Dr. Jack Lloyd

Transcript of Dr. John Dacey’ podcast Dr. John Dacey: Today I have a guest who is my first psychiatrist that I’m going to be eagerly listening to a lot of the things he has to say about anxiety disorders. His name is Jack Lloyd, Dr. Jack Lloyd and I’m going to welcome him to the studio today. Hi Jack. Dr. Jack Lloyd: Hi John. So nice to be here. Dr. John Dacey: Thank you. Jack, I want start off by asking you to describe your clientele to me as much as , in as much detail as you can. What kinds of people do you typically see? Dr. Jack Lloyd: well John, I work by in large with the college undergraduate and graduate student population. I’d say 80% of the clients I see are in that category. Dr. John Dacey: Ok Dr. Jack Lloyd: I also work with some... Dr. John Dacey: Are they at a college some place? Dr. Jack Lloyd: Yeah, primarily at a university. Dr. John Dacey: You’re at MIT if I remember correctly. Dr. Jack Lloyd: Right. Dr. John Dacey: No shortage of anxiety problems. Dr. Jack Lloyd: Yeah, it’s a good anxiety generator. I think that for all, it’s that age is rife with reasons to be anxious. And I also work in my private practice with some older adults middle age and even older adults so I really run the gamut but I don’t work with children. Dr. John Dacey: OK. All right.  fine. That’s good because that’s not what we’re talking about too much here anyway. I have another colleague who does work almost entirely with college students. Her name is Dr. Elizabeth Brocker. And, I, So I’m glad to be talking to you. I want to talk to you of course about the psychological side of things but you’re also able to speak about the physical side of things. Maybe we should start right off with that. I know that I have a very good friend who is a psychiatrist. And when I see, quite a few clients  I’ve seen over the years have needed some mild tranquilizer situation, some kind of medication, because they found it very hard to pay attention when they’re in the middle of an episode. And they find it very hard to remember what I told them to do. And if they can remember what to do, they’re fine. They can work things out pretty well. But it’s very hard to remember when you’re really having, when you’re really having a bad case of the jitters. So, what percentage would you say of the clients that come to you as opposed to a psychotherapist, I imagine A fairer number, you get more serious cases. Am I right?   Dr. Jack Lloyd: Well, yes, I suppose I probably do. And I may, I may, some of my clients may be individuals who have been working  in therapy for a while and making the best use they can, as you say, of cognitive behavioral therapy, and of exposure and response prevention; Different techniques, mindfulness meditation, Behavioral techniques, exercise. And I think When those techniques haven’t quite gotten as far as the therapist and the client would like, they will often refer them to me, and I, I actually think that for everybody those therapy and behavioral techniques ought to be the real cornerstone of treatment. But as an adjunctive, as an adjunctive measure and treatment, I certainly prescribe medications. And in my, I also do therapy, And so I sometimes in a sense would refer to myself in an analogous way, and there are a number of medicines that can be helpful. Would you like me to talk about some? Dr. John Dacey: Yeah I really would like you to talk about them. I would like to About the various categories and I think it would be wonderful chance to to to go to the horses mouth here so to speak. What kind of categories are there? And why do we prescribe them? Dr. Jack Lloyd: Well, there are a number of different varieties of anxiety, of categories. Some, one clear obvious one is simple phobias; for instance if someone is frightened of flying or frightened of escalators. They can benefit. Fear of flying is a good example. Someone Who flies a couple times a year could benefit from taking a benzodiazepine type of medication. As you say, kind of like a tranquilizer, which can really do well to calm their anxiety, help them to be able to get on the plane, Get out to visit their families during the holidays. Dr. John Dacey: What are some exact examples of, you don’t mind if I call you Jack? Dr. Jack Lloyd: No, please do. Dr. John Dacey: What are some examples of benzodiazepines, Jack? Dr. Jack Lloyd: Commonly known ones are Xanax or lorazepam. Any that the... Dr. John Dacey: Clonopin? Dr. Jack Lloyd: Clonopin. Another word for that is clonazepam. Dr. John Dacey: Yeah that’s right. Dr. Jack Lloyd: Diazepam which is Valium. Alprazolam which is Xanax. Those are all, all those “-asolams” are all benzodiazepines. Dr. John Dacey: They are. Dr. Jack Lloyd: And they work very quickly. After taking it, they will take sometimes as short as 20 to 30 minutes to work and they last for a while. Dr. John Dacey: Xanax Will work faster even than that.   