# Stress of being a lawyer



## cbtodacb (Aug 13, 2013)

I am a lawyer working in an office with over 200 other employees + (and a big plus at that) I have a chronic social phobia. Work is hellish at time. The constant fear.

Does anyone know of drugs I can ask my doc to prescribe me that are better than Lyrica and Valium? I am on those now.


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## eveningbat (Jan 21, 2013)

Yes, it seems like a stressful job. But maybe it is good that you have it because it is quite a good job, I think a lawyer is one of the most prestigious jobs, isn't it? As for the social phobia I do not think medications will make you more self -confident. It is a social skill that has to be developed with time. But the medicines may just lessen your nervousness and maybe depression to some extend. 
Dealing with people is one if the most difficult things in life. Especially if some complicated legal issues are involved.


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## nml (Jan 21, 2012)

what kind of lawyer are you? What are the sorts of situations that cause you the most grief?

it being hard to give advice without knowing more about your situation...but anyway you've got a good job, and it can't be easy at all with SA


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## cbtodacb (Aug 13, 2013)

I am a commercial lawyer mainly dealing in insurance litigation. Every situation causes me grief if it involves people, which is always. I have serious social anxiety plus chronic generalized anxiety.

Looking for meds which might work better than lyrica, lexapro or valium


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## sas2012solar (Sep 26, 2011)

Try a small dose of Paxil. I started taking 20 mg 4 days ago but last night
took 10 mg and tonight 5 mg. I actually talked with 2 family
members on the phone tonight which Id NEVER do.

It just seems that the 20 was causing increased anxiety so
im backing down to 5 for awhile.

Id definitely try paxil it has worked for me in the past also, like 10 years
Ago. I have anxiety also take klonopin. Anyways good luck


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## cbtodacb (Aug 13, 2013)

Thanks sas,
I have heard mixed reviews about paxil although a lot of people do seem to be taking it. Is paxil an ssri? I totally support the klonopin your taking, this seems to be highly recommended amongst the SAD and GAD community.

Is paxil in the same category as Lexapro? Does anyone experienced in this area know what is the most highly recommended, patient reviewed SSRI (or the like) for severe anxiety? (ill take on and off label)

Thanks.


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## nml (Jan 21, 2012)

I see, boy that can't be easy with anxiety. But they hired you after all, so you can't be too bad at it! Have you gone for therapy at all? some of the anxiety might go down if you challenge the beliefs that you can't do your job (if you have beliefs like that).

As for drugs I don't have much experience with any of those I'm afraid. I tried propranolol a while ago, it's quite mild but helped me through some tough situations.


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## InnerPeace (Apr 21, 2011)

I'd consider Paxil first and if it fails Venlafaxine next. Currently you are on the most selective SSRI available so it seems serotonin reuptake alone doesn't help you enough. Paxil is a "dirtier" SSRI with action on mAChRs, NET and DAT. That's the reason why it often works better for SA than other SSRIs.
Venlafaxine is a SNRI at doses beyond 150mg and has an even better chance to work for SA.

If you find no success with either drug you might want to look into psychostimulants like Ritalin, Adderall or a reversible MAOI like Moclobemide.

You you do not respond to them either, then your last resort would be the irreversible MAOIs like Nardil and Parnate.


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## depressed77 (Dec 9, 2010)

cbtodacb said:


> Thanks sas,
> I have heard mixed reviews about paxil although a lot of people do seem to be taking it. Is paxil an ssri? I totally support the klonopin your taking, this seems to be highly recommended amongst the SAD and GAD community.
> 
> Is paxil in the same category as Lexapro? Does anyone experienced in this area know what is the most highly recommended, patient reviewed SSRI (or the like) for severe anxiety? (ill take on and off label)
> ...


