial pressure from my family, I need to earn money.
However, it’s not that I am not looking for a job; I have found one, but I lack transportation (a scooter) to get to the workplace.
My family initially promised to help me buy a scooter once I obtained my driver's license.
During my sophomore and junior years, I attempted to take the motorcycle driving test, but due to excessive nervousness and the presence of many people, I was unable to concentrate and failed.
Because of the pressure from my family, I pushed myself to retake the test, thinking that having transportation would allow me to work and alleviate the financial burden of electricity, rent, and living expenses on my family.
Eventually, I succeeded, and I was so happy that I could hardly breathe.
The next day, I called my father to tell him I had obtained my driver's license and asked if he could help me with the down payment for a scooter.
My dad responded by saying, "Ask your mom." I then called my mom and shared my thoughts, but she only replied with two words: "No money." My plans fell apart after the first step, leading to feelings of depression and irritability.
The initial agreement was not followed through, leaving me feeling disappointed and frustrated.
Additionally, I have to rely on classmates for rides to and from school, which I dislike because I don’t want to be a burden to others, but I have no choice but to maintain the status quo.
Just three days later, my mood began to deteriorate.
At night, I would think about it and cry, feel anxious, and have nightmares where I would scream.
I have always believed that self-harm is a foolish act, yet I still engaged in it.
A few days before self-harming, I tried to resist, reminding myself that it was stupid and pointless, and I succeeded for a while, but it was difficult.
Later, I realized that my condition seemed increasingly like depression, so I returned to Taipei for a follow-up appointment.
During the visit, I told the doctor that I was suffering greatly from family pressure, school stress, and personal issues.
I showed the doctor my self-harm scars (not deep but still noticeable), and I explained that I had tried all possible distraction methods, such as exercising, walking, and venting to my best friend, but I still ended up self-harming.
The next day, I was shocked to see my wounds, but my feelings about self-harm were somewhat blurred.
(The reason I didn’t cut deeply is that I knew I would need emergency care, which would burden my classmates.)
The doctor adjusted my medication to 0.5 mg of Xanax in the morning, 150 mg of Wellbutrin, 0.5 mg of Xanax at night, 0.5 mg of Abilify, and 50 mg of Mirtazapine.
Recently, my mood has been stable but predominantly negative, with little emotional fluctuation.
I feel indifferent to everything, like a walking corpse, and I have started to have dark thoughts, but I lack the energy to act on them.
However, I have stopped taking Cymbalta.
I know Cymbalta can be addictive, but I didn’t expect the withdrawal process to be so uncomfortable.
Now, whenever I turn my head, I feel dizzy, and when I walk, my limbs feel like they are being electrocuted.
At night, I can’t distinguish between dreams and reality; I dream of being unable to breathe and feeling weak, and this happens repeatedly but intermittently.
I see objects that should not be moving shake up and down, but upon closer inspection, they are still.
As soon as I close my eyes, I hear a whooshing sound that makes me dizzy.
I don’t know what my current symptoms are...
I ask the doctor, but they do not answer my questions directly.
The doctor only tells me to express my emotions appropriately, but I have tried all the methods I can think of, such as yelling and exercising, and nothing seems to work.
I am unsure whether my discomfort is due to Cymbalta or the withdrawal process...
This is very distressing, and I don’t know what to do...

Hawking, 20~29 year old female. Ask Date: 2014/10/21

Dr. Ding Shuyan reply Psychiatry

Hello, I see the various difficulties you have encountered and the efforts you have made, and I feel both admiration and concern.
The physical discomforts you mentioned may arise during the process of changing medications.
The reasons could potentially be withdrawal symptoms from discontinuing the original medication or side effects from the new medication.
However, it is also important to consider that these could be manifestations of your original condition, and I have encountered all these situations.
Since you are already consulting a physician, I recommend discussing your concerns with them, as online platforms are not suitable for diagnosing these issues remotely.
Withdrawal symptoms from certain medications typically improve significantly within about a week, which I hope you find helpful.