Dr. Jack Lloyd: Xanax might even work faster than that. And sometimes just the act of taking it will help anxiety. Or the active having it in your cupboard or in your purse may make it so that you don’t even need it after a while, but, ... Dr. John Dacey: One of the most fascinating medical discoveries that I found, read about recently Is that for a lot of people even if they know that it’s a Dr. Jack Lloyd: Placebo? Dr. John Dacey: A placebo. Even if they know it, It still helps. Dr. Jack Lloyd: Yeah, it’s awesome that way. Dr. John Dacey: That’s incredible! Dr. Jack Lloyd: iI’s a wonderful tool to use that. Dr. John Dacey: What do you think is going on there? Is it that…? Dr. Jack Lloyd: Belief that it will work. It’s that power. Is the belief that... Dr. John Dacey: Oh, of course. Unintelligible Dr. Jack Lloyd:  ... Thinking ...If someone is taking a sugar pill and the real pill and the individual who’s taking it doesn’t know... Dr. John Dacey: Well if that’s the case…then... Dr. Jack Lloyd: Then the placebo effect might be even stronger. Dr. John Dacey: That’s right. We could, but we’re not surprised about that because they think it may well be the kind of thing, they are looking for the response and they get it, and of course that’s really terrific. I wonder if there are some doctors Who say, “I’m going to give you a tranquilizer.” And it’s really a sugar pill. But it works fine and ... Dr. Jack Lloyd: (laughs) Dr. John Dacey: and I don’t know. Have you ever…? Dr. Jack Lloyd:  No, I’ve never done that, but I have given, I often load up the medicine that I’m prescribing with hope. Dr. John Dacey: Yes. Yes Dr. Jack Lloyd: And so, one might consider that placebo. But I will often say this is a this is a powerful medicine. This is likely to help you. And I think you’re going to find that after such and such minutes you’re going to feel a little bit like a little bit more relaxed. And I will try to point   people in the direction of what I think that they’re expected to feel. And I think that helps the medicine along... Dr. John Dacey: I have to ask this question before we get back to the other types of medications that there are. I went to a doctor once with a very sore back, a lot of back pain. And he said “you know what I would like to tell you is...” And I think he was talking about more about depression. That he thought had something to do with what was going on.And he said “you know, I would like to have a bowl of 50 pills and I’d just say ‘take one, anyone whatever,’ and if it gives you a really bad side effects that you can’t tolerate Or it doesn’t seem to do anything for you, I would say ‘OK, now I can remove that pill plus four others that are just like it in some other ways’. Now I’m down to 45 pills,  And take another one…” Dr. Jack Lloyd: Right. (Laughing)Try this one. Dr. John Dacey: Is it like that way with anxiety? Or can you pretty well tell in advance what’s going to ... what effect it’s going to... because I’ve heard that from a lot of people, about either the side effects are unbearable or there wasn’t much effect from the pill, at least in terms of depression. Dr. Jack Lloyd: Yeah… Dr. John Dacey: Is it the same kind of thing with anxiety or not? Dr. Jack Lloyd: Well depression and anxiety really are siblings. Dr. John Dacey: They really are. 50% of people who have one, have the other. Because anxiety is scary and it’s depressing, and depression is scary, so... Dr. Jack Lloyd: Well we talked about one of the types of medicines used to treat anxiety which are the benzodiazepines. Dr. John Dacey: Yeah that’s right. Dr. Jack Lloyd: The other most common type of medication used to treat anxiety are the anti- depressant class of medicines, the selective serotonin reuptake inhibitors. Dr. John Dacey: The SSRIs Dr. Jack Lloyd: SSRIs; Zoloft, Prozac, Paxil, a host of them.And they, they act differently than the benzodiazepines. They’re more of a in a sense a preventive type of medicine that you need to take daily and for a period of time before they begin to lower the anxiety levels Dr. John Dacey: so, you don’t take them PRN as they say. You don’t take them… You take them on a more orderly or regular basis. Dr. Jack Lloyd:   Right, exactly. Dr. John Dacey: And why do they work better if they’re taken on a more regular basis?   Dr. Jack Lloyd:  Well, really because they don’t work at all if they’re not taking regularly. Dr. John Dacey: Oh , I see. Dr. Jack Lloyd: If you just take it like a benzodiazepine, just once, then you’re really only exposing yourself to the side effects and the risks of the medication. It’s not having, the medicine will not have benefit of just once unless there’s a placebo effect as we talked about earlier. Dr. John Dacey: So someone who carries one around in his wallet for the rare, for the rare opportunity, rare problem that he has with anxiety, is making a mistake? Dr. Jack Lloyd: Well, it ought to be a benzodiazepine as opposed to an SSRI. Dr. John Dacey: It should be. OK. Now I see what you’re saying. That makes good sense to me. And I’ve also heard that Valium and Librium both through the liver. Dr. Jack Lloyd: Diazepam and Ativan which is lorazepam will go, will pass... Dr. John Dacey: ...and Klonopin. Dr. Jack Lloyd: ….will pass through the liver. Dr. John Dacey: They do pass through of the liver. Dr. Jack Lloyd: I think Librium does not. Dr. John Dacey: Oh, then perhaps I’m confused about that. Because I always heard that Valium and Librium do go through the liver, and you could become addicted to them.But a psychiatrist friend of mine once said if you take that whole bottle of Libri...Ativan you’ll just go to sleep. Dr. Jack Lloyd:  Well, this is the, this is the problem with benzodiazepine use is that they are; the benzodiazepines are really quite effective at decreasing anxiety, and people feel it right