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Dr. Saltzman,

I searched your website previous to sending this email and didn't find anything relating to my specific topic.

I am writing you because I have been struggling with various levels of fear / anxiety for the last 4 years. The first time I noticed a shift in my mental state was probably 4 years ago, when I began feeling "detached" from reality. Over the years I have battled my own thoughts day in and day out. My *most* pervasive fear is a fear of going insane or developing a mental disorder such as schizophrenia. While I am able to write about this fear from a calm and rational perspective right now, I cannot underscore how significantly this affects me on a day to day basis.

At least 20-25 times per day I will be "distracted" by myself. What I mean is, I will detach from whatever I am doing and make note of my mental state. I will suddenly feel uneasy and scared simply because I am aware that I am analyzing my mind, and I feel that doing so is probably a sign of insanity. Lately I have developed an especially scary "symptom" that has only further convinced me I may be losing my mind. I have begun to "over analyze" situations, discussions, and personal relationships to the point of confusion. I cannot simply see or hear something, and let my subconscious handle whatever importance is there. I have begun to think very critically about situations and decisions people make. More often than not, because of the inherent randomness in life, my thinking simply ends in confusion. I believe I shouldn't even be asking many questions in the first place, because they probably have no logical answer. Here is an example:

I will be watching TV and I'll see someone on a reality TV show. I will suddenly wonder what kind of person they are, and why they're on this show? What life events led them to the decision that the show would be a good idea? How is this person relating to other individuals and why is he/she acting the way they are? Am I at all similar to this person? What significance is there in their choice of clothing, slang, etc. WHY CANT I JUST WATCH THIS SHOW :(

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Anyways... I'm sorry this is such a long email. I'll try and wrap it up. Here's some background information about me:

- 22 years old, Engineering Student close to graduation

- Male

- no history of mental illness in the family (except for my aunt who described very similar anxiety symptoms)

- Illicit Drug use: Began smoking weed at the age of 18, nearly every day for 3-4 months. Had my first panic attack while high. Also began drinking alcohol around the age of 18 with friends, often "black-out" drunk. This type of drinking was every weekend for about 3 or 4 months. Since then in college I have "binge drank" many weekends, typical of some college students. I tried ecstasy once 3 years ago and felt nothing.

- Prescription Drug: I saw a doctor 2 years ago for depression/anxiety. I was prescribed Lexapro which I was reluctant to take. I did however take it for 3 months and "think" there was an improvement. I stopped taking the drug because I was unsure if it was helping.

- I started drinking coffee ~around~ the time when this all started. I still drink coffee, but I *have* stopped for a month before and noticed no significant decrease in symptoms

Lastly I must add - While I often FEAR and WORRY about going insane, I am still able to think rationally and that I am thankful for that. However as this anxiety worsens and other symptoms arise, I've decided I am at a breaking point and need help. What's wrong with me? Did I cause this due to adolescent drinking / smoking weed? Will this ever improve? Should I consider another SSRI? Could my ~1-2 cups of coffee per day be CAUSING this?

Any help you can provide is greatly appreciated. And I'm really sorry if this is too long.

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Agateophobia, the fear of insanity or of "losing ones mind," is a surprisingly common complaint. This is not hard to understand. The human mind is a surpassingly complex system which, if focused upon analytically, as you say you have been doing, can easily seem out of control, irrational, or only delicately balanced at best. In fact, the more one looks into it, the stranger our labyrinthine network of perceptions and associations--what we call "myself"--may seem, and some people, noticing this and trying to make sense of it, as you say you have been doing, begin to feel crazy, or at least fear that they may soon fall into "insanity," whatever that is. Indeed, well into the twentieth century, asylums had separate wings for sufferers of agateophobia where they could be treated without having to see people who really were "insane" (quotation marks because "insane" is not a psychiatric term, but a legal and social one). Sometimes agateophobia is called dementophobia or maniaphobia, but by whatever name, the fear of insanity, like other phobias, usually sets off dismaying anxiety reactions such as:

1. Fast breathing.

2. Feelings of dread.

3. Irregular heartbeat.

4. Profuse sweating

5. Shortness of breath.

6. Nausea.

These are all symptoms of panic, and are familiar to those who suffer from panic attacks. However, fear of insanity can be more serious and more debilitating than some other phobias because unlike a panic reaction which is initiated by a specific trigger which can be avoided to some extent (as seeing a spider, for example, triggers arachnophobia), in agateophobia the "trigger" is always present, for fear of insanity is generated in those subject to it simply by the fact of being alive and self-conscious of the workings of ones own mentation. The arachnophobic can deal with that problem fairly well by just avoiding spiders as much as possible. No trigger, no panic. But the person who fears insanity cannot avoid his or her own mind, and so without treatment, there really is no escape from such a fear.

As I have written elsewhere, there is no convincing explanation of the causes of phobia—at least none that convinces me, and so usually I do not recommend depth or analytic psychotherapy as a treatment for phobia, but prefer a treatment plan based on modeling and desensitization, which involves experiencing the fearsome object or situation in the company of the therapist. For example, in the case of arachnophobia, the patient and the therapist together would view spiders, and the therapist would model for the patient a behavior towards spiders which is not phobic, but realistic. Gradually, by means of repeated experiences, the patient would become desensitized to spiders, the fear and accompanying panic reactions would lessen, and might even disappear completely. Often this type of treatment is accompanied by valium or other benzodiazepine medication, or perhaps by an SSRI type of chemical such as the Lexapro you were taking.

Agateophobia, however, is more complicated to treat because the fear reaction is precipitated by a generalized self-conscious awareness of ones own mind, which obviously cannot be avoided in the same way that triggering of many phobias towards outward objects or situations can be avoided simply by staying away from such objects or situations. This is why, in my view, the only viable treatment option in cases such as yours requires a psychotherapy aimed a finding when and how the fear for ones sanity began. Simple reassurance--"You aren't insane, and show no signs of impending insanity"--usually is not enough. The necessary talk therapy might be accompanied by medication, but medication alone is insufficient, as I think you found when taking Lexapro. I would suggest you get into therapy immediately--find the best therapist you can--and stay with it until the problem abates, which it almost certainly will if handled properly by the therapist.

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As for your questions about coffee, alcohol, and other drugs:

1. Coffee is a bad idea for anyone who feels anxious, and I suggest you avoid it completely, Drink decaf if you like.

2. Binge drinking is a bad idea for anyone, but I don't imagine that it would be much of a factor in provoking panic or fears for sanity.

3. Marijuana produces panic or paranoia in some users, and should be avoided by anyone who experiences such states of mind while high on pot. I want to add here that marijuana. like alcohol, seems to be good for many users, and I disagree with those who demonize it as a "dangerous drug."

Judging from your letter, you certainly are not "insane," so I urge you to stop worrying. Just get some therapeutic help with this phobia, and you will be OK.

Be well.

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Dr. Saltzman,

I'm shocked you took the time to read my email! I cannot tell you how incredibly nice it is to read what you've written, because it shows me that there are people who DO understand what is going on in my mind. You have detailed it perfectly, and this gives me much confidence that your prescription of therapy (possibly with medication) will indeed help. I will begin looking for a therapist tonight and will see them as soon as possible. Hopefully someday I will be free of this. Thank you SO much for your detailed response, I appreciate it more than I can explain.

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