OCD, My Exhausting Best Friend

I obviously need a new best friend.

Most people wouldn’t guess that I’m constantly tortured by disturbing thoughts. I’ve hosted live TV shows and given speeches in front of large audiences. During the LSAT, a few friends from college sat next to me because they said I had a calming energy. They had no idea of the internal storm always raging in my mind.

As far as acting on my thoughts and fears, I don’t: I’m possibly the most boring man on earth. I’m married with kids, don’t drink or get into bar fights. This makes sense. “Themes of O.C.D. have no absolutely no implication about the character of a person,” Dr. Phillipson said.

David Adam, author of the memoir “The Man Who Couldn’t Stop,” told me, “O.C.D. makes everything harder.” His book describes how he confronted his own O.C.D., which involved an intense, irrational fear of contracting H.I.V. We agreed that O.C.D., like all mental health afflictions, is not an artistic muse or creative gift but is ultimately unfair, with no complimentary benefits. Even though he likens his condition to being a recovering alcoholic, Mr. Adam was thankfully able to treat his O.C.D. and eventually write two books after he did a form of behavioral therapy called exposure and response prevention.

This is the most successful treatment for O.C.D., and it involves repeated exposure to the fearful thoughts without giving into the short-term relief delivered by compulsions. The trick is that you can’t outthink the disorder, you can’t outargue it, you can’t outrun it. You have to make the voluntary choice to confront it. It’s like inviting Pennywise the Clown, the demon from Stephen King’s “It” who feeds off your fears, over for a nice cup of tea. For example, if you’re obsessed with germs and contamination, then you have to abandon your compulsions and instead use public toilets and avoid repeatedly washing your hands. You choose to sit with the threat. Eventually, your brain habituates to the threat and is even bored by it, realizing there is nothing to fear.

Dr. Phillipson said people should first choose to forgive themselves for having O.C.D. If everyone had our misfiring brains, the whole world would behave exactly like us. Second, he advised against using negative imagery and instead welcoming our “best friend’s warning” but then choosing to ignore it. “The goal of the treatment is to make the thoughts irrelevant,” he said, “it’s not to make the thoughts go away.”

O.C.D. has exhausted me. I’m tired of suffering. I’m now doing exposure and response prevention, voluntarily exposing myself to my fears. It’s terrifying and often excruciating, like walking through a gauntlet of horrors without a shield or sword, armed only with belief and resolute conviction.

All the while, I’m working to abandon shame and guilt about my mental health disorder and to embrace the “best friend” I didn’t ask for.

Wajahat Ali (@WajahatAli) is a playwright, lawyer and contributing opinion writer.

Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

Opinion | O.C.D., My Exhausting Best Friend – The New York Times

I obviously need a new best friend.

Most people wouldn’t guess that I’m constantly tortured by disturbing thoughts. I’ve hosted live TV shows and given speeches in front of large audiences. During the LSAT, a few friends from college sat next to me because they said I had a calming energy. They had no idea of the internal storm always raging in my mind.

As far as acting on my thoughts and fears, I don’t: I’m possibly the most boring man on earth. I’m married with kids, don’t drink or get into bar fights. This makes sense. “Themes of O.C.D. have no absolutely no implication about the character of a person,” Dr. Phillipson said.

David Adam, author of the memoir “The Man Who Couldn’t Stop,” told me, “O.C.D. makes everything harder.” His book describes how he confronted his own O.C.D., which involved an intense, irrational fear of contracting H.I.V. We agreed that O.C.D., like all mental health afflictions, is not an artistic muse or creative gift but is ultimately unfair, with no complimentary benefits. Even though he likens his condition to being a recovering alcoholic, Mr. Adam was thankfully able to treat his O.C.D. and eventually write two books after he did a form of behavioral therapy called exposure and response prevention.

This is the most successful treatment for O.C.D., and it involves repeated exposure to the fearful thoughts without giving into the short-term relief delivered by compulsions. The trick is that you can’t outthink the disorder, you can’t outargue it, you can’t outrun it. You have to make the voluntary choice to confront it. It’s like inviting Pennywise the Clown, the demon from Stephen King’s “It” who feeds off your fears, over for a nice cup of tea. For example, if you’re obsessed with germs and contamination, then you have to abandon your compulsions and instead use public toilets and avoid repeatedly washing your hands. You choose to sit with the threat. Eventually, your brain habituates to the threat and is even bored by it, realizing there is nothing to fear.

Dr. Phillipson said people should first choose to forgive themselves for having O.C.D. If everyone had our misfiring brains, the whole world would behave exactly like us. Second, he advised against using negative imagery and instead welcoming our “best friend’s warning” but then choosing to ignore it. “The goal of the treatment is to make the thoughts irrelevant,” he said, “it’s not to make the thoughts go away.”

O.C.D. has exhausted me. I’m tired of suffering. I’m now doing exposure and response prevention, voluntarily exposing myself to my fears. It’s terrifying and often excruciating, like walking through a gantlet of horrors without a shield or sword, armed only with belief and resolute conviction.

All the while, I’m working to abandon shame and guilt about my mental health disorder and to embrace the “best friend” I didn’t ask for.

Wajahat Ali (@WajahatAli) is a playwright, lawyer and contributing opinion writer.

Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

Dr. Phil Kronk: Do you have real worries or obsessive ruminations?

      Worry does not empty tomorrow of its sorrow, it empties today of its strength.” “Corrie Ten Boom

      “Sorrow looks back, Worry looks around, Faith looks up.” Ralph Waldo Emerson

There are enough things to worry about in the everyday world—finances, raising children—without the added burden of having intrusive, unwanted obsessive ruminations.

Such worrisome over-thinking can become all-consuming, emotionally devastating and socially destructive.

Along with compulsive behaviors, such obsessions are part of the diagnostic category of an “Impulsive-Compulsive Disorder.” They are felt to be brain-based and localized in brain circuits that are mis-firing.

As I have said before in past columns, intrusive, obsessive thoughts are similar to a fever. They are a warning sign that something is wrong with your body. The negative feelings that one has about having obsessive thoughts or behavioral compulsions must not make you feel embarrassed, shameful, guilty or socially isolated. They must be acknowledged as being a medical problem that must be treated by a combination of medication and cognitive therapy.

A person with an obsessive-compulsive disorder should seek the help of both a physician and a clinical psychologist.

Obsessive-compulsive disorder often waxes and wanes over time for many who suffer from it. In the short run, cognitive therapy can help quiet the thoughts down. I tell patients it is similar to turning down a radio, so that it blends into background noise.

I always recommend that treatment for obsessive thoughts first involve learning how to relax oneself through progressive relaxation techniques. The next step is to counter the negative messages of the thoughts, by realizing that they are brain-related symptoms. These negative thoughts need to be countered with positive, affirmative statements that you and your therapist work on together.

The goal is to change one’s own relationship to one’s intrusive thoughts. And to learn what are real worries.

Psychologists have written about “real” worries. They involve, for example, bereavement and grief. (In fact, others often tell us that we have been grieving too long. They are wrong!)

PTSD is another diagnostic disorder with worry in its make-up. Its therapeutic relief is complex and not easily done. One must respect the rate at which the victim heals.

Gender Identity Disorder involves another form of over-thinking that needs to be better understood and accepted by the general public. The question, “Am I stuck in the wrong body?” is not easily answered.

Another overwhelming, anxiety-producing thought that patients share is the question, “Is this life I am living real?” or “What if I wake up and find that this is not reality?”

Some fear that they will wake up some day and find that the reality by which they live is not real.

Sometimes, I find that such fearful doubting is due to a significant depression. Sometimes, it is due to an unexpressed past trauma. Sometimes, it is a refusal to look at an upcoming negative life event, such as financial reality.

Obsessive individuals also worry if they are in the right reality. The answer I give them is supportive and non-authoritative. I tell them, no matter what reality you find yourself in, you should try to be happy and secure with the one you find yourself in. Being doubtful is not a reason to feel unhappy.

