The Invasion of Tibet by China (1948)

By Tenzin Gyatso (HH Dalai Lama XIV)

In 1948, while I was still a student, the government heard there were Chinese Communist spies in the country. They had come to find out how strong our army was, and whether we were receiving military aid from any foreign power.

They cannot have found it very hard to discover the facts they wanted. Far from receiving military aid, we had only six Europeans in Tibet, so far as I am aware. Three of them, one missionary and two radio operators, were British. The other three were two Austrians and one White Russian, all of whom had been refugees from British internment camps in India during the war. None of them had anything to do with military matters.

As for the army, its strength was 8,500 officers and men.

There were more than enough rifles for them, but only about fifty pieces of artillery of various kinds—250 mortars and about 200 machine guns. The purpose of the army, as I have said, was to stop unauthorized travelers and act as a police force. It was quite inadequate to fight a war.

Soon after this first sign of impending trouble, more serious news was heard from the eastern parts of Tibet. The governor of eastern Tibet, whose name was Lhalu, was stationed in the town of Chamdo. close to the frontier, and he had one of the British radio operators with him, the other being in Lhasa.

Soon coded signals began to come in from the governor reporting that the Chinese were moving up strong forces and massing them along our eastern border. It was obvious that they intended either to attack or intimidate us.

As soon as this alarming information reached the Cabinet, they convened a meeting of the National Assembly. Evidently, Tibet was facing a far more serious threat from the east than it had ever faced in all the centuries before. Communism had conquered China, and given the country a military strength it had not had for many generations. So the threat to us was not only more powerful, it was also different in its very nature.

In past centuries, there had always been some religious sympathy between our countries, but now we were threatened not only with military domination, but also with the domination of an alien materialistic creed which, so far as any of us understood it in Tibet, seemed totally abhorrent.

The Assembly agreed unanimously that Tibet had neither the material resources nor the arms or men to defend its integrity against a serious attack, and so they decided to make an urgent appeal to other countries, in the hope of persuading the Chinese to halt before it was too late. Four delegations were appointed to visit Britain, the United States of America, India, and Nepal to ask for help. Before the delegations left Lhasa, telegrams were sent to these four governments, to tell them of the apparent threat to our independence, and of our government’s wish to send the delegations.

The replies to these telegrams were terribly disheartening.

The British government expressed their deepest sympathy for the people of Tibet, and regretted that owing to Tibet’s geographical position, since India had been granted independence, they could not offer help. The government of the United States also replied in the same sense and declined to receive our delegation. The Indian government also made it clear that they would not give us military help, and advised us not to offer any armed resistance, but to open negotiations for a peaceful settlement on the basis of the Simla agreement of 1914. So we learned that in military matters we were alone.

It happened that Lhalu’s term as governor of eastern Tibet was over, and at this crucial moment he had to be replaced by another official, Ngabo Ngawang Jigme. Ngabo left Lhasa for the eastern province, and as the situation was so delicate the Cabinet told Lhalu to stay at his post and help his successor, sharing the responsibility with him. But Ngabo soon said he was ready to take the full responsibility, and so Lhalu was recalled. Very soon afterwards, without any formal warning, the armies of Communist China invaded Tibet.

For a short time, and in a few places, the Tibetan army fought them back with some success, aided by volunteers from the local race of Khampas. But our army was hopelessly outnumbered and outmatched. The change of governor had confused the administration, and Ngabo began to move his headquarters back from Chamdo toward the west. When the Tibetan troops, retreating from the frontier, arrived at Chamdo, they found he had already abandoned the place, and so they had to bum the armory and ammunition store and join him in further retreat.

But retreat was of no avail. Ngabo found his line of communication cut, and himself outflanked by more mobile Chinese forces, and he and many Tibetan troops were forced to surrender.

The Chamdo radio transmitter and its British operator were also captured, and so for a time no news of what was happening reached the government. And then two officials arrived in Lhasa, sent by Ngabo with the Chinese commander’s permission, to tell the Cabinet that he was a prisoner, to ask for authority to negotiate terms of peace, and also to give the Cabinet an assurance from the Chinese commander that China would not extend her rule over more Tibetan territory.

While these disasters were taking place in the distant eastern marches of Tibet, the government in Lhasa was consulting the oracles and the high lamas, and guided by their advice, the Cabinet came to see me with the solemn request that I should take over the responsibility of government.

This filled me with anxiety. I was only sixteen. I was far from having finished my religious education. I knew nothing about the world and had no experience of politics, and yet I was old enough to know how ignorant I was and how much I had still to learn. I protested at first that I was too young, for eighteen was the accepted age for a Dalai Lama to take over active control from his Regent. Yet I understood very well why the oracles and lamas had caused the request to be made. The long years of Regency after the death of each Dalai Lama were an inevitable weakness in our system of government. During my own minority, there had been dissensions between separate factions in our government, and the administration of the country had deteriorated. We had reached a state in which most people were anxious to avoid responsibility, rather than accept it. Yet now, under the threat of invasion, we were more in need of unity than ever before, and I, as Dalai Lama, was the only person whom everybody in the country would unanimously follow.

I hesitated—but then the National Assembly met, and added its plea to the Cabinet’s, and I saw that at such a serious moment in our history, I could not refuse my responsibilities.

I had to shoulder them, put my boyhood behind me, and immediately prepare myself to lead my country, as well as I was able, against the vast power of Communist China.

So I accepted, with trepidation, and full powers were conferred on me with traditional celebration. In my name a general amnesty was proclaimed, and every convict in prison in Tibet was given freedom.

At just about that time, my eldest brother arrived in Lhasa from the east. He had returned, as Abbot, to the monastery of Kumbum, near the village where we had been born. In this Chinese-controlled territory, while he was Abbot, he had been witness to the downfall of the governor under Chiang Kai-shek’s regime, and the advance of the armies of the new Communist government. He had seen a year of confusion, oppression and tenor, in which the Chinese Communists had claimed that they had come to protect the people, and had promised them freedom to pursue their own religion, and yet at the same time had begun a systematic undermining and destruction of religious life. He himself had been kept under a strict guard and subjected to an almost continuous course of Communist argument, until finally, the Chinese had explained to him that they intended to reclaim the whole of Tibet, which they still insisted was a part of China, and to convert it all to communism. Then they tried to persuade him to go to Lhasa as their emissary, and to persuade me and my government to agree to their domination. They promised to make him governor of Tibet if he succeeded. Of course, he refused to do anything of the kind. But at last he saw that his life would he in danger if he continued to refuse, and he also saw that he had a duty to warn me of the Chinese plans. So he pretended to agree, and thus managed to escape from Chinese supervision and reached Lhasa with a detailed warning of the dangers we were facing.

