Shirah Vollmer MD
Learning to Play
Medicating Anxiety: How Do I Decide?
To medicate or not to medicate: that is the question.
Posted Jan 07, 2010
My 24 year old patient, the subject of my most recent blogs, complained that he was scared at night when he was alone in his apartment. In a previous post, I commented that in the old days, his fear would have prompted him to ask me to prescribe medication. I went on to say that I was happy that he did not go there. This narrative brings up the question of why, as a psychiatrist, would I be happy when a patient is NOT asking me for medication.
As a physician, my first job is to diagnose the problem. In my field, as with other fields in medicine, diagnosing is guessing. At this point, I hear my critics sending this blog across the internet saying "Dr. Vollmer says that psychiatry is guesswork". Clinical diagnosis is the technical language to describe what I am calling speculation. In other words, there are no medical tests to confirm a diagnosis. However, years of training sets the groundwork for educated guessing. Part of this training involves learning how to tolerate ambiguity and uncertainty. For me, this is one of the most challenging aspects of my field.
My teachers in medical school repeated over and over again that 80% of the diagnosis is based on the patient's history and 20% is based on the physical examination and laboratory tests. I know that with modern technology this equation has changed for many fields in medicine. In psychiatry though, the history, along with my clinical impressions, is all I have to work with. In the future, I will blog about the lost art of history taking in medical education, but for now I will return to thinking about evaluating this particular patient.
In thinking about a patient who presents with pain, physical or mental, I need to think about certain dimensions of the presenting problem. That is, I need to think about the duration, the intensity, the setting in which the pain takes place, what makes it better, what makes it worse, what previous interventions have been tried and what impact this pain has had on his life. I also need to explore the family history to look for a genetic link.
As I think about this young gentleman, I am aware of how far he has come. His coping skills have improved enormously. When faced with uncertainty, he has learned how to problem solve. When faced with loneliness, he has learned how to reach out. When faced with hurt and disappointment, he has learned how to process his feelings and deal with sadness and despair. He looks forward to his future and he has healthy relationships. Still, there is work to be done. He has episodes of overwhelming anxiety. He is angry about his parents' divorce. Sometimes, he procrastinates so much that he barely gets through school.
With this patient, I see movement and I see growth. As such, one night of overwhelming loneliness and despair does not indicate a need for medication. More importantly, this client was not asking me for medication to treat his anxiety. I was excited by that, as I understood that he was motivated to reflect on his feelings so that he could cope better in the future. This was further evidence of his maturity. The goal of my work is to strengthen people internally. Medication is always a last resort. Having said that, seeing people respond to psychotropic medication is exciting. Seeing people respond to themselves in a healthy way is even more thrilling. It was a good day.