Obsessive worrying can include “content that is odd, irrational, or of a seemingly magical nature.” Another way to differentiate obsessive worrying from normal, or even other types of anxiety, is by the fact that compulsive behaviors are often present.

As the psychologist, Adam Phillips, Ph.D. is famous for saying, “The past influences everything, but dictates nothing.” I find solace in such a belief in hope. I try to share such a hope for all who suffer from what seems like over-whelming fearful and negative thoughts.

[This is the second column this month on a series about obsessive thinking and compulsive behaving. A future column will look at the impaired brain circuits thought to be underlying this disorder.]

Phil Kronk, M.S., Ph.D. is a semi-retired child and adult clinical psychologist and clinical neuropsychologist. Dr. Kronk writes a weekly online column on mental health for the Knoxville News Sentinel’s website, knoxnews.com. He can be reached at (865) 330-3633.

Let’s Talk About Anxiety

Anxiety in teens and children is increasingly common, and it’s the most prevalent mental health diagnosis among adolescents in the U.S. In spite of that, it’s rarely discussed openly in our community, which largely continues to stigmatize mental health issues. An upcoming screening of a powerful documentary intends to jumpstart a much-needed conversation about anxiety and normalize this common struggle.

On Tuesday evening, October 16, the Parent School Partnership of Yeshivat Noam will be hosting a community-wide screening of the compelling IndieFlix documentary “Angst: Raising Awareness Around Anxiety.” This film is a must-see for parents, educators and others who care for children or teens with anxiety. The film’s goal is to help viewers identify and understand the symptoms of anxiety and encourage them to reach out for help; to destigmatize, normalize and offer hope.

“Angst” engagingly and thoughtfully explores anxiety, its causes and effects and ways of dealing with it. The film features candid interviews with kids and teens who suffer, or have suffered, from anxiety, and what they’ve learned about it. “Angst” includes commentary from mental health professionals, and the screening next week will be followed by a live panel of experts who will field questions and further the conversation.

Many individuals experience an anxiety disorder, but particularly in communities that don’t discuss the problem, those who suffer often feel like their situation is rare or unique. According to the National Institutes of Mental Health, the prevalence of any anxiety disorder (including generalized anxiety disorder, obsessive-compulsive disorder, and specific phobias) in adolescents in the U.S. is 31.9 percent. That means this is an important, if not pressing, topic for many families, including those in our community.

According to Dr. John Duffy, clinical psychologist and best-selling parenting author, “The teenagers in the film describe their suffering with stunning openness, grace and courage…the filmmakers were able to capture what so many of my young clients are suffering in these complicated days: the bullying, perfectionism, panic, obsession, and too often, hopelessness…. Whether you are a teenager, parent, educator or a mental health professional, you simply need to see this movie, and soon. And every school needs to screen this film. It’s that important.”

Chani Oshinsky, a Teaneck resident who saw the film at a private screening this spring, found it eye-opening. “‘Angst’ really helps educate adults so they can validate their children’s or students’ struggles and help them, instead of dismissing or misunderstanding them,” she says.

Notes Dr. Jerry Bubrick, senior director of the Child Mind Center, “In our world there is a stigma attached to mental health disorders. People see anxiety as a personal failing rather than a medical condition; they see it as something to be ashamed of, rather than something to be treated. In reality, anxiety is universal. It doesn’t discriminate—and it’s very treatable. We just need to acknowledge it and talk openly first.”

The firsthand accounts of kids and teens in the film describing their experiences tend to strike a chord with viewers, many of whom have seen their children or students struggle similarly. The film and expert panel on Tuesday will address some of the different ways that anxiety presents in children, which can often be misunderstood by adults, including parents and educators.

Loretta Paley, co-chair of Yeshivat Noam’s Parent-School Partnership, was instrumental in arranging the upcoming screening after she saw the film last year. “I feel that it’s so critical for everyone in our community to see this film, to stop stigmatizing these kids, and to finally understand what they’re going through so we can help them. There needs to be a big change in how we view mental health concerns, and we’re hoping that ‘Angst’ contributes to that change.”

The film and expert panel will take place at Yeshivat Noam Middle School on Tuesday, October 16, at 8 p.m. Admission is free and the event is open to the community. “Angst” is recommended for teens and adults but may be too intense for younger viewers. For questions, please email [email protected]

By Talia Marmon, Ph.D.


Dr. Talia Marmon is a clinical psychologist.

John Green on how he deals with Obsessive-Compulsive Disorder and "thought spirals"

While you may not have heard of the author John Green, be assured that the teenagers in your life have. He is America’s answer to J.K. Rowling, with his mega best-sellers spawning blockbuster movies. Green has become wildly popular thanks largely to his loyal teenage audience. Green is also the rare literary talent who doubles as a podcaster and a YouTube star.

His success stems from his intuitive understanding of adolescents, his ability to meet them on their level and on their devices. To those who consider today’s teens a disaffected tribe, rarely glancing up from their phones and video games, John Green offers a counter narrative.

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Correspondent Jon Wertheim with John Green

Jon Wertheim: Let’s talk about teenagers.

John Green: 60 Minutes’ core audience, I understand.

Jon Wertheim: (LAUGH) It’s trending, uh… well, you know. You write a lot about teenagers.

John Green: Yeah.

Jon Wertheim: Why this cohort?

John Green: They’re doing so many things for the first time and there’s an intensity to that. You know, there’s an intensity to falling in love for the first time and also there’s an intensity to asking the big questions about life and meaning that just isn’t matched anywhere else.

Jon Wertheim: You’ve said before that adults underestimate teenagers.

John Green: Well, I think sometimes teenagers maybe don’t have the language to talk to us in ways that seem compelling to us. And maybe that makes it easy for us to dismiss them or think of them as less intellectually curious or intellectually sophisticated than we are. But I don’t think that’s true at all.

John Green’s books, in the YA — or young adult — genre dominate best-seller lists and while the stories take place in the U.S., They echo worldwide, having been translated into 55 languages.

Jon Wertheim: Lithuanian, Slovenian, Croatian.

John Green: Yeah, yeah It’s really wonderful to have your books travel to places you’ve never been. I mean it’s a weird but really beautiful experience.

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His most famous book, “The Fault in Our Stars,” was a best-seller for more than three years.

And adapted to a hit film in 2014 that grossed more than $300 million. Tinged with tragedy, the story follows two teenagers with cancer who fall in love – heavy, and heady stuff for an adolescent audience.

Jon Wertheim: The subjects you deal with are quite weighty. Death and suicide and cancer. A lot of teenagers haven’t had these experiences per se, but these books resonate with them. How is that?

John Green: Maybe lots of teenagers haven’t had these particular experiences, but I do think they know of loss, and they know of grief, and they know of pain. Maybe the particulars of an experience aren’t universal, but the feelings are.

One reason he connects so well with teenagers? At age 41, Green is still a kid at heart.

His youthful spirit drives more than book sales. It made him a YouTube star.

In 2007, the early days of YouTube, John Green and his kid brother Hank began sharing videos as a way to stay in touch with each other.

In short order, and in lockstep with the growth of YouTube, the Greens’ videos amassed a huge audience, now nearly a billion total views strong. This online video platform in turn fueled John Green’s readership.

Jon Wertheim: They play off each other.

John Green: Yeah. In a way, they’re different sides of the same coin, right? Because what interests me really is the idea of connecting with a viewer or with a reader without having to like actually talk to them and look at them and all that.

This preference, Green said, is the legacy of his own socially awkward adolescence.

Jon Wertheim: Who do you envision are your readers?

John Green: I don’t envision a reader.

Jon Wertheim: You don’t.

John Green: I think in some ways I’m writing back to my high school self  to try to communicate things to him, to try to offer him some kind of comfort or consolation.

Jon Wertheim: Who was that guy?

John Green: I had a difficult time in high school. I wasn’t a very good student and I had a lot of self-destructive impulses and I felt scared all the time.

Jon Wertheim: What were you scared of?

