Question: I would like to get your take as a psychiatrist on what I wrote to a cardiologist about my high blood pressure, anxiety attacks and difficulty concentrating:

Many Thanks

Good day,
I would like to give a fair amount (sorry) of background before I ask my questions:

A lot of this probably seems psychological in nature but my cardio health is what I am concerned about here:

I've always been borderline hypertensive - BP hovering between 120/80 to 130/90. This was discovered at a specialist for nerves as I had damaged my Ulner never (irrelevant). However this doctor for some reason asked if I was depressed and when I realised I was, he prescribed Prozac for me (2008 – I was 20. I tried this for about a month but I was having difficulty concentrating after taking it.

After seeing another doctor and describing the problem and wanting his advice on if I should discontinue the drug or if there was possibly something similar he could help me with. To my surprise he offered Ritalin, something I thought was only for kids with ADD.

After taking the Ritalin I realised how obvious the changes it makes are - I could focus on something - a lot better than before I started taking the Prozac. On top of that it actually sort of helped motivate me to do my chores and homework. I've always never been able to finish doing something but on Ritalin it was easy. (I still think this is a character flaw which was just run over by the methylphenidate).
The fact here was that I was studying engineering and being able to focus as well as everyone else was a huge necessity. From then on I felt no depression and didn't see the need for the Prozac so I stopped taking it (was on it for a total of about 3 months).

Beginning of 2011 (I would be 23) I had what I later found to be a Panic Attack. Like many who experience it for the first time I assumed I was having a heart attack. At the time of this however I was also taking Ritalin which to be effective for me needed to be a somewhat high dose of 40mg split up through the day. That particular day I was pushing it a bit hard and took and extra 10mg pill in the evening to try stay clear headed while making a presentation. Then it hit me, a wave of adrenaline and a heart which was racing faster than mercialago. I was convinced it was going to beat "overload" and that would be it. I think mine was worse, as the Ritalin allowed to to focus hard on the panic attack and also giving thoughts like "It's the ritalin which has done this".

Eventually after an EKG (normal) and waiting for my BP to drop, the panic attack subsided. I was monitored in the ER for a while before I was let go.
During that panic attack episode my blood pressure was as high as 190/100 so the doctor gave me something to bring the blood pressure down. And before he released me put me on 5mg of amlodipine.

After such a fright and suddenly being put on high BP meds, I made an appointment with a cardiologist. The cardiologist said that the amlodipine would give me low blood pressure if I didn’t need it so kept me on it (My BP was then 130/80). He did a few blood test including cholesterol and whatever you analyse urine for indicating that they were all fine.

I also went for an echo which indicated my heart itself was also fine. He was particularly obsessed with the idea that I had a pheochromocytoma and checked my ephedrine as well as norephedrine in my urine. When that came back normal he had me on a CT machine with an Iodine solution to rule it out completely.
After that he declared my problem essential hypertension with panic attacks.
Since then I have been taking the 5mg amlodipine once a day and was still suffering from occasional panic attacks.

I eventually had a doctor prescribe a benzo (Ativan) to take during the attacks as they were debilitating (especially when flying). This worked relatively well as I could just take a couple of them when the attack happened (say once a month) (Is this not better than SSRI? I can't get addicted to the stuff which is what I understand is the concern as he only needs to give me 4 a month or somethign)
.
My doctor then decided (2012) that I should give an SSRI a shot to manage my anxiety rather than relying on the Ativan. I took his advice and began on 10mg Lexamil (escitalopram). I was on this up until recently where I decided that I need to deal with the attacks without medication, so tapered down and eventually stopped. This decision was based on wanting to stop taking unnecessary medication as well as the side effects of apathy and sexual dysfunction.
The withdrawal here has been tough with now having no libido and a fair number of brain zaps. I’m also having trouble staying awake. (Any tips for the brain zaps??)
Before stopping the SSRI my blood pressure was averaging 145/80 which I still wasn’t happy with but my doctor insisted was fine. After stopping the SSRI I have had a few panic attacks and my blood pressure is creeping up to a 160/90. After having a few chest pains I went to my doctor and asked him to check my BP and add another medication which he did so – 4mg Prexum (which is an ACE inhibitor).
This seems to be doing a gradual job of returning my blood pressure to the ideal range (every time it’s taken the result is better – its still not perfect). I have notice that it increased my resting heart rate however.
When I was taking no medication my resting heart rate was ~70. Once I started taking amlodipine it dropped to 60. The ACE inhibitor seems to have increased it to ~ 80 to 90 – is this normal?
I’d like to also mention that before all this happened I was relatively fit and weight approximately 90kg at 6’3”. Over time (but especially after the first panic attack and the following year) I put on and extra 30kg and now weigh (120kg) which I understand makes me very overweight. I have tried to lost this weight through diet and light exercise (my doctors aren’t keen on my doing anything that gets my heart going to wild) with no success.
So finally my questions are as follows: Was the procedure correct in determining I definitely have essential hypertension (which if I didn’t have then has definitely set in now) my doctor seemed so dead set that it was a pheochromocytoma that I’m sure he ignored a lot of other possible causes – for instance would an underactive thyroid not cause my weight gain as well as explain the hypertension?
What tests (other than having my BP taken regularly) should I possibly undergo (eg, should I be having my kidneys checked annually or anything like that)? The reason I ask is because although my medical aid has those benefits outlined in my “care programme” I am never requested to do them.
My waist size is 42” now (used to be 36”), could all the fat I’m carrying cause an insulin resistance making it harder for me to lose weight? Is it reasonable that the doctors won’t let me go to gym and really get my heart going? (I’m sure this would have the most benefit. Walking my dog for half an hour a day may be good for the mind and soul but I can’t see it making my heart that much stronger…)
Lastly, with regards to the Ritalin which helped me so much to concentrate is this drug a “no no” for me? (I did stop taking it after the panic attack for fear of another panic attack)
I have told you a lot and asked a lot of questions, my main question however is really: Should I go to another specialist to reassess my situation rather than accepting the hypertension has no root cause – was adequate medical reasoning done?
Last question out of interest: why would I not have been put straight onto a beta blocker since this can also help with anxiety? Also, why would a calcium channel inhib be first choice over diuretic or ACE inhibitor?

Thank you in advance!
XXXXXX

Good day Dr Shah,

Thank you for your excellent reply. I started taking 10mg escitalopram last year for anxiety/panic attacks which worked pretty well. I however stopped taking them because I wanted to get off any unnecessary medication as well as the fact that it affected my sexual function, concentration and made me somewhat apathetic. I wheened down, but have been off for completely for about 2 weeks now.

On a scale to ten with regards to depression and anxiety I probably sit at about 4 which I consider as manageable.

I am getting better at dealing with panic attacks normally to the point where adrenaline doesn't kick in. If I get the adrenaline surge I take 2mg of ativan to calm down.

The problem with having panic attacks when I also have hypertension is I can't shake the feeling that my heart is the cause. Without the chronic illness I don't think I would have a problem with panic attacks as I could then be certain of what it is which would instantly stop it from being terrifying.

Luckily though, I rarely get panic attacks these days, maybe two a month, sometimes none for 2 months.

On a seperate note, after stopping the escitalopram I have been having the "brain shocks" or "zaps" that people talk about - a shock feeling especially when moving your eyes. Is there any way to lessen this until the "discontinuation sydrome" wears off?

Secondly not being able to again use ritalin, is there anything that can focus my thoughts or at least make them less scattered and make me more motivated? Not necessarily drugs -foods to avoid, food to use more of, obviously exercise which I do do etc.

Thank you in advanced,
XXXXXX