Cynthia (not her real name) is a 38 year old manager working in a federal government agency. When she first presented she described a history of anxiety; choking spells; social anxiety, fears of swallowing, flying in an airplane, traveling in a train, seeing doctors, and loss of control; anxiety before meetings, and “I hate talking in front of others at meetings.” Past history was revealing for alcohol abuse, and a concussion with a post-concussion disorder when she was a sophomore in high school. She also had a history of anger outbursts, but no mood swings or irritability. Several years earlier she reportedly drank ten Jack Daniels drinks up to four days per week for a six month time period. She denied any post-concussion disorder sensory illusions such as déjà vu, olfactory illusions, episodic changes in focus or memory, visual illusions, or zoning out or staring episodes (all possible signs of partial complex seizures). There was no history of migraine. Family history was unrevealing for anxiety or depression.
She was diagnosed with panic disorder including symptoms of social anxiety, anticipatory anxiety, multiple phobias, and stage fright. In addition, she had a prior history of concussion, episodic excessive alcohol abuse, and continuing stress with an ex-boyfriend who was stalking her.
We initially started her on clonazepam 0.5 mg twice a day, and Viibryd 40 mg a day. One month later the effects of these medications were assessed across a broad range of symptoms from which she was suffering, and she reported that they had brought about a 50% improvement in general anxiety, choking spells, social anxiety, anxiety before meetings, fears of loss of control, hatred of meetings at work, and fears of passing out at those meetings. There was no improvement in fear of flying or riding in a train. She had also begun seeing a psychologist on a weekly basis for cognitive behavioral and EMDR therapy to treat her symptoms and deal with the ex-boyfriend.
After 2 months of medication therapy, she noted that she was about 60% better on measures of generalized anxiety, choking spells, fears of meetings at work and social anxiety. She was no better with her fear of riding in a train, or flying in an airplane. She noted that without the medication she would be much worse, but to-date it was just a partial response.
Several months later, she reported that she was still having pre-panic attacks without frank panic attacks, a lower general level of anxiety, less anxiety at meetings, and reduced anxiety taking communion in front of others at church. She still was having initial and anticipatory anxiety when meeting with her boss. As this continued to be a sub-optimal response, and our aim was to achieve a full remission of symptoms, we performed genetic testing using the Genomind Genecept assay.
The genetic testing revealed that she had genetic variations in her 5-HT2C (related to increased risk of weight gain from antipsychotic medications), ANK3 (related to excessive sodium channel activity levels in her brain cells), and COMT (she had excessive amounts of this enzyme that breaks down dopamine) genes, and was an ultra-rapid metabolizer with the CYP2D6 gene (an enzyme that breaks down certain medications). Because of the COMT genetic variation, and the role of dopamine in ADHD conditions, we also administered the ADHD RS-IV screen and she scored 12/27 on the inattentive scale and 9/27 on the hyperactivity scale, indicative of mild symptoms of ADHD. However, there was no childhood history of ADHD symptoms.
Because of the excessive sodium channel activity, we began her on Lamictal (a sodium channel blocker) 25 mg a day, increasing it up to a 100 mg a day by week 4. We maintained the Viibryd at 40 mg a day (it increases dopamine release which countered her excess COMT activity) and clonazepam 0.5 mg twice a day. We also added omega-3 1000 mg twice a day.
One month later, the patient was seen again. She noted “I feel a lot better.” She reported that she was not very nervous at a management meeting the day before and for the first time she willingly contributed to that meeting. Tomorrow she was due to go to a big meeting where normally she would be dreading it and would feel “catastrophically nervous,” but now she only had mild nervousness. She had stopped going to the psychologist several months before.
Cynthia noted, “This has been a blessing”, and “I feel excited about this.” Her generalized anxiety, choking spells, social anxiety, fears of being called upon in meetings, riding in a train, anticipatory anxiety, and stage fright were all 80% better; and her panic attacks were 100% better. She still had not yet attempted to fly in an airplane. Because of this very positive response, we agreed to increase her Lamictal from 100 mg a day to 200 mg a day over the next month.
Six months later she was able to fly to Boston!
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