Valium does nothing for my SAD while clonazepam does. Paxil is an SSRI but is not as 'clean' as Lexapro (which is cleanest). It's one of the most potent SRIs, with some mild noradrenaline reuptake inhibition and anticholinergic properties. Although effective it's plagued with side effects.
I would suggest switching to clonazepam first.

/depressed77


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## 0707129r (Apr 22, 2013)

Go for nardil and change your life.


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## InnerPeace (Apr 21, 2011)

I forgot to say that if physical symptoms of anxiety are your main concern then your best bet is Propranolol. Non-addictive and no withdrawal problems.

I recommend to try switching from Valium to Propranolol. It's generally best to reserve Benzos as last resort due addiction issues, brutal and possibly prolonged withdrawals as well as cognitive impairment amongst other problems associated with this class of meds.
Lyrica is also known to cause cognitive problems. I'm not sure if this is a drug cocktail you want to stay on forever as a lawyer if not absolutely necessary. From what you wrote it doesn't even help you much. I wouldn't want to take a benzo long-term if it doesn't even provide much benefit.


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## depressed77 (Dec 9, 2010)

InnerPeace said:


> I forgot to say that if physical symptoms of anxiety are your main concern then your best bet is Propranolol. Non-addictive and no withdrawal problems.
> 
> I recommend to try switching from Valium to Propranolol. It's generally best to reserve Benzos as last resort due addiction issues, brutal and possibly prolonged withdrawals as well as cognitive impairment amongst other problems associated with this class of meds.
> Lyrica is also known to cause cognitive problems. I'm not sure if this is a drug cocktail you want to stay on forever as a lawyer if not absolutely necessary. From what you wrote it doesn't even help you much. I wouldn't want to take a benzo long-term if it doesn't even provide much benefit.


If he has chronic social phobia and constant fear on Lyrica + Valium, it's something propranolol can't touch. He's already on Valium so a switch to clonazepam wouldn't be big deal plus it has the advantage of possibly helping. I'm dependent on benzos in the same way a diabetic is dependent on insulin. Although I hate to sound pro-benzo, I think their side effect profile is benign compared to other classes, no weight gain, no sexual dysfunction etc. Cognitive issues are not in the same league as with tricyclics or anticonvulsants.

/depressed77


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## A Little Crazy (Aug 4, 2013)

Hey OP, you replied in my other thread. I work in an office environment too.

I highly recommend you try propranolol (beta blocker). It helps remove the physical symptoms of anxiety - fast heart beat, shaky hands/voice, sweating, blushing, etc. 

If you're in a situation where you need to meet/speak with clients.. this will def. help. It will lessen your shaky hands and stop your stuttering/cracks in voice. The only problem is it doesn't last too long (3 hours or so) and I'm not totally sure its safe to take everyday. Also, it dries your mouth out so you need to carry around water.

And I can't speak about valium but I take klonopin (.5mg twice a day) and it helps/works well with propranolol.

Yesterday, I tried the klonopin + propranolol (twice - morning and after lunch) and it worked like a charm until around 4ish.


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## UltraShy (Nov 8, 2003)

cbtodacb said:


> Does anyone know of drugs I can ask my doc to prescribe me that are better than Lyrica and *Valium*? I am on those now.


Seeing how benzos top the list of most liked drugs on this forum I'm a bit surprised Valium isn't helping you. A lot of times when a benzo isn't working it's a dosage issue, so I must ask how much are you taking? Often times we find that a really conservative doctor has a patient on so little that it's no surprise that it's not getting the job done. While all benzos are much the same, everybody is different so you might find that a different one such as Xanax, Klonopin, or Ativan would do better for you.

Have you tried SSRIs yet? They're the standard first line treatment for SA, so it would be surprising if you got to Lyrica & Valium without going past one or more SSRIs/SNRIs first.

I can only imagine how stressful it must be to be a lawyer. Merely talking to my lawyer on the phone is quite enough anxiety for me.

Good luck.

Edit: I now see you have tried Lexapro which already answers one of my questions above.