away. The problem, and the downside and the reason why there’s the need for another medicine like the SSRis which are actually less effective in the moment.The problem with the benzodiazepines is that those  are all potentially habit-forming. Dr. John Dacey: They are because they’re so quick. And that’s what I heard about the really fast one there the Dr. Jack Lloyd:  Xanax? Dr. John Dacey: Xanax. Yes. That Xanax is problematic because it’s so fast acting.That it can easily become addictive. Not necessarily physically addictive, is that correct, but psychologically,? Dr. Jack Lloyd: Well if you take any of the benzodiazepines regularly, not on an as needed basis, you can get tolerant to them. And they begin to work less well and you need to take more. And they really end up going down in a bad direction.. I think. I don’t like prescribing those   medicines on a routine basis.Although in some cases it’s all that works and so that’s what we end up doing. But i think it’s much better to take them on an as needed basis. Dr. John Dacey: So it’s a little bit of an exploration. You really have to try some things out to see what going to happen. And I’ve often heard psychiatrist talk about “well I tried this.That didn’t have any…” And I thought, “ that’s really interesting“ It’s sort of like almost impossible to predict which of the… SSRIs… are you going to have exactly, Are going to really  work the way that you want them to. Dr. Jack Lloyd:  John, I think maybe I should mention a third type of medication which is sometimes very helpful particularly for individuals wiith performance anxiety of any almost any sort. Dr. John Dacey: There is a third category, yes. Dr. Jack Lloyd: And this is a medicine that’s a long-standing medicine used for blood pressure control, propranolol. It’s very interesting. Dr. John Dacey: Really. I have not heard of that. Dr. Jack Lloyd: Yes It’s really interesting. This is a medication that will control physical effects of anxiety. For instance, what it does is that he keeps the heart; this is how it controls blood pressure, it keeps the heart from squeezing very hard and very quickly. It kind of governs the heart from going very hard. Dr. John Dacey: So it keeps your blood… Your heart rate is a little slower. Dr. Jack Lloyd: It helps keeps your heart rate and also the intensity of the squeeze less. It also decreases tremulousness. So people don’t get a shaky. And so it does all these things to the body, peripherally. It doesn’t have much direct affect on the mind. But the mind seems to take a cue from the body. Dr. John Dacey:  It certainly does. Dr. Jack Lloyd: Since the body is not shaking and the hearts not pounding the mind thinks “oh, this is usually a situation in which I’d be anxious, but somehow today I’m not.“And if the body is relaxed the mind will follow. So, sometimes professors who have difficulty with tremulousness as they’re holding their pointer and don’t want to shake, or musicians who are giving a performance. Dr. John Dacey: Could be a violinist. Dr. Jack Lloyd: The violinist doesn’t want to shake. Dr. John Dacey: (Laughing) arpeggios. Dr. Jack Lloyd: They can use this kind of medication, propranolol. Dr. John Dacey: Propranolol   Dr. Jack Lloyd: Propranolol, it’s a beta blocker. Dr. John Dacey: It is a beta blocker. OK and what do you feel about beta blockers in general? Dr. Jack Lloyd: Well, I think they can be very useful for this type of anxiety. As opposed to the benzodiazepines they are not addictive or habit-forming and and they can be very effective. And they don’t have that risk. That’s the real problem with the benzodiazepines; That’s they’re so useful that someone might just want to take them routinely and all the time and then they end up being less effective over the long run. Dr. John Dacey: I was told by a friend of mine, who is a psychiatrist, that I should probably… I was taking one, the smallest dose of lorazepam in the middle of the night. It helped me to go right back to sleep. And otherwise I would lay awake thinking about what I’m writing or whatever. And he said to me “now that you’re as old as you are, you should think about getting off it because it could make you fall. “ Dr. Jack Lloyd: Right. Dr. John Dacey: So, it makes you a little less steady on your feet. What category is that the result of? Is that the whole category or is it just lorazepam? Dr. Jack Lloyd: That’s the benzodiazepines. The whole category. Dr. John Dacey: The whole category, they’re all that way they can make you a little less stable. Dr. Jack Lloyd: Yeah, they also, can, if you take them kind of during the day for instance before a performance or before a lecture, they can decrease your anxiety, but they are also a little bit sedating. So, they may not keep you quite as cognitively sharp as you might want to be as opposed to the beta blockers which don’t affect your cognition really at all. Dr. John Dacey: That is really very interesting. You know our time is just about up here and I try to keep these at the longest to 15 minutes. This has been extremely helpful, and I wonder if maybe sometime I can come back to you again and have you talk some more about this. Dr. Jack Lloyd: Oh, absolutely, John. It’s a pleasure.  I’m happy to talk to you whenever you like. Dr. John Dacey: Well thank you so much I certainly appreciate it. Dr. Jack Lloyd: Thank you, John.