By then, the Cabinet had taken steps to put our case before the United Nations. While we were waiting for it to be considered, it seemed to me that the first of my duties must be to follow the advice of the Indian government, and try to reach an agreement with the Chinese before more harm was done. So I wrote to the Chinese government, through the commander of the army which was occupying Chamdo.

I said that during my minority relations had been strained between our countries, but that now I had taken over full responsibility and sincerely wanted to restore the friendship which had existed in the past. I pleaded with them to return the Tibetans who had been captured by their array, and to withdraw from the part of Tibet which they had occupied by force.

At about the same time, my Cabinet convened the National Assembly again, in order to test public opinion about the threat which confronted us. One result of this Assembly was very unwelcome in my eyes. The members pointed out that the Chinese armies might advance to Lhasa and capture it at any moment, and they decided that I should be requested to leave the city and go to the town of Yatung, near the border of India, so that I would be out of any personal danger. I did not want to go at all. I wanted to stay where I was and do what I could to help my people. But the Cabinet also urged me to go, and in the end I had to give in. This conflict was often to occur again, as I shall tell. As a young and able-bodied man, my instinct was to share whatever risks my people were undergoing, but to Tibetans, the person of the Dalai Lama is supremely precious, and whenever the conflict arose I had to allow my people to take far more care of me than I would have thought of taking of myself.

So I prepared to go. Before I left, I appointed two Prime Ministers—a high monk official called Losang Tashi, and a veteran and experienced lay administrator called Lukhangwa.

I gave them full authority and made them jointly responsible, and told them they need only refer to me in matters of the very highest importance.

It was in the minds of my ministers then that if the worst came to the worst I might have to go to India for refuge, as my predecessor had done when the Chinese invaded us forty years before. I was advised to send a small part of my treasure there. So some gold dust and bars of silver were taken from Lhasa and put in a vault across the border in Sikkim, and there they lay for the next nine years. In the end, we needed them badly.

The next grievous blow to us was the news that the General Assembly of the United Nations had decided not to consider the question of Tibet. This filled us with consternation.

We had put our faith in the United Nations as a source of justice, and we were astonished to hear that it was on British initiative that the question had been shelved. We had had very friendly relations with the British for a long time, and had benefited greatly from the wisdom and experience of many distinguished servants of the British Crown; and it was Britain who had implied her recognition of our independence by concluding treaties with us as a sovereign power. Yet now, the British representative said the legal position of Tibet was not very clear, and he seemed to suggest that even now, after thirty-eight years without any Chinese in our country, we might still be legally subject to China’s suzerainty. The attitude of the Indian representative was equally disappointing.

He said he was certain a peaceful settlement could be made and Tibet’s autonomy could be safeguarded, and that the best way to ensure this was to abandon the idea of discussing the matter in the General Assembly.

This was a worse disappointment than the earlier news that nobody would offer us any military help. Now our friends would not even help us to present our plea for justice. We felt abandoned to the hordes of the Chinese army.

Of course, looking back at our history now, it is easy to see how our own policies had helped to put us in this desperate position. When we won our complete independence, in 1912, we were quite content to retire into isolation. It never occurred to us that our independence, so obvious a fact to us, needed any legal proof to the outside world. If only we had applied to join the League of Nations or the United Nations, or even appointed ambassadors to a few of the leading powers, before our crisis came, I am sure these signs of sovereignty would have been accepted without any question, and the plain justice of our cause would not have been clouded, as it was, by subtle legal discussions based on ancient treaties which had been made under quite different circumstances. 

Now we had to learn the bitter lesson that the world has grown too small for any people to live in harmless isolation.

The only thing we could do was pursue our negotiations as best we could. We decided to give Ngabo the authority he had requested. One of the two officials he had sent to Lhasa took a message from myself and my Cabinet, in which we told Ngabo he should open negotiations on the firm condition that the Chinese armies would not advance any further into Tibet. We had understood that the negotiations would be held either in Lhasa or in Chamdo, where the Chinese armies were stationed, but the Chinese ambassador in India proposed that our delegation should go to Peking. I appointed four more officials as assistants to Ngabo, and they all arrived in Peking at the beginning of 1951.

It was not until they returned to Lhasa, long afterwards, that we heard exactly what had happened to them. According to the report which they submitted then, the Chinese foreign minister Chou En-lai had invited them all to a party when they arrived, and formally introduced them to the Chinese representatives. But as soon as the first meeting began, the chief Chinese representative produced a draft agreement containing ten articles ready-made. This was discussed for several days. Our delegation argued that Tibet was an independent state, and produced all the evidence to support their argument, but the Chinese would not accept it. Ultimately, the Chinese drafted a revised agreement, with seventeen articles.

This was presented as an ultimatum. Our delegates were not allowed to make any alterations or suggestions. They were insulted and abused and threatened with personal violence, and with further military action against the people of Tibet, and they were not allowed to refer to me or my government for further instructions.

This draft agreement was based on the assumption that Tibet was part of China. That was simply untrue, and it could not possibly have been accepted by our delegation without reference to me and my government, except under duress.

But Ngabo had been a prisoner of the Chinese for a long time, and the other delegates were also virtual prisoners. At last, isolated from any advice, they yielded to compulsion and signed the document. They still refused to affix the seals which were needed to validate it. But the Chinese forged duplicate Tibetan seals in Pelting, and forced our delegation to seal the document with them.

Neither I nor my government were told that an agreement had been signed. We first came to know of it from a broadcast which Ngabo made on Peking Radio. It was a terrible shock when we heard the terms of it. We were appalled at the mixture of Communist cliches, vainglorious assertions which were completely false, and bold statements which were only partly true. And the terms were far worse and more oppressive than anything we had imagined.

The preamble said that “over the last one hundred years or more,” imperialist forces had penetrated into China and Tibet and “ carried out all kinds of deceptions and provocations,” and that “under such conditions, the Tibetan nationality and people were plunged into the depths of enslavement and suffering.”

This was pure nonsense. It admitted that the Chinese government had ordered the “People’s Liberation Army” to march into Tibet. Among the reasons given were that the influence of aggressive imperialist forces in Tibet might be successfully eliminated, and that the Tibetan people might be freed and return to the “ big family” of the People’s Republic of China.