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## UltraShy (Nov 8, 2003)

InnerPeace said:


> If you find no success with either drug you might want to look into *psychostimulants like Ritalin, Adderall* or a reversible MAOI like Moclobemide.
> 
> Stimulants simply aren't going to be prescribed for SA period. While you'll find many on this forum, including me, who take them we all get them for ADHD. In rare cases, including me originally, you may also get stimulants for treatment-resistant depression.
> 
> Moclobermide isn't available in the US, though I have no idea where the OP lives.


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## InnerPeace (Apr 21, 2011)

UltraShy said:


> Stimulants simply aren't going to be prescribed for SA period.


I doubt you know all the psychiatrists in the world. It's not helpful to discourage the OP from at least asking several psychiatrists.

I agree that the ordinary psychiatrist probably won't prescribe them for SA, but I'm sure there are enough open-minded psychiatrist in the world who would consider psychostimulants off-label if conventional treatments bring no relief.

If we as laymen come up with the idea to try psychostimulants, you can bet that some professionals are also aware of their potential application for SA.

Should all else fail one can still fake ADS and get a prescription.


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## InnerPeace (Apr 21, 2011)

depressed77 said:


> If he has chronic social phobia and constant fear on Lyrica + Valium, it's something propranolol can't touch. He's already on Valium so a switch to clonazepam wouldn't be big deal plus it has the advantage of possibly helping. I'm dependent on benzos in the same way a diabetic is dependent on insulin. Although I hate to sound pro-benzo, I think their side effect profile is benign compared to other classes, no weight gain, no sexual dysfunction etc. Cognitive issues are not in the same league as with tricyclics or anticonvulsants.
> 
> /depressed77


Propranolol also crosses the blood-brain-barrier and will also slightly affect the mental aspects of anxiety although admittedly not nearly as much as benzos do.

The OP should definitely try antidepressants first. Benzos are simply not a first line treatment for SA except for on an as needed basis.

I disagree that antidepressants cause worse cognitive impairment than benzos. Sertraline for instance hasn't been shown to affect cognition, it even improves it in some areas probably due to its mild DA reuptake. Other SSRIs like citalopram and in particular paroxetine negatively affect vigilance, verbal recall and some forms of memory, but in general these effects are rather mild when compared to benzos which affect many aspects of cognition and can even induce anterograde amnesia. With benzos you also have the risk of screwing up your cognition for many years or even permanently after discontinuation of treatment (---> very long PAWS). Also, with ADs you can often easily add an augmentation drug to ameliorate cognitive issues. With benzos you hardly can.

I remember taking two IQ test several years ago, both taken a couple of days apart. The first one was while being on 10mg Lexapro, the other one on 1mg Xanax. The IQ score under the influence of Xanax was 38 points less (99 points!! :-D ) ! This is of course anecdotal, but it also agress with the research which has consistently shown that benzos mess up your cognition. And at that time I thought Xanax allowed me to think clearer (!) because I felt it suppressed anxious thoughts that made it otherwise hard for me to focus on demanding tasks.

Generally speaking, antidepressants should always be the first line treatment and NOT benzos. Don't get me wrong, I'm absolutely not contra benzos, but as a long-term treatment I find they should be reserved when most other avenues have been exhausted.

Btw, benzos can absolutely cause sexual side effects, too, (erection difficulties, decreased libido, etc.) although most antidepressants are probably harsher in this respect.


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## UltraShy (Nov 8, 2003)

InnerPeace said:


> If we as laymen come up with the idea to try psychostimulants, you can bet that some professionals are also aware of their potential application for SA.


You should do a poll to see if you can find anybody who's received a stimulant for SA treatment. I'd be fascinated to see the results, as I'm not aware of a single case where that's ever happened.

I never meant to suggest that it literally has never happened in to anybody in the history of the world, but was simply being realistic about the odds of getting a stimulant for SA being exceedingly low.


