Can I get a side of Xanax with that?


Here’s the thing, Reader.

We all have anxiety. We just have different amounts and feel it differently in our bodies.

I was recently in a group where we were discussing opportunities in our lives and I was considering the next door that was opening to me. It was a pretty cool metaphor.

And behind my door was a lovely cocktail party with sequins and bow ties and delicate flutes of overflowing champagne. Oh and a pianist in the grand room ensuring everyone had nice soothing tunes for their conversation and caviar.

And then the screaming started.

Delightful screeches of joy as a soggy hoard of children streaked through the party dripping (hopefully only) pool water all over the floor as they smushed giant sprinkle-covered cupcakes into their mouths and proceeded to wipe frosting on the walls (to maintain their pristine swimming attire, obviously).

The horror!

Maybe not for some people but this mini-movie playing in my head is so painfully nerve wracking it’s hard to even write about! All from a metaphor about where I am in my life right now. Ha!

Cue the anxiety.

And mine definitely doesn’t look like other people’s for sure. In fact you may think the cocktail party sounds like a slow, painful death and the wet sticky kids sound fun! Yay you, Reader! Winning.

At one point I took anxiety medication because #residencyishard. Or at least it was for me. I had some PRN benzos that I used more often during my child psych rotations and much less often on my days off while pretending that I didn’t have textbooks and journal articles to read (thanks, Day Drinking and Grands! cinnamon buns!)

All this to express my love for treating anxiety with the right meds for the right person. And I get it, because I’ve been there before too.

From my video a few weeks ago we got a nice big overview of different kinds of anxiety people experience from physical to emotional and all the juicy stuff in between.

This is your promised next step where you’ll hear me talk through the main options and how I pick what I prescribe.

For me this is the fun part!

And for you, this makes your job easier and more fulfilling because it will help your clients get the right fit medications to maximize the awesome therapy they see you for!

Here it is! Your 17 minutes of glorious medication magic to get those sticky kids back where they belong without tears! (Mine, not theirs. The tears, I mean, not the sticky!)

Major take aways:

You still gotta know stuff about the qualities of the anxiety we’re treating:

  • short or long term
  • specific triggers or random
  • how much is physical vs emotional symptoms
  • how well received with medication be?

Main anxiety medication choices:

PRNs, SSRIs, SNRIs, BusPar

PRNs are as needed medications and I break them into 3 groups:

  • Benzos i.e. Xanax (alprazolam), Ativan (lorazepam), Klonopin (clonazepam), Valium (diazepam), etc.
  • Hydroxyzine (Vistaril or Antarax)
  • Propranolol

Daily medications that help improve overall quality of life in the anxiety realm (and often mood and PTSD areas too). If we’re dealing with constant, daily, or unpredictable anxiety this may be the best place to start.

  • SSRIs are great daily meds for newbie and veteran med-takers alike and I discuss them in more detail HERE.
  • SNRIs, especially Pristiq and Effexor, are also excellent daily medications but I reserve these for people who don’t do well on SSRIs or are committed to taking medication for a while, like, years.
  • BusPar (buspirone) is the other daily medication I discuss and it’s a little bit different. It works on serotonin (and a little on dopamine) but is only for anxiety and not mood. The pain in the booty part? It’s gotta be taken twice a day! It kicks in faster than SSRIs and has few side effects (and NO sexual side effects!). It’s not my favorite but it can be perfect for the right person’s anxiety and physiology.

Not to spoil the good part but here’s a very quick and dirty rundown of my fake decision tree (which is much better than my dusty fake fiddle fig in the corner of my closet).

  • Short term physical anxiety? Propranolol
  • Short term anxiety for a specific period of time or situation? Benzos or hydroxyzine
  • Long term anxiety with a significant emotional or mental component? SSRIs first
  • Longer term issues with past SSRIs? Maybe an SNRI
  • Experience with medications but no mood symptoms? BusPar
  • And then any of these that have moments where things get much worse or someone has specific triggers? Add a PRN, especially propranolol if there’s a physical component
  • And finally for people that continue to struggle with managing anxiety they may require an SSRI or SNRI, plus BusPar, plus one or 2 different PRNs.

See? Totally simple. -ish.

But this should provide some context for helping clients figure out what mix may work best for them. And now you have a sweet cheat sheet to help guide them with confidence!

We have a lot of different ways to work with people’s anxiety and medications to find a good fit, it just usually takes a while to get it all figured out!

Hopefully my patience with treatment rubs off on my own patients so we can get through it together without too much caviar or sticky sprinkles (choose the one that induces more hives for you!)

Cheers to healthy brains,

Dr. B

Jessica Beachkofsky, MD

Your calm, friendly, unsticky online psychiatrist!

P.S. If you have clients who see a prescriber virtually, this may be worth a read…. Looks like in November 2024, controlled meds won’t be available online without an in-person visit first. Just a heads up for people on benzos, z drugs (for sleep), or stimulants (for ADHD)!

P.P.S. Sick of hearing about all the lame medications out there that never seem to help enough? Create your own fabulous new med!! Fill out this google form and receive the ad for your new amazing medication!! It takes 5 minutes and is super fun!

Welcome to Brain Bites with Dr. B!

Brain Bites is all about broadening your reach with easy-to-digest psych knowledge! Join me for quick, interesting medication and brain science tidbits! Elevate your therapy practice with insight and data from your friendly online psychiatrist!

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