Feeling anxious and fearful in unfamiliar social situations is something many people experience.
In addition to medication, you might consider some psychological strategies.
First, remember that most people are primarily concerned with themselves rather than others.
Unless we are particularly noticeable due to our appearance or behavior, most people in a crowd are not paying much attention to us.
Therefore, in such situations, remind yourself not to be overly anxious, as others are not as focused on us as we might think.

Additionally, try to shift your focus away from yourself and pay more attention to helping others.
This has two benefits: first, focusing on others rather than yourself can reduce social anxiety and depressive feelings, as it interrupts the nearly compulsive negative thinking in our minds, allowing for moments of mental rest and even the emergence of positive thoughts.
Second, caring for and helping others brings joy and a sense of happiness to both them and yourself, leading to more positive interpersonal relationships.
Over time, this can significantly reduce anxiety and worries about social interactions.
I hope you find this information helpful.

Wishing you all the best,
Dr.
Ding Shuo-Yan

Reply Date: 2014/10/21

More Info

It sounds like you are going through a very challenging time, and I want to acknowledge the courage it takes to share your experiences and seek help. Your journey with social anxiety and depression is not uncommon, especially among students who face academic and personal pressures. Let's break down your situation and explore some potential paths forward.

Understanding Your Symptoms
From what you've described, it seems that you are experiencing a combination of social anxiety and depressive symptoms. Social anxiety can manifest as intense fear or anxiety in social situations, leading to avoidance behaviors, while depression can bring feelings of sadness, hopelessness, and a lack of interest in activities you once enjoyed. The fact that you have been experiencing physical symptoms, such as dizziness and a sense of disconnection from reality, can be distressing and may indicate that your mental health challenges are affecting your overall well-being.

Medication Management
You mentioned that you have been prescribed medications like Zoloft (Sertraline) and Xanax (Alprazolam). It's important to understand that while these medications can help manage symptoms, they may not work the same way for everyone. The initial improvement you felt might have diminished over time, which is not uncommon. This could be due to several factors, including tolerance to the medication or the need for a dosage adjustment.

If you are experiencing withdrawal symptoms from stopping Zoloft, it’s crucial to discuss this with your doctor. They can provide guidance on how to manage these symptoms and may suggest a gradual tapering schedule to minimize discomfort. Additionally, if you feel that your current medication regimen is not effective, it’s worth discussing alternative options with your healthcare provider. There are various classes of antidepressants and anti-anxiety medications, and sometimes it takes time to find the right combination.

Therapeutic Support
In addition to medication, therapy can be a valuable tool in managing social anxiety and depression. Cognitive Behavioral Therapy (CBT) is particularly effective for social anxiety, as it helps individuals challenge and change negative thought patterns and behaviors. If you haven’t already, consider seeking a therapist who specializes in CBT or other evidence-based therapies. It might also be beneficial to explore group therapy, where you can connect with others facing similar challenges in a supportive environment.

Coping Strategies
While you mentioned that you have tried various coping strategies without success, it’s essential to keep experimenting with different approaches. Mindfulness and relaxation techniques, such as deep breathing exercises, meditation, or yoga, can help reduce anxiety and improve emotional regulation. Engaging in regular physical activity, even if it’s just a short walk, can also have a positive impact on your mood.

Family Dynamics
You also touched on the pressure from your family regarding financial responsibilities and the impact it has on your mental health. It’s understandable to feel overwhelmed by these expectations. If possible, consider having an open conversation with your family about your mental health struggles. They may not fully understand what you are going through, and sharing your feelings might help them provide the support you need.

Seeking Immediate Help
If you ever feel overwhelmed to the point of considering self-harm or having thoughts of suicide, it’s crucial to seek immediate help. Contact a mental health professional, call a crisis hotline, or go to the nearest emergency room. Your safety is the top priority.

Conclusion
Navigating social anxiety and depression can be a long and complex journey, but you are not alone. Many individuals face similar challenges, and with the right support and treatment, improvement is possible. Keep advocating for yourself, whether it’s through medication adjustments, therapy, or finding new coping strategies. Remember that it’s okay to ask for help and that taking small steps can lead to significant changes over time. Stay hopeful, and take care of yourself.

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