That was also the subject of Clause One of the agreement: “The Tibetan people shall unite and drive out imperialist aggressive forces from Tibet, The Tibetan people shall return to the big family of the Motherland~the People’s Republic of China.” Reading this, we reflected bitterly that there had been no foreign forces whatever in Tibet since we drove out the last of the Chinese forces in 1912. Clause Two provided that “the local government of Tibet shall actively assist the People’s Liberation Army to enter Tibet and consolidate the national defense.” This in itself went beyond the specific limits we had placed on Ngabo’s authority. Clause Eight provided for the absorption of the Tibetan army into the Chinese army. Clause Fourteen deprived Tibet of all authority in external affairs.

In between these clauses which no Tibetan would ever willingly accept were others in which the Chinese made many promises: not to alter the existing political system in Tibet; not to alter the status, functions, and powers of the Dalai Lama; to respect the religious beliefs, customs, and habits of the Tibetan people and protect the monasteries; to develop agriculture and improve the people’s standard of living; and not to compel the people to accept reforms. But these promises were small comfort beside the fact that we were expected to hand ourselves and our country over to China and cease to exist as a nation. Yet we were helpless. Without friends there was nothing we could do but acquiesce, submit to the Chinese dictates in spite of our strong opposition, and swallow our resentment. We could only hope that the Chinese would keep their side of this forced, one-sided bargain.

Soon after the agreement was signed, our delegation sent a telegram to tell me that the Chinese government had appointed a general called Chang Chin-wu as their representative in Lhasa. He was coming via India, instead of the long overland route through eastern Tibet. Yatung, where I was Staying, was just inside the Tibetan border on the main route from India to Lhasa, and so it was clear that I would have to meet him as soon as he set foot in our country.

I was not looking forward to it. I had never seen a Chinese general, and it was a rather forbidding prospect. Nobody could know how he would behave—whether he would be sympathetic, or arrive as a conqueror. Some of my officials, ever since the agreement had been signed, had thought I should go to India for safety before it was too late, and it had only been after some argument that everyone agreed I should wait until the general came, and see what his attitude was before we decided.

Some of my senior officials met him in Yatung. I was staying in a nearby monastery. There was a beautiful pavilion on the roof of the monastery, and we had arranged that I should meet him there. He insisted in Yatung that he and I should meet on equal terms, and we got over any difficulties of protocol by providing chairs of equal merit for everybody, instead of the cushions which were the custom in Tibet.

When the time came, I was peering out of a window to see what he looked like. I do not know exactly what I expected, but what I saw was three men in gray suits and peaked caps who looked extremely drab and insignificant among the splendid figures of my officials in their red and golden robes. Had I but known, the drabness was the state to which China was to reduce us all before the end, and the insignificance was certainly an illusion.

But when the procession had reached the monastery and climbed up to my pavilion, the general turned out to be friendly and informal. The other two gray-coated men were his aide and his interpreter. He gave me a letter from Mao Tse-tung, which more or less repeated the first clause of the agreement by welcoming us back to the great motherland, a phrase I had already come to detest. Then he said the same thing all over again through his interpreter. I gave him tea, and an observer who had not known what was in our hearts might have thought the whole meeting was perfectly cordial.

His arrival in Lhasa was not so successful. I sent instructions to the Cabinet that he would have to be properly received and treated as a guest of the government. So two members of the Cabinet went out beyond the Norbulingka to meet him with suitable ceremony, and on the following day the Prime Ministers and the Cabinet gave a dinner party in his honor.

But that did not satisfy him. He complained that he had not been given the reception due to the representative of a friendly power. So we were made to see that he was not quite as wholeheartedly friendly as he looked.

However, under these circumstances I was compelled to go back to the Norbulingka, and there I witnessed the next extensions of Chinese military rule.

Two months after the arrival of General Chang Chin-wu, three thousand officers and men of the Chinese army marched into Lhasa. Soon after that, another detachment of about the same size arrived there, under two more Generals, Tang Kohwa and Tang Kuan-sen. The people of Lhasa watched them come with the apparent indifference which I believe is usually shown at first by ordinary people in the face of such national humiliation. At first there was no contact between the Chinese commanders and our government except when the Chinese demanded supplies and accommodations. But these demands soon began to cause havoc in the city.

The Chinese requisitioned houses, and bought or rented others; and beyond the Norbulingka, in the pleasant land beside the river which had always been the favorite place for summer picnics, they took possession of an enormous area for a camp. They demanded a loan of 2,000 tons of barley. This huge amount could not be met from the state granaries at that time because of heavy expenditure, and the government had to borrow from monasteries and private owners. Other kinds of food were also demanded, and the humble resources of the city began to be strained, and prices began to rise. And then another general, and another eight to ten thousand men appeared.

They seized a further area for camps, and under the burden of their extra demands for food our simple economy broke down. They had brought nothing with them, and all expected to be fed from our meager sources of supply. 
The prices of food-grains suddenly soared up about ten times; of butter, nine times; and of goods in general, two or three times.
For the first time that could be remembered, the people of Lhasa were reduced to the edge of famine.

Their resentment grew against the Chinese army, and children began to go about shouting slogans and throwing stones at the Chinese soldiers—a sign that the adults were barely keeping their own bitterness in check. Complaints began to pour in to the offices of the Cabinet, but nothing could be done. The Chinese armies had come to stay, and they would not accept any suggestions, or help our government in any way at all. On the contrary, their demands went on increasing every day. Soon they demanded another 2,000 tons of barley, and it had to be found.

It was called a loan, and the Generals promised to repay it by investing its value in the development of industries in Tibet, but that promise was never fulfilled.

While conditions were going from bad to worse for the people of Lhasa, high Chinese officials were constantly arriving in the city, and a long series of meetings was convened by General Chang Chin-wu. Members of my Cabinet were requested to attend them, and it fell mostly to Lukhangwa, as my lay Prime Minister, to try to find a balance between the essential needs of the people and the requests of the invaders.

He had the courage to tell the Chinese plainly that Tibetans were a humble religious community, whose production had always been just sufficient for their own needs. There was very little surplus—perhaps enough to support the Chinese armies for another month or two, but no more—and a surplus could not be created suddenly. There was no possible reason, he pointed out, for keeping such enormous forces in Lhasa. If they were needed to defend the country, they should be sent to the frontiers, and only officials, with a reasonable escort, should remain in the city.

The Chinese answers were very polite at first. General Chang Chin-wu said that our government had signed the agreement that Chinese forces should be stationed in Tibet, and we were therefore obliged to provide them with accommodation and supplies. He said that they had only come to help Tibet to develop her resources and to protect her against imperialist domination, and that they would go back to China as soon as Tibet was able to administer her own affairs and protect her own frontiers. “When you can stand on your own feet,” he said, “we will not stay here even if you ask us to.”