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## adamaus (Mar 24, 2013)

Amphetamines are good but not long term


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## cbtodacb (Aug 13, 2013)

Hey guys,
Some very interesting posts from you all.
Just to let you know, I'm not new to the anxiety game. I have been seeing a psychiatrist for 5 years and have tried both zoloft and lexapro. I have been on lexapro for 5 years now. My dosage was 60mg (im not kidding) for over 24 months, the social anxiety remained. The reason for my thread is that the SSRI's have done **** all for me in regard to social phobia and severe GAD. I want to keep taking some underlying SSRI or something similar (Nardli, SNRI) but I want to have some heavy **** on top or in conjunction with it.

Propranolol sounds promising as a beta bloca. Can I take this with Lexapro and Lyrica.

Also, UltraShy I think dosage is the issue with valium. Docs always say not more than 20mg a day but I need 20mg to get any positive effect and I need to take 20mg at least twice a day to be able to function well. What sort of does is normal for someone with severe anxiety to get positive effects?


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## depressed77 (Dec 9, 2010)

InnerPeace said:


> Propranolol also crosses the blood-brain-barrier and will also slightly affect the mental aspects of anxiety although admittedly not nearly as much as benzos do.
> 
> The OP should definitely try antidepressants first. Benzos are simply not a first line treatment for SA except for on an as needed basis.
> 
> ...


I wasn't comparing benzos with SSRIs regarding cognitive issues but tricyclics and anticonvulsants. SSRIs are not as innocent as they may seem and can cause Post-SSRI sexual dysfunction, as if the sexual dysfunction while on them isn't enough. From my experience the only thing that speaks against benzos is dependence, if it weren't for that I'm fairly certain they would be a first-line choice. Their side-effects are not as trouble-some as other classes, the sedation and cognitive slowing wears off after a couple of weeks so it's not like when you're taking them prn.
Also, the OP seems to have struggled with ADs for five years which should warrant the use of a high-potency benzo like clonazepam, which is the benzo I find superior for social phobia.

/depressed77


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## cbtodacb (Aug 13, 2013)

thanks again for another insightful message my friend


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## UltraShy (Nov 8, 2003)

cbtodacb said:


> Also, UltraShy I think dosage is the issue with valium. Docs always say not more than 20mg a day but I need 20mg to get any positive effect and I need to take 20mg at least twice a day to be able to function well. What sort of does is normal for someone with severe anxiety to get positive effects?


Dosage varies greatly from one person to another so it's hard to simply pick a certain amount as normal, though your dose is nothing unusual. I'll use myself as an example. I have a Xanax prescription for 4mg per day. That would be equivalent to 40mg of Valium, which is the amount you find necessary to function well.

If it works for you, then I'd say the obvious answer is to find a doc who will provide you with that dosage. It's totally arbitrary when your doc say not more than 20mg. It's all just medical opinion and if you ask ten doctors you'll get ten opinions where they range from no benzos at all for anyone to a high dosage that would work for the vast majority of patients.

I'm an oddity myself in that benzos are only marginally effective for me at any dose. There are some who'd think my 4mg of Xanax per day is excessive, though years ago I used to take 10mg per day, so a 60% reduction over the last several years.


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## cbtodacb (Aug 13, 2013)

That sucks you tolerate benzos hey. You tried Lyrica, I am getting positive results within the 5 days I have been on it. I also just got a prescription of propranolol yesterday - 4mg morning and night.


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## reese27 (Aug 15, 2013)

After I finish graduate school, I want to become a lawyer but I fear that my social anxiety has kept me from pursuing my dream. I have pursued another field because I don't think I will be able to handle the pressure of speaking publicly in court or being able to think straight without letting my nerves influence my speech and interaction with clients. I really don't want to get on medication but I have almost two years left of graduate school and then I planning to enter law school. I hope everything works out for you because it will continue to give me hope that it is possible to have social anxiety and to work in such a demanding and public job as a lawyer.