John Green: The short answer is everything.

john-on-laptop.jpg

He explores those fears in his most recent book, “Turtles All the Way Down,” a best-seller for 50 straight weeks since it debuted at number one. Its theme: obsessive-compulsive disorder, OCD, based on Green’s own. For this book, he obeyed that time honored rule of the craft: write what you know.

John Green: I wanted to try to give people a glimpse of what it is. I wanted to try to put them, you know, at least a little bit inside of that experience.

Jon Wertheim: You use the word “thought spiral.” What does that mean?

John Green: The thing about a spiral is that it– it goes on forever, right? Like, if you zoom in on the spiral it can keep tightening forever. And that for me is the nature of obsessive thought that it’s this inwardly turning spiral that never actually has an end point. So it might be I’m eating a salad and it suddenly occurs to me that somebody might have bled into this salad. Now, they probably didn’t.

Jon Wertheim: This is what you’re thinking?

John Green: But this is what I’m thinking. And instead of being able to move on to a second thought, that thought just expands and expands and expands and expands. And then, I use compulsive behaviors to try to manage the worry and the overwhelmedness that that thought causes me.

Jon Wertheim: So how do you get out of this coil, and how do you break this infinity?

John Green: I have a few strategies. I exercise. That’s probably the biggest thing. Exercise is pretty magical in my life. I don’t enjoy it. (LAUGH) I don’t relish the thought of going for a run but it is very helpful because I can’t think.

John Green lives in Indianapolis, where his life comes short on stress, long on anonymity. He and his wife, Sarah Urist Green, a curator and online art educator, are parents of a son, age 8, and daughter, 5. Sarah began reading his manuscripts when they started dating 14 years ago.

Sarah Green: And I was really nervous because I really liked John, and I knew that if the book was bad it wasn’t gonna work. (LAUGHTER)

Jon Wertheim: The relationship wasn’t going to work. Not the book wasn’t going to work.

Sarah Green: No, no. The book might have worked or not, but I couldn’t be dishonest about, about that and if I didn’t like it, sorry.

John Green: I mean, I’m super glad I didn’t know that at the time. (LAUGHTER) I don’t think I coulda handled that pressure.

Jon Wertheim: Unfiltered criticism.

Sarah Green: Yeah, (LAUGH) yeah.

John Green: Yeah.

Jon Wertheim: John, do you remember when you told Sarah about your OCD?

John Green: I don’t know that it was an event so much as it was a process. And part of getting to know me was understanding that I had problems with anxiety.

Sarah Green: There was never a moment where John kind of sat me down and said, “I have OCD.” Um, it was more of a gradual process– where we were able to kind of put this label on it.  And so I can’t say that I would ever wish it to go away, because it’s a– it’s a part of him.

John Green: I– I’d like it to go away, (LAUGH) for the record.

So much so that, in 2015, fresh off the spectacular success of “The Fault In Our Stars,” Green decided to take a chance and go off the anti-anxiety medication he’d been taking for years.

Jon Wertheim: Why did you do that?

John Green: Well, ’cause I bought into this old romantic lie that– in order to write well– you need to sort of, like, be free from all of these mind-altering substances or whatever. And the consequences were really dire, unfortunately. And– and I– I’m lucky that they weren’t catastrophic, but they were serious. And coming out of that experience I found myself wanting to try to give some sort of form or structure—um, to this fear that I had lived with for my– most of my life.

These John Green fans call themselves “Nerdfighters” – part of a community that now includes hundreds of thousands of members around the world. The Nerdfighters formed in response to green misreading the name of a video game, “Aerofighters.”

Jon Wertheim: What’s a Nerdfighter?

John Green: A Nerdfighter is a person who fights for nerds.

Jon Wertheim: Not against nerds?

John Green: No.

Jon Wertheim: These are empowered nerds.

John Green: Yeah. Obviously we’re pro-nerd. (LAUGH) Really what it’s about is being enthusiastic. Being nerdy is really about how you approach what you love.

Jon Wertheim: Unabashedly.

John Green: Yeah.

Jon Wertheim: All five of you, proud, unapologetic nerds.

Presley: Oh yeah. Yep.

Ben: We take the name with pride.

We met these Nerdfighters last June. They were attending the ninth annual VidCon, a YouTube conference John and Hank Green created to help online video fans and creators meet in person. These five told us they were especially grateful to John Green for writing about his anxiety in “Turtles All the Way Down.”

Becky: It’s reassuring for sure.

Jack: For someone who does experience anxiety, he like, articulates things I could never articulate before. Which both, like, makes me feel seen but also helps me, like, understand and sort of, you know, feel better from different things.

Presley: Yeah, there’s this metaphor of a spiral in the book, and that was one of the most useful things I’ve ever come across in describing my own anxiety. And we use it in the house all time. And being around this community of people that was so loving  really made me grow to be a better person than I would have without it.

Presley at seven years old: I am a homeschooled child… and you all are my favorite teachers.

This was her – Presley Alexander – when she was just seven years old and she first came into the John Green orbit, not by reading one of his books but by watching him on Crash Course, the educational YouTube series that he started with his brother Hank in their manic signature style.

The videos offer lessons in the humanities and sciences with more than eight million subscribers, they are now offered as part of the curriculum in classrooms around the country. On account of his popularity across platforms, Green cuts a figure he never would have imagined when he was a teenager: something akin to a rock star.

Jon Wertheim: I want to know what your high school self would have thought if– if they saw you now.

John Green: Uh, my high school would be very– very happy and excited. (LAUGH) I’m embarrassed to admit. Uh, I wish that weren’t the case.

Hank Green: That’s a great– that’s a great way to put it. I agree completely.

The Green brothers are exceptionally supportive of each other, especially when it comes to John’s OCD – described so vividly in his latest book.

Jon Wertheim: “Turtles All The Way Down.” What was it like for you to read that?

Hank Green: It did help me understand John better. And– and, but– but in general be more empathetic toward people who deal with anxiety and OCD.

Jon Wertheim: What’d you learn about him?

Hank Green: The extent to which sometimes he is at the mercy of his own mind.

Jon Wertheim: But did it cause you to reexamine or reassess moments in your childhood?

Hank Green: Yeah, I mean, there– there have definitely been times in, you know, when John had a less stable life where I think, like, the family was worried about him. You know, those, the– the–

John Green: With good reason. (LAUGHTER)

Lately, there’s a lot less to worry about. With his multimedia, multimillion-dollar empire, John Green is using his pen, his keyboard and his video camera to normalize teenage social awkwardness and also to destigmatize mental illness.

Jon Wertheim: You’ve said that it’s important for young people to be able to see successful, productive adults challenged by mental illness.

John Green: Yeah.

Jon Wertheim: Expand on that.

John Green: Well, I have a really wonderful life. I have a really rich, fulfilling life. I also have a pretty serious chronic mental health problem. And those aren’t mutually exclusive. And the truth is that lots of people have chronic mental health problems, and still have good lives.

Produced by Sarah Koch and Chrissy Jones

Dr. Phil Kronk: What you should know about obsessive thoughts and compulsive behaviors

“Everybody is dealing with how much of their own aliveness they can bear and how much they need to anesthetize themselves.” Adan Phillips, Ph.D.

 “To grow up is to discover what one is unequal to.” Adam Phillips, Ph.D.

You are not alone if you suffer from an anxiety. At times, the world can feel overwhelming.

While we tend to see television commercials for depression or for bipolar disorder, the reality is that anxiety disorders are the most common form of mental suffering in our country.

One of five adults report some form of anxiety each year, but only slightly more than one third of these individuals receive treatment and relief from their suffering.

This month, in this column, I would like to focus on obsessive-compulsive forms of thinking and behaving.

For decades, mental health professionals viewed obsessive-compulsive disorder (OCD) as purely one type of anxiety disorder. While anxiety is certainly an important experienced component of OCD, today it is diagnosed as an “impulsive-compulsive disorder.”

Today, many clinicians and researchers realize that OCD is related to impaired neural brain circuits. I will share where mental health professionals believe these impaired neural brain circuits are located in one of the next columns.