Lukhangwa forebore to point out that the only people who had ever threatened our frontiers were the Chinese themselves, and that we had administered our own affairs for centuries.

But at another meeting he told the General that in spite of his assurance that the Chinese had come to help Tibet, they had so far done nothing at all to help. On the contrary, their presence was a serious hardship, and most of their actions were bound to add to the anger and resentment of the people. One action he mentioned, more important to us than it may appear, was the burning of the bones of dead animals within the Holy City of Lhasa: this was very offensive to the religious feelings of Tibetans, and had caused a great deal of hostile comment.

But rather than discuss the causes of the people's obvious hostility, Chang Chin-wu expected our government to put an end to it. Among other complaints, he said that people were going about in the streets of Lhasa singing songs in disparagement of the Chinese. He suggested that our government should issue a declaration calling for friendly relations with the Chinese, and he wrote a draft and handed it to Lukhangwa.

When Lukhangwa read it, he found it was an order putting a ban on singing in the streets; and of course, rather than issue anything so ludicrous, he rewrote it in a somewhat more dignified form. I do not think the Chinese ever forgave him for that.

Throughout the series of meetings, Chinese complaints grew more forceful Although they were trying to make it clear to the people, they said, that they had only come to Tibet to help the Tibetans, the behavior of the people was deteriorating every day. They said that public meetings were being held to criticize the Chinese authorities, which no doubt was true, and they requested the Cabinet to put a ban on meetings. That was done, but the people of Lhasa immediately began to put up posters and circulate pamphlets in the city, saying that they were facing starvation and asking the Chinese to go back to China. And in spite of the ban, a large meeting was held at which a memorandum was written setting forth the people’s grievances, pointing out that conditions in Lhasa were very serious, and asking that the Chinese troops should be withdrawn and only a few officials be left in the city. One copy of this memorandum was sent to the Chinese generals, and one to the Cabinet. The Chinese said the document was due to the incitement of imperialists, and began to hint that there were certain people in Lhasa who were deliberately creating trouble. On one occasion, Chang Chin-wu came to the Cabinet office and angrily accused the two Prime Ministers of being the leaders of a conspiracy to violate the agreement which had been signed in Peking.

The pattern of these events will be distressingly familiar in any country which has been the victim of invasion. The invaders had arrived believing—with how much sincerity one cannot tell—that they had come as benefactors. They seemed to be surprised to find that the invaded people did not want their benefactions in the least. As popular resentment grew against them, they did not try to allay it by withdrawing, or even by making concessions to the people’s wishes. They tried to repress it by ever-increasing force, and rather than blame themselves, they searched for scapegoats. In Tibet, the first scapegoats were purely imaginary “imperialists,” and my Prime Minister, Lukhangwa. But this course of action can never lead to anything but disaster. Popular resentment can never be repressed for more than a short time by force, because forceful repression always makes it stronger. This lesson, which one would have thought so obvious, has yet to be learned by the Chinese.

All through this period of mounting tension, the Chinese insisted from time to time on by-passing my Cabinet and the usual agencies of the government and making direct approaches to me. At the beginning, my two Prime Ministers 94 my land and my people had always been present to advise me when I met the Chinese generals, but at one meeting Chang Chin-wu entirely lost his temper at something my monk Prime Minister Losang Tashi said. It was rather a shock to me at that age. I had never seen a grown man behave like that before. But young though I was, it was I who had to intervene to calm him down; and it was after that that they started demanding to see me alone.

Whenever they came to see me, they brought an escort of guards who were stationed outside my room during the interview. This display of bad manners, if it was nothing more, intensely offended the Tibetans who knew of it.

The final crisis between the Chinese and Lukhangwa arose over a matter which had nothing to do with the sufferings of Lhasa. An especially large meeting was called by Chang Chinwu.

My Prime Ministers and Cabinet were summoned, and all the highest Chinese officials, both civil and military, were present. The General announced that the time had come for Tibetan troops to be absorbed in the “ People’s Liberation Army” under the terms of the Seventeen-Point Agreement, and he proposed that as a first step a number of young Tibetan soldiers should be chosen for training at the Chinese army headquarters in Lhasa. Then, he said, they could go hack to their regiments and train the others.

At this, Lukhangwa spoke out more strongly than he ever had before. He said the suggestion was neither necessary nor acceptable. It was absurd to refer to the terms of the Seventeen-Point Agreement. Our people did not accept the agreement and the Chinese themselves had repeatedly broken the terms of it. Their army was still in occupation of eastern Tibet; the area had not been returned to the government of Tibet, as it should have been. The attack on Tibet was totally unjustifiable: the Chinese army had forcibly entered Tibetan territory while peaceful negotiations were actually going on.

As for absorbing Tibetan troops in the Chinese army, the agreement had said the Chinese government would not compel Tibetans to accept reforms. This was a reform which the people of Tibet would resent very strongly, and he as Prime Minister would not approve it.

The Chinese generals replied softly that the matter, after all, was not of very great importance, and they could not see why the Tibetan government should object to it. Then they slightly changed their ground. They proposed that the Tibetan flag should be hauled down on all Tibetan barracks, and the Chinese flag should be hoisted there instead. Lukhangwa said that if Chinese flags were hoisted on the barracks, the soldiers would certainly pull them down again, which would be embarrassing for the Chinese. In the course of this argument about the flags, Lukhangwa said outright that it was absurd for the Chinese, after violating the integrity of Tibet, to ask Tibetans to have friendly relations with them. “If you hit a man on the head and break his skull,” he said, “you can hardly expect him to be friendly.” This thoroughly angered the Chinese. They closed the meeting, and proposed to hold another one three days later.

When all the representatives met again, another general, Fan Ming, acted as the Chinese spokesman. He asked Lukhangwa whether he had not been mistaken in his statements at the earlier meeting, no doubt expecting an apology. But Lukhangwa, of course, stood by all that he had said. It was his duty, he added, to explain the situation frankly, because rumors had spread throughout Tibet of Chinese oppressions in the eastern provinces, and feelings were running high. If the Chinese proposals about the army were accepted, the reaction would certainly be violent, not only from the army but from the Tibetan people in general.

At this reply, General Fan Ming lost his temper, and accused Lukhangwa of having clandestine relations with foreign imperialist powers, and shouted that he would request me to dismiss Lukhangwa from his office. Lukhangwa told him that of course if I, the Dalai Lama, were satisfied that he had done any wrong, he would not only give up his office but also his life. Then General Chang Chin-wu intervened to say that Fan Ming was mistaken, and to ask our representatives not to take what he had said too seriously. The meeting broke up again without agreement.