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## cbtodacb (Aug 13, 2013)

My dear friend Reese27:

A few points:

1) *Do not be afraid of medication.* I have suffered this horrific disorder (SAD, GAD) through many publicly demanding phases i.e. I played profession rugby union for 4 years in front of 50,000 strong crowds, the games were televised internationally. I was able to do it, though the anxiety eventually corroded my ability to play and it destroyed my career. THIS WAS DUE TO ME BELIEVING MEDICATION WOULD AND COULD NOT HELP.
Had I been medicated I would still be playing today, probably for the Australian National Team (as I was on the cusp when before the anxiety got too much) and earning well over $400,000 a year.

2) It is only due to the grace of God that I was able to obtain my University Qualifications, let alone get a job in a law firm, with this disorder. I was on SSRI's throughout my degree (60mg Lexapro) and that didn't do **** for the anxiety. HAD I BEEN MORE OPEN OR KNOWLEDGABLE ABOUT MEDICATION OPTIONS I COULD HAVE ENJOYED MY UNIVERSITY LIFE.

3) SEVERE, LONG TERM SUFFERERS OF ANXIETY KNOW THAT MEDICATION IS REQUIRED IF THEIR CONDITION IS CHRONIC. It may be that you are yet to accept that you actually have disorder which needs medical intervention. It is much like having a broken leg and refusing to have it put in a cast. Our disorder (if yours is in my class) needs medical intervention. IF YOU DO NOT SEEK HELP FROM MEDICATION YOU WILL DRIFT THROUGH LIFE FROM FEAR TO FEAR, MISSED OPPORTUNITY TO MISSED OPPORTUNITY.
This is all about BECOMING A MATURE SUFFERER OF THE SAD/GAD DISORDER.

4) WOULD YOU REFUSE AN ASPIRIN IF YOU HAVE A THROBBING HEADACHE? Same thing.

Summary:
My dear friend, your aspirations of practicing in the law are admirable, it is an exciting profession. IT IS NOT POSSIBLE TO FUNCTION EFFECTIVELY UNMEDICATED THOUGH IN SUCH A HIGHLY SOCIABLE, HIGH STRESS ENVIRONMENT. 
Do not let your SAD/GAD keep you from your aspirations. Seek medical help, or the help of highly experienced and mature fellow sufferers of SAD/GAD on this and other forums.

P.S in my experience SSRI's are useless and so is therapy (caveat: this is my opinion from personal experience, other's may differ)


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## AussieGuy (Aug 23, 2013)

Hey cbtodacb

I'm also in the legal field in Brisbane, I'm hoping to get back to 'top performer' status soon, because if I don't get on top of my SA I'm not going to make it to the Bar!

I would suggest talking to your doctor about Aurorix. It's a selective monoamine oxidase inhibitor (MAOI).

My psychiatrist has started me on it to deal with anxiety that I have been (until now) dealing with by using diazepam. Apparently there's a lot of psychiatrists who won't prescribe MAOIs because they're not that familiar with them.

If you need to, send me a PM and I'll forward my psychiatrist's office's details to you.

The Wikipedia page is here: http://en.wikipedia.org/wiki/Moclobemide

If that doesn't work, then I'm onto the harder stuff (Parnate or Nardil), but my psychiatrist's opinion is that Aurorix has a good chance of suppressing the anxiety (although he thinks it's ineffective for depression), and there are no dietary restrictions unlike with the non-selective MAOIs.

The other bonus is that you don't suffer from some of the side effects that plague SSRIs. I was on Zoloft a few years back and found it dulled my ability to make quick and decisive calls.

Just a thought?

~AussieGuy


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## cbtodacb (Aug 13, 2013)

Hey Aussie Guy,
Mate great to hear from you. So comforting and encouraging to know there is someone close by who suffers the same ailment.
I'll PM you.


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