Obsessions are intrusive and unwanted thoughts, urges or images that cause distress or anxiety.

Compulsions are repetitive behaviors or mental actions (such as counting, etc.) that a person performs in a rigid way in an attempt to respond to and alleviate an obsession.

Such anxiety can affect anyone. The singer-songwriter, Fiona Apple, shares that she “had a really bad obsessive-compulsive disorder.” She remembered that “At its worst, I was compelled to leave my house at three o’clock in the morning and go out in the alley because I just knew that the paper-towel roll I threw in the recycling bin was uncomfortable, like it was lying the wrong way, and it should be down in the garbage.”

Anxiety is rarely experienced by itself for many individuals. Depression often accompanies an anxiety disorder in half of those diagnosed with an anxiety disorder.

While the average age for an obsessive-compulsive disorder’s onset is around nineteen years of age, children also experience such symptoms.

In the next four weeks, in this column on mental health, I would like to share the extent of the destructiveness of the tendency to ruminate for individuals with obsessive-compulsive behaviors. I will also share some techniques to quiet the ruminations.

The need for perfection will be addressed, and the strain it can place on an individual. Guilt and shame are often intertwined with an over-concern about what others are thinking of us.

The obsessive-compulsive’s need to control will be addressed. So, will the need to be “sure.” And, the need, by some, to known what exactly reality is.

The difference between anxiety and fear will be addressed, as will be the fact that anxiety has both a biological and a cognitive etiology.

This is important because effective treatment for obsessive thoughts/urges and compulsive actions needs to have a dual form of combined treatment. Both cognitive therapy and medication can be effective in bringing relief and ending suffering.

Phil Kronk, M.S., Ph.D. is a semi-retired child and adult clinical psychologist and clinical neuropsychologist. Dr. Kronk has a doctorate in clinical psychology and a postdoctoral degree in clinical psychopharmacology (the use of drugs to treat mental disorders.) His year-long internship in clinical psychology was served at the University of Colorado Medical School. Dr. Kronk writes a weekly, Friday online column on mental health for the Knoxville News Sentinel’s website, knoxnews.com. He can be reached at (865) 330-3633.

 

Dr. Phil Kronk: What you should know about obsessive thoughts and …

“Everybody is dealing with how much of their own aliveness they can bear and how much they need to anesthetize themselves.” Adan Phillips, Ph.D.

 “To grow up is to discover what one is unequal to.” Adam Phillips, Ph.D.

You are not alone if you suffer from an anxiety. At times, the world can feel overwhelming.

While we tend to see television commercials for depression or for bipolar disorder, the reality is that anxiety disorders are the most common form of mental suffering in our country.

One of five adults report some form of anxiety each year, but only slightly more than one third of these individuals receive treatment and relief from their suffering.

This month, in this column, I would like to focus on obsessive-compulsive forms of thinking and behaving.

For decades, mental health professionals viewed obsessive-compulsive disorder (OCD) as purely one type of anxiety disorder. While anxiety is certainly an important experienced component of OCD, today it is diagnosed as an “impulsive-compulsive disorder.”

Today, many clinicians and researchers realize that OCD is related to impaired neural brain circuits. I will share where mental health professionals believe these impaired neural brain circuits are located in one of the next columns.

Obsessions are intrusive and unwanted thoughts, urges or images that cause distress or anxiety.

Compulsions are repetitive behaviors or mental actions (such as counting, etc.) that a person performs in a rigid way in an attempt to respond to and alleviate an obsession.

Such anxiety can affect anyone. The singer-songwriter, Fiona Apple, shares that she “had a really bad obsessive-compulsive disorder.” She remembered that “At its worst, I was compelled to leave my house at three o’clock in the morning and go out in the alley because I just knew that the paper-towel roll I threw in the recycling bin was uncomfortable, like it was lying the wrong way, and it should be down in the garbage.”

Anxiety is rarely experienced by itself for many individuals. Depression often accompanies an anxiety disorder in half of those diagnosed with an anxiety disorder.

While the average age for an obsessive-compulsive disorder’s onset is around nineteen years of age, children also experience such symptoms.

In the next four weeks, in this column on mental health, I would like to share the extent of the destructiveness of the tendency to ruminate for individuals with obsessive-compulsive behaviors. I will also share some techniques to quiet the ruminations.

The need for perfection will be addressed, and the strain it can place on an individual. Guilt and shame are often intertwined with an over-concern about what others are thinking of us.

The obsessive-compulsive’s need to control will be addressed. So, will the need to be “sure.” And, the need, by some, to known what exactly reality is.

The difference between anxiety and fear will be addressed, as will be the fact that anxiety has both a biological and a cognitive etiology.

This is important because effective treatment for obsessive thoughts/urges and compulsive actions needs to have a dual form of combined treatment. Both cognitive therapy and medication can be effective in bringing relief and ending suffering.

Phil Kronk, M.S., Ph.D. is a semi-retired child and adult clinical psychologist and clinical neuropsychologist. Dr. Kronk has a doctorate in clinical psychology and a postdoctoral degree in clinical psychopharmacology (the use of drugs to treat mental disorders.) His year-long internship in clinical psychology was served at the University of Colorado Medical School. Dr. Kronk writes a weekly, Friday online column on mental health for the Knoxville News Sentinel’s website, knoxnews.com. He can be reached at (865) 330-3633.

 

Comorbid Considerations Q&A: Treating Bipolar Disorder, Depression, Anxiety, or Autism Alongside ADHD

Comorbidity is the rule, not the exception, in most psychiatric practices. Clinicians today must possess a thorough and nuanced understanding of disparate conditions in order to effectively diagnose and treat their patients’ symptoms attention deficit disorder (ADHD or ADD).

This is the overarching principle of Dr. Anthony Rostain, professor of psychiatry and pediatrics at the Perelman School of Medicine at the University of Pennsylvania and attending and supervising psychiatrist at the Children’s Hospital of Pennsylvania and the University of Pennsylvania Health System. Dr. Rostain — who is triple boarded in pediatrics, adult psychiatry, and child and adolescent psychiatry — was interviewed recently for an Ask the Experts webinar hosted by The American Professional Society of ADHD and Related Disorders (APSARD). This is the first of five articles based on his responses to questions from Dr. Gregory Mattingly of Washington University School of Medicine about aspects of treating ADHD. This article is presented for general educational purposes, not medical advice.

Dr. Mattingly: Mood disorders, bipolar disorder, and emotional dysregulation all occur with great regularity alongside symptoms of ADHD. As a clinician, how do you balance treating your patients for ADHD and for these and other comorbid conditions?

Dr. Rostain: The majority of patients seeking psychiatric treatment arrive with not just attention deficit disorder, but also a variety of mood disorders, anxiety disorders, substance use disorders, and the like. As clinicians, we must expect that adults with ADHD — particularly those who have not ever been treated or those who have been treated for ADHD but continue to experience impairing symptoms of the disorder — will come to us with complex presentations.

For this reason, my rule of thumb is this: Complete a comprehensive history regarding every aspect of the person’s past and present functioning, as well as a thorough history of past treatments for psychiatric disorders. That is the sine qua non of good care.

[Free Download: 9 Conditions Often Linked to ADHD]

The four most common conditions diagnosed alongside ADHD are bipolar disorder, depression, anxiety, and autism spectrum disorder.

1. ADHD and Bipolar Disorder

Data from the National Comorbidity Study suggests that, among people with ADHD, almost 20% report having some form of bipolar spectrum disorder. These patients not only have inattention, impulsivity, and hyperactivity, but also the severe mood swings and/or prolonged downturns associated with bipolar disorder.

In treating patients with comorbid ADHD and bipolar disorder, clinicians have historically been concerned about the possibility that stimulant treatment might induce or exacerbate bipolar mania. Thus, a mood stabilizer, if not already part of the treatment plan, should be introduced to minimize the chances of triggering mania.