Nevertheless, in spite of the soothing intervention of Chang Chin-wu, I received a written report soon after this meeting, in which the Chinese insisted that Lukhangwa did not want to improve relations between Tibet and China, and suggested that he should be removed from office. They made the same demand to the Cabinet, and the Cabinet also expressed the opinion to me that it would be better if both Prime Ministers were asked to resign. So the crisis was brought to a head, and I was faced with a very difficult decision. I greatly admired Lukhangwa’s courage in standing up to the Chinese, but now I had to decide whether to let him continue, or whether to bow yet again to a Chinese demand.

There were two considerations: Lukhangwa’s personal safety, and the future of our country as a whole. On the first, I had no doubt. Lukhangwa had already put his own life in danger. If I refused to relieve him of office, there was every chance that the Chinese would get rid of him in ways of their own.

On the more general question, my views had evolved throughout this long period of tension. I had still had no theoretical training in the intricacies of international politics.

I could only apply my religious training to these problems, aided I trust by common sense. But religious training, I believed and still believe, was a very reliable guide.

I reasoned that if we continued to oppose and anger the Chinese authorities, it could only lead us further along the vicious circle of repression and popular resentment. In the end, it was certain to lead to outbreaks of physical violence.

Yet violence was useless; we could not possibly get rid of the Chinese by any violent means. They would always win if we fought them, and our own unarmed and unorganized people would be the victims. Our only hope was to persuade the Chinese peaceably to fulfill the promises they had made in their agreement. Nonviolence was the only course which might win us back a degree of freedom in the end, perhaps after years of patience. That meant cooperation whenever it was possible, and passive resistance whenever it was not.

And violent opposition was not only unpractical, it was also unethical. Nonviolence was the only moral course. This was not only my own profound belief, it was also clearly in accordance with the teaching of Lord Buddha, and as the religious leader of Tibet I was bound to uphold it. We might be humiliated, and our most cherished inheritances might seem to be lost for a period, but if so, humility must be our portion, I was certain of that.

So I sadly accepted the Cabinet’s recommendation and asked the Prime Ministers to resign. They came to call on me, and I gave them scarves and gifts and my photograph. I felt that they understood my position very well. I did not appoint any successors. It was no use having Prime Ministers if they were merely to he scapegoats for the Chinese. It was better that I should accept the responsibilities myself, because my position was unassailable in the eyes of all Tibetans. Later, Lukhangwa went to India and became my Prime Minister in exile until his advancing age made him retire, and he is still my trusted advisor. But it grieves me to say that in 1959, after I left Tibet myself, Losang Tashi, the monk Prime Minister, was thrown into prison by the Chinese and has not been released.

When that incident came to an end, the attitude of the Chinese became more friendly and conciliatory. They suggested to the Cabinet that a delegation of Tibetan officials, monks, merchants, and other people should be sent to China to see for themselves, as they put it, that the people of China had absolute freedom to practice their religion. We accepted this suggestion, and chose members for a delegation.
They were taken on a conducted tour of China, and when they came back they submitted a report which everybody knew had been written under Chinese orders.

And then I myself was invited by the Chinese government to visit China. Although there had certainly been a slight improvement in relations between my government and the Chinese authorities in Tibet, I was still greatly disappointed at their complete disregard for the interests and welfare of our people. I thought I ought to meet the highest authorities in China, and try to persuade them to carry out the promises they had made in the agreement they had forced on us. So I decided to go.
Labels: Indian Politics,Politics,Behavioral Science,Biography,Book Summary,Emotional Intelligence,Psychology,Technology,

2011-Jan-07 (Gareema Sethi's threat abt internals, lunch table issue by aunt)

Index of Journals

7 January 2011, Friday

I always had this fear that Gareema ma’am would be nearly failing me in internals so I was little worried about the DS theory exam. Because less marks in internals put a direct pressure on the student to cover up from theory exam. And I guess that helped, because I’m worried about math, analog-electronics, and FOCS (fundamentals of computer science) that’s when I got 15 and 21 out of 25 in internals in Math and A.E.

I had come to college on my regular time, 9 AM. I entered the college gates to stand somewhere that it wouldn’t feel cold as usual when I would sit on the entrance of that building of non-functional institute. I did well in the exam. Though I exam was way too lengthy when I got struck in formulating countless algorithms asked in the paper. But in the end, it was all well. 

At the time of leaving college premises, I met Anurag (Saxena, boxer). It felt real-special. First reason was that no one from my old contacts was acting normal. All of them were weirdly ignoring me. I too wasn’t too in the mood to confront them so just let it go. But it wouldn’t have been a nice thing to walk out the college on the day of last exam like this. So it felt good when Anurag called for my attention. Secondly, he too hadn’t talked to me for quite a while now. I mean it has been time since we last talked. 
I like his sense of humor; he made me laugh and almost lifted my mood up again. But I had to go and stay normal so just said goodbye before he did. Uh, we talked enough already.

I was thinking about how to start preparing for back papers in the train back to home. I reach home there it is badi buaji and Manju buaji. Nothing so special, just that badi buaji had been on trip to Shikharji. I had to go to sleep but I didn’t because there was too much noise around in the house. I had lunch at four. 
Though chachiji had called me early but I didn’t want to so I didn’t. And what I get on coming here late is 3-and-a-half rotis instead of four. That was not cool, when amma told Anu to cook two more I didn’t say no. Aunt intervened. Actually, amma thought it was two, so. But I hate aunt for almost every act of her ever since I’ve known her.

I was too tired to even sit to eat dinner at eight but I did it.

In the morning, I took Irfan (who was there outside college gates even before me) inside the college campus and there he tells me about mobile-theft that happened during last day. He never acted like pointing at me, but I reckoned others were well about this. Ishan didn’t hold sight for long. Ravi and others who were walking in group seemed to unaware of my presence as we crossed. Plus, on the Metro station, Nishant had seemed resistant to shaking hands with me. Shruti was one of the victims. I recalled the plastic face expressions she had on her face when I had seen her coming out with her bag on the entrance on the last day. (Nishant was thrown out of the class on the same day. An invigilator came and took Nishant out of the class, holding him from his collar. Actually, there was total discussion going between Parul, Sonam, and Srishti. They had always been doing that. But they never get caught, girls hardly get caught.) 
It was awkward to think about this attitude of college friends about me at all times. 

Guess what, I had asked a number of people for Apurva Sood’s number and no one helped on that night at about 2330. But in the morning at 0630 Vibha sent her number, I felt thankful to her in my sleep. Later during the day, I realized I hadn’t even asked her!

So, exams are over. But Vibha and I didn’t talk. We didn’t know what to talk. I had nothing to say, I just wanted to reach home when exam got over. 

God Bless ‘Me’
Ashish

2011-Jan-06 (Why didn’t Tanvi speak)

Index of Journals

6 January 2011

There was too much sleeping around today. I’m in deep trouble now. But by waking up whole night, I think I will make it so I’m still rolling slowly.

I was traveling in women’s car yesterday while travelling between Kashmere Gate and Rithala. Actually, a woman had offered me to sit when I had pointed at the empty seat on the Kashmere Gate station. I didn’t realize that there were TRIG women watching me later. They were there from pretty much time but I realized it when one of the three made a loud comment on the one who stepped out on Rohini. They could have taken action against me but they didn’t. That was brave, I felt for myself. Because, on other day women beat a man who had climbed the women’s car. They beat him real hard. It was on the news. 

And at the time of returning from Rithala to Kashmere Gate, I was accompanied by Tanvi Gaur but we didn’t speak a word during the hour long journey. That was awkward to notice. But I needed to use restroom so I thought instead of acting weird while speaking it’d be better to stay quiet. I had been holding myself since very long time, right from the college gates. Okay, I was awkward inside but not on the outside. Why didn’t Tanvi speak?

I had always dreamt of being one-in-every-fifty, but I never realized that Naveen was one-in-every-two-hundred. And every time I think of doing great to be one-in-fifty I used to take inspiration from him, but today I realize (after two years) that I can never be him. Being One-in-Two-Hundred is surely a god gift. Wish I could be that lucky.

I better go now, I have whole syllabus to do.

God Bless ‘Me’
Ashish

Medications for Anxiety (Ch 17, Edmund Bourne)

The use of medication is a critical issue among those who struggle with anxiety on a daily basis, as well as for professionals treating anxiety disorders. For many people, medication is a positive turning point along the path to recovery. For others, medication can confuse and complicate the recovery process, when freedom from anxiety is purchased at the cost of long-term addiction to tranquilizers. For still other people—those who are either phobic of or philosophically opposed to all types of drugs—medication may seem not to be an option, even when it’s needed. 
One thing is clear: the pros and cons of relying on medication are unique and variable in each individual case.

As you will have gathered, this workbook offers a range of nonmedical strategies to help you overcome anxiety, panic, and phobias. My personal view is that natural methods should always be thoroughly explored before you develop a reliance on prescription drugs. Medications can induce unnatural changes in your body’s physiology, with attendant short-and long-term side effects.

Quite a few people find that they can avoid drugs—or eliminate those they have been taking— by implementing a comprehensive personal health program that includes: 

• Positive changes in nutrition and the use of appropriate supplements 

• A program of daily, vigorous exercise 

• A daily practice of deep relaxation or meditation 

• Changes in self-talk and basic beliefs encouraging a less driven, more relaxed approach to life 

• Human support from family and/or friends 

• Simplifying your life and environment to reduce stress Such approaches may be all you need if your anxiety symptoms are relatively mild. By “mild,”

I mean that your problem does not significantly interfere with your ability to work or interfere with important personal relationships. Also, the problem does not cause you serious and/or constant distress.

If, on the other hand, you have a more severe problem with anxiety, appropriate use of medication may be an important part of your treatment. This is particularly true if you’re dealing with panic disorder, agoraphobia, or obsessive-compulsive disorder. It’s also true for social phobia and generalized anxiety disorder when these problems interfere with the quality of your life in a major way. Approximately 50 to 60 percent of my clients take medication. My impression is that for them, a combination of natural methods and medication provides the most helpful, effective, and compassionate approach to recovery.
Be aware that it’s often unnecessary to take medications indefinitely. However, the use of the right medication for the right period of time can help you to turn a corner toward improving your condition. This chapter presents some information about the various types of medication used to treat anxiety problems. Beyond this, you’ll find a number of guidelines to help you decide whether medication is something you should consider.

When to Consider Medication

In my experience, there are certain types of individuals, in certain types of situations, for whom medications are appropriate. What follows is a list of these types of situations, along with the types of medication that might appropriately be used.

1. You have panic attacks that are so frequent (for example, one or more per day) and severe that they impede your ability to work and earn a living, your primary personal relationships, and/or your sense of basic security and control over your life. It is particularly important to consider medication if you have severe symptoms of panic or anxiety that have not improved over a period of two or three weeks. “Severe” means that you have difficulty functioning and/or are suffering considerable distress. Enduring severe levels of anxiety for long periods of time can, unfortunately, predispose your nervous system to stay anxious much longer than it would if the anxiety were reduced by medication early on. Two types of medication are most frequently used to treat panic attacks. The first type is antidepressants. Though they’re labeled “antidepressants,” such medications also have a potent effect in reducing anxiety. The most commonly used antidepressants are SSRIs, or selective serotonin reuptake inhibitors, such as: 

#1 Paxil (paroxetine), 
#2 Zoloft (sertraline),
#3 Luvox (fluvoxamine), 
#4 Celexa (citalopram), and 
#5 Lexapro (escitalopram). 

Another class of antidepressant medications sometimes used is the tricyclics, such as: 
#1 Tofranil (imipramine) or 
#2 Pamelor (nortriptyline); these days, however, they are a second choice after SSRIs have been tried. 

The other type of medication used to treat panic (and other anxiety disorders) is the benzodiazepine tranquilizers. Among these, 

#1 Xanax (alprazolam), 
#2 Klonopin (clonazepam), or 
#3 Ativan (lorazepam) are typically used. (Descriptions of the major types of drugs used to treat anxiety disorders follow this section.) 

Usually, tranquilizers are prescribed for a period of six months to two years at a high enough dose to significantly reduce the frequency and severity of panic, as well as anxiety about panic.

2. You are agoraphobic and have a difficult time undertaking real-life exposure to phobic situations (see chapter 7). That is, you’ve tried for some time without medication and not gotten very far. Low doses of a benzodiazepine tranquilizer, such as Klonopin (in the range of 0.25 to 0.5 mg per day), may enable you to negotiate the first stages of graded exposure to your phobias. The benefits of exposure are likely to be retained even after the medication is discontinued, if the dose has been sufficiently low. This is less likely, however, for higher doses of tranquilizers (that is, more than 2 mg per day). You need to feel at least mild anxiety while undertaking exposure for the technique to be effective. 
After exposure hierarchies have been completed with tranquilizers, it’s important to rework them without medication, to ensure a full and permanent recovery from your phobias. The SSRI antidepressants (see the section of the same name later in the chapter) can also be highly effective in helping people undertake exposure. In fact, many psychiatrists consider SSRI medications to be an essential part of the treatment of agoraphobia.