The bigger challenge, as we have come to understand bipolar disorder better, has to do with the persistent depressive states that affect patients with both bipolar disorder and ADHD. Because stimulants don’t significantly improve the mood of patients with bipolar depression, I suggest treating bipolar depression first and saying to your patient, “Once your mood is more stable and/or you’re no longer as depressed then we can address your cognitive difficulties, your inattention, your problems with sustaining effort.”

[Self-Test: Bipolar Disorder in Adults]

I am asked frequently: What is your point of view on treating patients for bipolar disorder who are already successfully using stimulant medications? Does it make sense to keep patients on ADHD medications while initiating treatment for bipolar disorder? For example, a recent trial found that children with both ADHD and bipolar who were treated for both ADHD and bipolar had the best outcomes of any patients treated for bipolar disorder.

This is important. There is no reason to stop a medication that’s been helpful when you’re trying to treat a second condition. The bipolar patients I worry about using stimulants are college-aged students and/or people who are not getting enough sleep. With that rare exception, there is no reason not to use a stimulant while you’re treating the aspect of bipolar disorder that remains a problem.

2. ADHD and Depression

Both depression or dysthymia — either longstanding low-level depression or more severe depression — present frequently in patients with ADHD. The notion now is to introduce a medication such as bupropion (Wellbutrin) initially. Once the patient shows improvement in their mood, the clinician can decide how to add a stimulant to address ADHD symptoms.

There’s no simple algorithm for adding stimulants to medications for depression. The evidence suggests that stimulants can be effective in conjunction with these medications, but it is important to watch for side effects such as cardiovascular problems, weight loss or insomnia. As long as these basic functions are monitored carefully, you can proceed safely with stimulants.

[Self-Test: Depression in Adults]

It turns out that clinicians in the depression unit here at the University of Pennsylvania are more and more inclined to add stimulants to boost effective antidepressants. It is a fascinating time to be in psychiatry as we learn that the persistent cognitive impairments and/or inattentiveness or distractibility that many patients experience with depression can be helped by prescribing stimulants as an adjuvant for treatment-resistant depression.

3. ADHD and Anxiety

I am frequently asked by residents in my clinic how to disentangle anxiety from ADHD. Truth be told, it’s very difficult to do.

Anxiety can interfere greatly with both performance and focus. Thus the first step is to probe the patient’s history to understand how anxiety presents itself. In patients with both anxiety and ADHD, the two conditions feed one another. If the patient’s anxiety is largely performance anxiety — centering on difficulties with task performance or, in the case of a prior history of ADHD, on school, interpersonal or occupational difficulties caused by the patient’s ADHD-driven lack or reliability — then my advice is to treat the ADHD first.

If, on the hand, the patient presents with obsessive-compulsive disorder (OCD), longer-standing generalized anxiety disorder, or panic disorder, then I start a treatment plan directed at the anxiety itself. Some clinicians use Atomoxetine because it addresses both ADHD and comorbid anxiety. I have also come to appreciate the use of alpha agonists for people with anxiety and ADHD, especially those who have had a bad response to stimulants.

[Self-Test: Symptoms of Generalized Anxiety Disorder]

4. ADHD and Autism

Until the DSM-5, we were not supposed to diagnose autism and ADHD simultaneously, an error that has now been corrected. For patients with both conditions, ADHD stimulant medications have an effect size slightly lower than would be observed for patients without autism, but the data is clear that treatment for ADHD is warranted. The effect size in autism patients might be 0.5 instead of 0.7 or 0.7 instead of 0.9 for different stimulant classes. Nevertheless, there is absolutely no reason not to use doses that are comparable to any other patient to start with.

As long as your patient is not having side effects, start the dosage low and increase it slowly — continuing until the patient has a clinical response. As a rule, I try both methylphenidate and amphetamine so I can judge which is more effective. In cases of patients with sensory difficulties, I sometimes use the new liquid and oral disintegrating tablet (ODT) formulations of ADHD stimulant medications.

Medication efficacy is challenging to assess when your patient cannot report well or is not able to observe the effects of medications. You need good collateral information, such as the usual teacher or parent data, and you also need to observe the patient’s performance on tasks presented in the office.


CW: The Anxiety of Alma Fischer: A Webcomic About Anxiety, Depression & Obsessive-Compulsive Disorder

Many years ago, I took a theatrical script analysis class at Marymount Manhattan College. Back then, I was an awful student. I didn’t go to class more than I did go, and I loved a good party. At a rare occasion when I went to class, my professor talked about a one-act play that stayed with me.

I don’t remember the name of the play. I’m not sure I remember the plot particularly well. Still, the amorphous anti-plot, the loneliness, and the absurd realism of it all stuck with me decades later.

As someone who deals with anxiety, depression, and obsessive-compulsive disorder — just to name a few things — I’m well aware of the power of comics and graphic novels, particularly in memoir or non-fiction form. Comics felt like the perfect medium to express the crushing experience of living with intrusive thoughts and the debilitating weight of hopelessness depression causes.

I’m honored to have worked with artist Mair Sierra and editor Kat Vendetti on this webcomic.

Please heed our content warning moving forward!


The Anxiety of Alma Fischer by Justin Alba cover
The Anxiety of Alma Fischer by Justin Alba page 1 The Anxiety of Alma Fischer by Justin Alba page 2 The Anxiety of Alma Fischer by Justin Alba page 3 The Anxiety of Alma Fischer by Justin Alba page 4 The Anxiety of Alma Fischer by Justin Alba page 5 The Anxiety of Alma Fischer by Justin Alba page 6

WCTC will host a movie screening and an expert panel discussion about obsessive-compulsive disorder

With Obsessive-Compulsive Disorder Week happening the second week of October, OCD Wisconsin, based in Oconomowoc, wants to educate people on the disorder that affects 1 in 100 adults and 1 in 200 children and teens.

Beginning at 6:30 p.m. Thursday, Oct. 11, “Unstuck: An OCD Kids Movie” will be screened at Waukesha County Technical College’s Richard T. Anderson Center in Pewaukee.

Additionally, a panel of experts will discuss OCD and open the floor for questions and answers. The event will conclude at 8 p.m.

OCD is a common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over, according to the National Institute of Mental Health website.

Dr. Bradley Riemann, who serves as chief clinical officer for Rogers Behavioral Health, will be one of the speakers at the event.


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“Dr. Riemann is a leading expert in the assessment of obsessive-compulsive disorder and anxiety disorders and use of cognitive behavioral therapy treatment,” a news release stated. “At Rogers, he serves as the clinical director of the adult OCD Center, one of the leading residential treatment centers for OCD and anxiety in the country. He also directs cognitive behavioral therapy services at Rogers.”

Riemann has also authored numerous scientific papers on obsessive-compulsive disorder and anxiety and has spoken at national and international conventions, according to the release.

Chad Wetterneck, a licensed clinical psychologist who specializes in using cognitive behavioral therapy in the treatment of anxiety and post-traumatic stress disorder, will also speak.

“Dr. Wetterneck has developed training modules and interventions for application in Rogers’ residential, partial hospitalization, and intensive outpatient programs,” the release stated. “He supervises the behavioral specialists treating residential adult patients with dual diagnoses in the Herrington Recovery Center, and developed and oversees the PTSD partial hospital programs at Rogers’ West Allis, Brown Deer, Oconomowoc, and Appleton locations.”

Psychologist Nicholas Farrell will also speak at the event. Farrell provides clinical consultation and supervises the work of the behavioral specialists in Rogers’ Eating Disorder Center as well as in the inpatient, partial hospitalization and intensive outpatient programs.

“Dr. Farrell embraces an integrated care model that promotes collaboration between patients and the health professionals involved in their care,” the release stated.

The event is free and open to the public, but registration is required. To register, email Kia LaBracke at ocdwisconsin@gmail.com.

OCD Wisconsin was founded in 2013 as the Wisconsin affiliate of the International OCD Foundation with the mission to be a trusted resource and voice for those affected by OCD.