3. You’re dealing with acute anxiety in response to a crisis situation. You may benefit from relying on a benzodiazepine tranquilizer on a short-term basis to get you through a particularly stressful time (such as interviewing for a new job, dealing with a significant health crisis, the death of a close relative, or other such major life events). 
Alternatively, a sedative (Restoril or Ambien, for example) might be prescribed to help you sleep during such a time.

4. If you have chronic or severe depression accompanying panic disorder, agoraphobia, or any other anxiety disorder, you will usually benefit from a prescription antidepressant medication. Milder cases of depression (that is, you do not lose your appetite, your ability to sleep, or your interest in simple pleasures, and/or you do not have suicidal thoughts) may respond to the herb Saint-John’s- wort, the supplement S-adenosylmethionine (SAM-e), or amino acids such as tryptophan (tryptophan itself or the popular supplement 5-HT), tyrosine, or DL-phenylalanine (see the section “The Use of Natural Supplements” at the end of this chapter). Moderate to severe cases of depression are best treated with SSRIs, tricyclics, or another type of antidepressant medications. Such medications will help relieve depression, panic, and anxiety at the same time.

5. If you suffer from performance anxiety in public speaking or other performance situations—especially if the anxiety involves heart palpitations—you may be helped by short-term doses of beta-blocking drugs, such as Inderal (propranolol). A benzodiazepine tranquilizer, such as Xanax or Klonopin, may also be used on occasion (not regularly) to help you negotiate high-performance situations.

6. Difficult cases of social phobia or social anxiety (for example, you avoid a wide range of social situations or you are unable to attend important meetings at work) may be helped by SSRI antidepressant medications or sometimes by SNRI medications. Medications should be taken in conjunction with individual or, preferably, group cognitive behavioral therapy (see chapter 1, the section on social phobia).

7. Those with obsessive-compulsive disorder often benefit from the use of antidepressant medication, usually in combination with cognitive therapy, exposure, and response prevention.
Medications such as Anafranil (clomipramine), Prozac (fluoxetine), Paxil (paroxetine), or Luvox (fluvoxamine) are frequently used in the treatment of this disorder.
Between 60 and 70 percent of persons with obsessive-compulsive disorder experience an improvement in their symptoms while taking one of these drugs. All of these medications appear to be helpful in treating obsessive-compulsive disorder itself, whether or not it is accompanied by depression. Anafranil, however, does have some potentially undesirable side effects.
For further information on various factors that can affect your decision to rely on medication, see the section “The Choice to Use Medication: What to Consider” later in this chapter.

Types of Medication Used to Treat Anxiety Disorders

What follows is a description of the major classes of prescription medications used in the treatment of anxiety disorders. Potential advantages and drawbacks of each type of medication are considered.

SSRI Antidepressant Medications

The SSRI (selective serotonin reuptake inhibitor) antidepressant medications include: 
#1 Prozac (fluoxetine), 
#2 Zoloft (sertraline), 
#3 Paxil (paroxetine), 
#4 Luvox (fluvoxamine), 
#5 Celexa (citalopram), and 
#6 Lexapro (escitalopram). 

In the past twenty years, they have become the first-line medications used by most psychiatrists to treat anxiety disorders. The SSRIs all increase levels of the neurotransmitter serotonin in the brain by preventing the reabsorption of serotonin at synapses (spaces between nerve cells). With increased serotonin, the number of serotonin receptors on nerve cells in the brain can decrease (not as many are needed). The reduction in serotonin receptors takes place over the first month or two of taking an SSRI and is technically called downregulation.

Downregulation allows the millions of nerve cells in the serotonin receptor system (particularly those in parts of the brain responsible for anxiety) to become less sensitive to changes in the neurochemical environment of the brain created by stress. That means less dramatic shifts in mood and less vulnerability to anxiety.
The SSRIs tend to be as effective—sometimes more effective—than the older tricyclic antidepressants that have been used to treat panic (for example:

#1 imipramine, 
#2 desipramine, 
#3 nortriptyline).

They also have the distinct advantage of causing fewer side effects for most people than the older antidepressants. SSRIs are used most often to treat panic, panic with agoraphobia, or obsessive-compulsive disorder. They have also found use with social phobia, particularly generalized social phobia, in which a person is phobic of most types of social situations and encounters. Sometimes they are used to treat post-traumatic stress disorder or generalized anxiety disorder, especially when these difficulties are accompanied by depression. People differ quite a lot in their response to the SSRIs. If you try one and experience no benefit, be willing to try another. To gain full benefit from an SSRI, you may need to take it for one to two years. Relapse with SSRI medications appears to be low when the medication is taken for at least eighteen months; however, reliable data on the exact percentage of relapse is not available at the time of this writing. Typical effective daily doses for SSRIs are Prozac, 20 to 40 mg; Paxil, 20 to 40 mg; Zoloft, 50 to 100 mg; Luvox, 50 to 100 mg; Celexa, 20 to 40 mg; and Lexapro, 10 to 20 mg. Effective doses of these medications for OCD tend to be somewhat higher. However, some OCD clients find that they obtain good results from lower doses.

Advantages

1. The SSRIs can be helpful for any of the anxiety disorders or depression. 

2. They have been particularly helpful for people with panic disorder, agoraphobia, or obsessive-compulsive disorder.

3. SSRIs are easily tolerated and safe for medically ill or elderly persons. 

4. They are not addictive.

5. They do not cause problems when taken long term. 

6. In most cases, they do not lead to weight gain.

Drawbacks

Although SSRIs have fewer side effects than the older tricyclic antidepressants, they can cause side effects in some people including: 
#1 jitteriness, 
#2 agitation, 
#3 restlessness, 
#4 dizziness, 
#5 drowsiness, 
#6 headaches, 
#7 nausea, 
#8 gastrointestinal distress, and 
#9 sexual dysfunction. 