Top Headlines Around the Community:

Here’s a roundup of many fall activities and events in the Milwaukee suburbs

Oak Creek man who was shot by police found dead

Photos: Check out these gorgeous images of Pewaukee Lake

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Paroxetine: Side effects, dosage, uses, and more

Highlights for paroxetine

  1. Paroxetine oral tablet is available in immediate-release and extended-release forms. It’s also available as both a generic drug and brand-name drugs. Brand names: Paxil, Paxil CR, and Pexeva.
  2. Paroxetine is also available as an oral capsule and oral suspension.
  3. Paroxetine oral tablet can be used to treat depressive disorder, obsessive-compulsive disorder, panic disorder, social anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, and premenstrual dysphoric disorder.


Important warnings

FDA warning: Suicide warning

  • This drug has a black box warning. This is the most serious warning from the Food and Drug Administration (FDA). A black box warning alerts doctors and patients about drug effects that may be dangerous.
  • Antidepressant medications such as paroxetine may increase suicidal thoughts and behaviors, especially within the first few months of treatment or when your dose is changed. This risk is higher in children, teenagers, and young adults. You, family members, caregivers, and your doctor should pay attention to any unusual changes in your mood, behaviors, thoughts, or feelings.

Other warnings

  • Serotonin syndrome warning: This drug can cause a potentially life-threatening condition called serotonin syndrome. It can be caused by this drug alone or with the use of other medications that have similar effects. Symptoms of serotonin syndrome can include agitation, hallucinations, confusion, trouble thinking, coma, coordination problems, and muscle twitching (overactive reflexes).
  • Worsened depression warning: Paroxetine may worsen your depression. If you experience any unusual changes in behavior, especially during the first few months of treatment or when your dose changes, call your doctor. These can include anxiety, restlessness, panic attacks, sleeplessness, irritability, aggressiveness, acting on dangerous impulses, attempts to commit suicide, and extreme mood swings.
  • Stopping treatment warning: If you’re stopping treatment with this drug, it should be done gradually and with your doctor’s guidance. Don’t stop taking this drug abruptly. Withdrawal symptoms can occur when this drug is stopped too quickly. Symptoms of withdrawal include anxiety, irritability, restlessness, changes in sleep habits, headache, sweating, nausea, dizziness, shaking, and confusion. You should be monitored for these symptoms when stopping treatment with paroxetine.

What is paroxetine?

Paroxetine oral tablet is a prescription drug. It’s available in immediate-release and extended-release forms. These forms are available as the brand-name drugs Paxil, Paxil CR, and Pexeva. All brands do not treat all conditions.

Paroxetine oral tablet is also available as a generic drug. Generic drugs usually cost less than brand-name versions. In some cases, they may not be available in all strengths or forms as brand-name drugs.

Paroxetine also comes as an oral capsule and an oral solution.

Why it’s used

Paroxetine can be used to treat the following conditions:

Paroxetine may be used as part of a combination therapy. This means you may need to take it with other medications.

How it works

Paroxetine belongs to a class of drugs called selective serotonin reuptake inhibitors. A class of drugs is a group of medications that work in a similar way. These drugs are often used to treat similar conditions.

Paroxetine increases the amount of the hormone serotonin that your body makes and releases in your brain. Serotonin helps with symptoms of depression, compulsions, stress, and anxiety.


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Paroxetine side effects

Paroxetine oral tablet can cause drowsiness and may affect your ability to make decisions, think clearly, or react quickly. You shouldn’t drive, use heavy machinery, or do other activities for which you need to be alert until you know how this drug affects you.

Paroxetine can also cause other side effects.

More common side effects

The more common side effects of paroxetine oral tablet can include:

  • nausea
  • sleepiness
  • weakness
  • dizziness
  • anxiousness or sleeplessness
  • delayed ejaculation
  • decreased sexual desire
  • impotence
  • sweating
  • shaking
  • decreased appetite
  • dry mouth
  • constipation
  • infection
  • yawning

If these effects are mild, they may go away within a few days or a couple of weeks. If they’re more severe or don’t go away, talk to your doctor or pharmacist.

Serious side effects

Call your doctor right away if you have serious side effects. Call 911 if your symptoms feel life-threatening or if you think you’re having a medical emergency. Serious side effects and their symptoms can include the following:

  • Changes in mood, anxiety or behavior, such as:
    • new or worsened depression
    • new or worsened anxiety or panic attacks
    • thoughts of suicide or dying
    • attempts to commit suicide
    • acting on dangerous impulses
    • acting aggressive or violent
    • agitation, restlessness, anger, or irritability
    • sleeplessness
    • increase in activity or talking more than what is normal for you
  • Serotonin syndrome or neuroleptic malignant syndrome-like reactions. Symptoms can include:
    • agitation, hallucinations, coma, confusion, and trouble thinking
    • coordination problems or muscle twitching (overactive reflexes)
    • muscle rigidity
    • racing heartbeat
    • high or low blood pressure
    • sweating
    • fever
    • nausea, vomiting, or diarrhea
  • Eye problems, such as:
    • eye pain
    • changes in vision
    • swelling or redness in or around your eyes
  • Severe allergic reactions. Symptoms can include:
    • trouble breathing
    • swelling of your face, tongue, eyes, or mouth
    • rash
    • hives (itchy welts)
    • blisters
    • fever
    • joint pain
  • Abnormal bleeding
  • Seizures or convulsions
  • Manic episodes. Symptoms can include:
    • greatly increased energy
    • severe trouble sleeping
    • racing thoughts
    • reckless behavior
    • unusually grand ideas
    • excessive happiness or irritability
    • talking more or faster than usual
  • Changes in appetite or weight
  • Low sodium levels. Symptoms can include:
    • headache
    • weakness or feeling unsteady
    • confusion, problems concentrating or thinking, or memory problems
  • Bone fracture. Symptoms can include:
    • unexplained bone pain
    • tenderness
    • swelling
    • bruising

Paroxetine and suicide

SSRIs, such as paroxetine, may cause or increase suicidal thoughts and behaviors. The risk is especially high during the first few months of treatment, or following a change in dosage. Children, teenagers, and young adults are at highest risk for these symptoms. Contact your doctor right away if you experience any unusual or sudden changes in behaviors, thoughts, or mood when taking this drug. Learn more about antidepressants and suicide risk here.

Disclaimer: Our goal is to provide you with the most relevant and current information. However, because drugs affect each person differently, we cannot guarantee that this information includes all possible side effects. This information is not a substitute for medical advice. Always discuss possible side effects with a healthcare provider who knows your medical history.

Paroxetine may interact with other medications

Paroxetine oral tablet can interact with other medications, vitamins, or herbs you may be taking. An interaction is when a substance changes the way a drug works. This can be harmful or prevent the drug from working well.

To help avoid interactions, your doctor should manage all of your medications carefully. Be sure to tell your doctor about all medications, vitamins, or herbs you’re taking. To find out how this drug might interact with something else you’re taking, talk to your doctor or pharmacist.

Examples of drugs that can cause interactions with paroxetine are listed below.

Drugs you should not take with paroxetine

Do not take these drugs with paroxetine. Taking these drugs with paroxetine can cause dangerous effects in your body. Examples of these drugs include:

  • Thioridazine. Taking this drug with paroxetine can cause serious heart rhythm problems or sudden death.
  • Pimozide. Taking this drug with paroxetine can cause serious heart problems.
  • Monoamine oxidase (MAO) inhibitors, such as isocarboxazid, phenelzine, and tranylcypromine. Taking these drugs with paroxetine increases your risk of serotonin syndrome so much that they should not be taken with paroxetine. You should wait at least 14 days between use of paroxetine and these drugs.
  • Tryptophan (found in dietary supplements). Taking tryptophan with paroxetine increases your risk of serotonin syndrome. It should not be taken with paroxetine.
  • Linezolid, and intravenous methylene blue. Taking these drugs with paroxetine increases your risk of serotonin syndrome so much that they should not be used together.

Interactions that can increase your risk of side effects

Taking paroxetine with certain drugs raises your risk of side effects. Examples of these drugs include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as, ibuprofen and naproxen as well as aspirin and warfarin. Taking these drugs with paroxetine can increase your risk of bleeding or bruising.
  • Triptans such as sumatriptan
  • Lithium
  • Serotonergic drugs, such as fentanyl, tramadol, and St. John’s wort. Taking these drugs with paroxetine can increase your risk of serotonin syndrome.
  • Amphetamines, such as lisdexamfetamine and methamphetamine. Taking these drugs with paroxetine can increase your risk of serotonin syndrome.
  • Theophylline. Taking this drug with paroxetine can increase your risk of restlessness, trouble sleeping, and irritability.
  • Risperidone. Taking this drug with paroxetine can increase your risk of sleeping difficulty, anxiety, restlessness, and constipation.
  • Cimetidine
  • Antiarrhythmics, such as flecainide, and propafenone
  • Phenothiazines, such as chlorpromazine, and fluphenazine
  • Tricyclic antidepressants (TCAs), such as amitriptyline, imipramine and desipramine
  • Quinidine. Taking this drug with paroxetine can increase your risk of tiredness, decreased appetite, sweating, dry mouth, and decreased sexual desire.

Interactions that can make drugs less effective

Taking paroxetine with certain drugs may cause one or both of the drugs to not work as well. This is because the interaction between the drugs may cause a decrease in your body of paroxetine or the other drug. Examples of these drugs include:

  • Tamoxifen, a breast cancer drug
  • Digoxin
  • Protease inhibitors, such as fosamprenavir and ritonavir
  • Phenobarbital
  • Phenytoin

Disclaimer: Our goal is to provide you with the most relevant and current information. However, because drugs interact differently in each person, we cannot guarantee that this information includes all possible interactions. This information is not a substitute for medical advice. Always speak with your healthcare provider about possible interactions with all prescription drugs, vitamins, herbs and supplements, and over-the-counter drugs that you are taking.


Paroxetine warnings

Paroxetine oral tablet comes with several warnings.

Allergy warning

This drug can cause a severe allergic reaction. Symptoms can include:

  • trouble breathing
  • swelling of your face, tongue, eyes, or mouth
  • rash, itchy welts (hives), or blisters, alone or with fever or joint pain

If you have an allergic reaction, call your doctor or local poison control center right away. If your symptoms are severe, call 911 or go to the nearest emergency room.

Don’t take this drug again if you’ve ever had an allergic reaction to it. Taking it again could be fatal (cause death).

Alcohol interaction

You should avoid drinks that contain alcohol when taking this drug.

Warnings for people with certain health conditions

For people with glaucoma: Paroxetine may dilate your pupils, which may trigger a glaucoma attack. Notify your doctor if you have glaucoma before taking this drug.

For people with bipolar disorder: Caution should be used when taking this drug if you have bipolar disorder. Taking paroxetine alone may trigger a mixed or manic episode.

For people with seizures: Caution should be used when taking this drug if you have a history of seizures. If seizures occur while you take this drug, you should stop taking it and contact your doctor.

For people with kidney disease: If you have kidney disease, your kidneys may not be able to get rid of this drug as well as they should. This may cause levels of the drug to build up in your body and cause more side effects.

For people with liver disease: If you have liver disease, your body may not be able to process this drug as well as it should. This may increase the levels of this drug to build up in your body and cause more side effects.

Warnings for other groups

For pregnant women: Paroxetine oral tablet is a category D pregnancy drug. That means two things:

  1. Research in humans has shown adverse effects to the fetus when the mother takes the drug.
  2. This drug should only be used during pregnancy in serious cases where it’s needed to treat a dangerous condition in the mother.

Talk to your doctor if you’re pregnant or planning to become pregnant. Ask your doctor to tell you about the specific harm that may be done to the fetus. This drug should be only used if the potential risk is acceptable given the drug’s potential benefit. Call your doctor right away if you become pregnant while taking this drug.

For women who are breastfeeding: This drug passes into breast milk and may cause side effects in a child who is breastfed. Caution should be used when taking this drug while breastfeeding. Talk to your doctor if you breastfeed your child. You may need to decide whether to stop breastfeeding or stop taking this medication.

For seniors: The kidneys of older adults may not work as well as they used to. This can cause your body to process drugs more slowly. As a result, more of a drug stays in your body for a longer time. This raises your risk of side effects.

If you’re over the age of 65, you may be at higher risk of developing side effects while taking this drug, including low sodium levels in your blood (hyponatremia).

For children: It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

How to take paroxetine

This dosage information is for paroxetine oral tablet. All possible dosages and drug forms may not be included here. Your dosage, drug form, and how often you take the drug will depend on:

  • your age
  • the condition being treated
  • how severe your condition is
  • other medical conditions you have
  • how you react to the first dose

Forms and strengths

Generic: Paroxetine

  • Form: Immediate-release oral tablet
  • Strengths: 10 mg, 20 mg, 30 mg, 40 mg
  • Form: Extended-release oral tablet
  • Strengths: 12.5 mg, 25 mg, 37.5 mg

Brand: Paxil

  • Form: Immediate-release oral tablet
  • Strengths: 10 mg, 20 mg, 30 mg, 40 mg

Brand: Paxil CR

  • Form: Extended-release oral tablet
  • Strengths: 12.5 mg, 25 mg, 37.5 mg

Brand: Pexeva

  • Form: Immediate-release oral tablet
  • Strengths: 10 mg, 20 mg, 30 mg, 40 mg

Dosage for major depressive disorder

Adult dosage (ages 18–64 years)

You should take this drug in one dose per day. You should be on the lowest dose that works for you.

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The typical starting dose is 20 mg per day.
    • If a 20-mg dose is not enough, your doctor will start increasing your dose each week by 10 mg per day.
    • Your maximum daily dose shouldn’t exceed 50 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The initial dose is 25 mg per day.
    • If you don’t respond to a 25-mg dose, your doctor will increase your dose each week by 12.5 mg per day.
    • The maximum dose is 62.5 mg per day.

Child dosage (ages 0–17 years)

It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

Senior dosage (ages 65 years and older)

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.
    • The maximum dose is 50 mg per day.

Special dosage considerations

For severe kidney disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.
    • The maximum dose is 50 mg per day.

For severe liver disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dosage is 12.5 mg per day.
    • The maximum dosage is 50 mg per day.

Dosage for obsessive-compulsive disorder

Adult dosage (ages 18–64 years)

You should take this drug in one dose per day. You should be on the lowest dose that works for you.

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The typical starting dose is 20 mg per day.
    • The target dose is 40 mg day. Your doctor will increase your dose each week by 10 mg per day to get to the target dose.
    • The maximum dose is 60 mg per day.

Child dosage (ages 0–17 years)

It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

Senior dosage (ages 65 years and older)

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.

Special dosage considerations

For severe kidney disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.

For severe liver disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.

Dosage for panic disorder

Adult dosage (ages 18–64 years)

You should take this drug in one dose per day. You should be on the lowest dose that works for you.

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The typical starting dose is 10 mg per day.
    • The target dose is 40 mg per day. Your doctor will increase your dose each week by 10 mg per day to get to the target dose.
    • The maximum dose is 60 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The initial dose is 12.5 mg per day.
    • If you don’t respond to a 12.5-mg dose, your doctor will increase your dose each week by 12.5 mg per day.
    • The maximum dose is 75 mg per day.

Child dosage (ages 0–17 years)

It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

Senior dosage (ages 65 years and older)

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg once per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.
    • The maximum dose is 50 mg per day.

Special dosage considerations

For severe kidney disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.
    • The maximum dose is 50 mg per day.

For severe liver disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dosage is 12.5 mg per day.
    • The maximum dosage is 50 mg per day.

Dosage for social anxiety disorder

Adult dosage (ages 18–64 years)

You should take this drug in one dose per day. You should be on the lowest dose that works for you.

  • Immediate-release oral tablets (Paxil):
    • The typical starting dose is 20 mg per day.
    • If a 20 mg dose is not enough, your doctor will start increasing your dose each week by 10 mg per day.
    • The recommended dose to treat social anxiety disorder is 20–60 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The initial dose is 12.5 mg per day.
    • If you don’t respond to a 12.5-mg dose, your doctor will increase your dose each week by 12.5 mg per day.
    • The maximum dose is 37.5 mg per day.

Child dosage (ages 0–17 years)

It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

Senior dosage (ages 65 years and older)

  • Immediate-release oral tablets (Paxil):
    • The recommended starting dose is 10 mg once per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.
    • The maximum dose is 50 mg per day.

Special dosage considerations

For severe kidney disease

  • Immediate-release oral tablets (Paxil):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.
    • The maximum dose is 50 mg per day.

For severe liver disease

  • Immediate-release oral tablets (Paxil):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.
  • Extended-release oral tablets (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.

Dosage for generalized anxiety disorder

Adult dosage (ages 18–64 years)

You should take this drug in one dose per day. You should be on the lowest dose that works for you.

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The typical starting dose is 20 mg per day.
    • If a 20-mg dose is not enough, your doctor will start increasing your dose each week by 10 mg per day.
    • The recommended dose to treat generalized anxiety disorder is 20–50 mg per day.

Child dosage (ages 0–17 years)

It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

Senior dosage (ages 65 years and older)

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg once per day.
    • The maximum dose is 40 mg per day.

Special dosage considerations

For severe kidney disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.

For severe liver disease

  • Immediate-release oral tablets (Paxil, Pexeva):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.

Dosage for post-traumatic stress disorder

Adult dosage (ages 18–64 years)

You should take this drug in one dose per day. You should be on the lowest dose that works for you.

  • Immediate-release oral tablets (Paxil):
    • The typical starting dose is 20 mg per day.
    • If a 20-mg dose is not enough, your doctor will start increasing your dose each week by 10 mg per day.
    • The recommended dose to treat post-traumatic stress disorder is 20–50 mg per day.

Child dosage (ages 0–17 years)

It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

Senior dosage (ages 65 years and older)

  • Immediate-release oral tablets (Paxil):
    • The recommended starting dose is 10 mg once per day.
    • The maximum dose is 40 mg per day.

Special dosage considerations

For severe kidney disease

  • Immediate-release oral tablets (Paxil):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.

For severe liver disease

  • Immediate-release oraltablets (Paxil):
    • The recommended starting dose is 10 mg per day.
    • The maximum dose is 40 mg per day.

Dosage for premenstrual dysphoric disorder

Adult dosage (ages 18–64 years)

You should take this drug in one dose per day. You should be on the lowest dose that works for you.

  • Extended-release oral (Paxil CR):
    • The typical starting dose is 12.5 mg per day, usually taken in the morning.
    • Depending on your symptoms, your dose can be increased up to 25 mg per day.
    • Dose changes should occur at intervals of at least one week.

Child dosage (ages 0–17 years)

It hasn’t been confirmed that this drug is safe and effective for use in people younger than 18 years.

Senior dosage (ages 65 years and older)

  • Extended-release oral (Paxil CR):
    • The recommended starting dose is 12.5 mg once per day
    • The maximum dose is 50 mg per day.

Special dosage considerations

For severe kidney disease

  • Extended-release oral (Paxil CR):
    • The recommended starting dose is 12.5 mg per day.
    • The maximum dose is 50 mg per day.

For severe liver disease

  • Extended-release oral (Paxil CR):
    • The recommended starting dosage is 12.5 mg per day.
    • The maximum dosage is 50 mg per day.

Disclaimer: Our goal is to provide you with the most relevant and current information. However, because drugs affect each person differently, we cannot guarantee that this list includes all possible dosages. This information is not a substitute for medical advice. Always speak with your doctor or pharmacist about dosages that are right for you.


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Take as directed

Paroxetine oral tablet can be used for long-term or short-term treatment. It comes with serious risks if you don’t take it as prescribed.

If you stop taking the drug suddenly or don’t take it at all: If you don’t take it at all, your condition won’t get any better. If you suddenly stop taking it, you may see symptoms, such as anxiety, irritability, high or low mood, restlessness, changes in sleep habits, headache, sweating, nausea, dizziness, electric shock-like sensations, shaking, and confusion.

If you miss doses or don’t take the drug on schedule: Your medication may not work as well or may stop working completely. For this drug to work well, a certain amount needs to be in your body at all times.

If you take too much: You could have dangerous levels of the drug in your body. Symptoms of an overdose of this drug can include:

  • sleepiness
  • dizziness
  • nausea
  • vomiting
  • fast heart rate
  • tremor
  • confusion
  • coma

If you think you’ve taken too much of this drug, call your doctor or local poison control center. If your symptoms are severe, call 911 or go to the nearest emergency room right away.

What to do if you miss a dose: Take your dose as soon as you remember. But if you remember just a few hours before your next scheduled dose, take only one dose. Never try to catch up by taking two doses at once. This could result in dangerous side effects.

How to tell if the drug is working:

  • Major depressive disorder. You should have decreased feelings of depression and your mood should improve.
  • Obsessive-compulsive disorder. You should have decreased feelings of obsessions and compulsions.
  • Panic disorder. You should have decreased feelings of anxiety and panic.
  • Social anxiety disorder. You should have decreased feelings of anxiety.
  • Generalized anxiety disorder. You should have decreased feelings of anxiety.
  • Post-traumatic stress disorder. You should have decreased feelings of anxiety, memories, or dreams of traumatic events (flashbacks) and nightmares.
  • Premenstrual dysphoric disorder. You should have decreased tiredness, irritability, mood swings, sleeplessness, and anxiety.

Important considerations for taking paroxetine

Keep these considerations in mind if your doctor prescribes paroxetine oral tablets for you.

General

  • You can take this drug with or without food.
  • Take the oral tablet in the morning.
  • You can cut or crush the immediate-release oral tablet
  • You can’t chew, crush, or cut the extended-release tablet. It must be swallowed whole.
  • Not every pharmacy stocks all forms or brands of this drug. When filling your prescription, be sure to call ahead.

Storage

  • Store the oral tablets at room temperature between 59°F and 86°F (15°C and 30°C). Store the extended-release tablets at or below 77°F (25°C).
  • Keep this drug away from light.
  • Don’t store this medication in moist or damp areas, such as bathrooms.

Refills

A prescription for this medication is refillable. You should not need a new prescription for this medication to be refilled. Your doctor will write the number of refills authorized on your prescription.

Travel

When traveling with your medication:

  • Always carry your medication with you. When flying, never put it into a checked bag. Keep it in your carry-on bag.
  • Don’t worry about airport X-ray machines. They can’t hurt your medication.
  • You may need to show airport staff the pharmacy label for your medication. Always carry the original prescription-labeled box with you.
  • Don’t put this medication in your car’s glove compartment or leave it in the car. Be sure to avoid doing this when the weather is very hot or very cold.

Clinical monitoring

You and your doctor should monitor certain health issues. This can help make sure you stay safe while you take this drug. These issues include:

  • Mental health and behavior changes
  • Kidney function. Your doctor may have blood tests done to check how well your kidneys are working. If your kidneys aren’t working well, your doctor may decide to lower your dose of this drug.
  • Liver function. Your doctor may have blood tests done to check how well your liver is working. If your liver isn’t working well, your doctor may decide to lower your dose of this drug.

Insurance

Many insurance companies require a prior authorization for certain forms or brands of this drug. This means your doctor will need to get approval from your insurance company before your insurance company will pay for the prescription.

Are there any alternatives?

There are other drugs available to treat your condition. Some may be better suited for you than others. Talk to your doctor about other drug options that may work for you.

Disclaimer: Medical News Today has made every effort to make certain that all information is factually correct, comprehensive, and up-to-date. However, this article should not be used as a substitute for the knowledge and expertise of a licensed healthcare professional. You should always consult your doctor or other healthcare professional before taking any medication. The drug information contained herein is subject to change and is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. The absence of warnings or other information for a given drug does not indicate that the drug or drug combination is safe, effective, or appropriate for all patients or all specific uses.