These side effects tend to go away after two weeks, so it’s important to try to ride them out during the early phase of treatment. All of these side effects can be minimized by starting off with a very low dose of the medication and increasing it, over time, to therapeutic levels. For example, doses might start at 5 mg per day for Prozac or Paxil and 10 mg for Zoloft or Luvox. To achieve such doses, you need to start with a quarter of a tablet per day in most cases, then gradually increase up to a tablet per day over a period of several weeks. Be willing to take plenty of time in increasing the dose gradually. (You may notice side effects increase for a day or two after each dose increase.) The one side effect that can be problematic over time is reduced sexual motivation and/or sexual dysfunction (for example, absent or delayed orgasm). This can be upsetting to many people and, in some cases, can lead them to discontinue the medication. For a certain percentage of people who take SSRIs, normal sexual functioning will resume after two or three months on the medication, so it’s a good idea to stay with an SSRI even if at first you experience diminished sex drive.
If the problem doesn’t get better, it can be mitigated in one of four ways, under the supervision of your doctor: 

1) reducing the dose of the SSRI by half on days you choose to be sexually active,

2) augmenting the use of the SSRI with 5 to 10 mg per day of Buspar, 

3) supplementing the SSRI with the medications amantadine or cyproheptadine, or 

4) trying the supplement DHEA, available at most health food stores, at 25 to 50 mg per day. Many people find that one or two of these interventions can help them restore more normal sexual activity while continuing to take an SSRI.

A third disadvantage is that SSRIs, while often effective, take four to five weeks to produce any significant therapeutic benefit. Sometimes the full therapeutic potential is not achieved until the medication has been taken for twelve weeks or longer. (There is some evidence that even further benefits occur over the course of one year.) If you’re suffering from severe and disabling panic, your doctor may recommend you take a tranquilizer (most likely a high-potency benzodiazepine—see below) while waiting for the SSRI to take effect.
In the past few years, many people have found the medication Paxil to be especially difficult to discontinue. Approximately 5 to 10 percent of persons withdrawing from Paxil may experience severe symptoms such as panic attacks, mood swings, profuse sweating, depersonalization, and “electric shock”-like sensations. Before deciding to use Paxil, be sure to discuss this potential problem with your physician.
A final drawback of SSRIs is their expense. Without insurance, you can pay upward of $200 per month for some SSRIs. The optimal duration for taking an SSRI medication is one to two years. You increase your risk of a return of symptoms if you take the medication for a shorter time period.
Note: People with bipolar disorder (manic depression) should take SSRIs only under the supervision of a knowledgeable physician, as SSRIs can aggravate manic states.

High-Potency Benzodiazepines

The high-potency benzodiazepine tranquilizers (BZs): 
#1 Xanax (alprazolam), 
#2 Ativan (lorazepam), and 
#3 Klonopin (clonazepam) are commonly used to treat anxiety disorders. 

Older benzodiazepine drugs, such as: 
#1 Valium, 
#2 Librium, or 
#3 Tranxene, are occasionally tried when someone is sensitive to the side effects of the newer BZs. 

The benzodiazepines are often used in conjunction with SSRI antidepressants (or older tricyclic antidepressants) to treat severe cases of panic disorder.

Frequently, it’s possible to gradually withdraw from use of the BZ after the antidepressant medication has achieved its full antianxiety benefit (that is, from four to six weeks after starting the drug).

Benzodiazepine drugs generally depress the activity of the entire central nervous system and thus directly and efficiently decrease anxiety. They do so by binding with receptors in the brain that function to tone down or suppress activity in those parts of the brain responsible for anxiety:
#1 the amygdala, 
#2 locus coeruleus, and 
#3 limbic system, in general. 

In higher doses, BZ tranquilizers act like sedatives and may promote sleep. 
Lower doses tend to simply reduce anxiety without sedation. 
The main difference between various benzodiazepines is each medication’s “half-life,” or the length of time their chemical metabolites stay in your body. 
For example: 

1. Xanax has a half-life of eight hours;
2. Klonopin (clonazepam), eighteen to twenty-four hours; and 
3. Valium, forty-eight to seventy-two hours.

At present, the most common tranquilizer used to treat anxiety disorders is Xanax (alprazolam).
Alprazolam differs from other BZs in that it has an antidepressant effect, as well as the ability to relieve anxiety. It also tends to have a less sedating effect than other tranquilizers. Because Xanax has a short half-life, two or three doses per day are usually prescribed. If you take only one dose per day, you may experience “rebound anxiety”—the tendency to experience heightened levels of anxiety as the medication wears off. BZs with longer half-lives, such as Klonopin, tend to cause less rebound anxiety and can often be taken in a single dose per day. Research indicates that high doses of Xanax, 2 to 6 mg per day, are necessary to fully suppress panic attacks. In clinical practice, however, it’s common to administer low doses, in the range of 0.25 to 1 mg two or three times per day. (Daily doses of Xanax tend to be higher than for Klonopin.) Such doses can significantly reduce the symptoms of panic attacks with less sedating side effects.

Advantages 

BZs work very quickly, reducing symptoms of anxiety within fifteen to twenty minutes. Unlike antidepressants, which need to be taken regularly, BZs can be taken on an as-needed basis. That is, you can take a small dose of Xanax, Ativan, or Klonopin only when you have to confront a challenging situation, such as a graded exposure task, going to a job interview, or taking a flight.
The BZs tend to have less bothersome side effects for many people than the antidepressant medications (especially the tricyclic antidepressants). Sometimes they are the only medication that can provide relief when a person is unable to take any of the antidepressant medications.
Generic forms of BZs are available, reducing their cost.

Drawbacks

BZs, unlike antidepressant medications, tend to be addictive. The higher the dose (that is, more than 1 mg per day for high-potency BZs) and the longer you take them (that is, more than one month), the more likely you are to become physically dependent. Physical dependency means that if you stop taking the medication abruptly, severe anxiety symptoms are likely to occur.

Many people who have taken Xanax (or other BZs) in high doses for a month or low doses for several months report that it’s very difficult getting off the medication. (There is some evidence that withdrawal from Klonopin, because of its longer half-life, may be slightly easier and less protracted than withdrawal from Xanax.) Abrupt withdrawal from these medications is dangerous and may produce panic attacks, severe anxiety, confusion, muscle tension, irritability, insomnia, and even seizures. A more gradual tapering off of the dose, stretched out over many weeks or even months, is what makes discontinuation possible. The ease with which people can withdraw from Xanax varies, but as a general rule, it’s best to taper off very gradually over a period of one to four months, under medical supervision. During this withdrawal period, you may suffer a recurrence of panic attacks or other anxiety symptoms for which the drug was originally prescribed.

If a BZ medication is tapered off too quickly, you can experience rebound anxiety. 

Rebound anxiety is the occurrence of anxiety symptoms greater than those you experienced prior to taking the drug in the first place. Rebound may lead to relapse, a return of your anxiety disorder at equal or greater severity than what you experienced before taking the medication. To minimize the risk of rebound, it is critical to withdraw from your dose of a BZ very gradually, preferably over several months. (For example, if you have been taking 1.5 mg of Xanax per day for six months, reduce your dose by 0.25 mg every two to three weeks.) Another drawback of BZs is that they are effective only as long as you take them. When you stop taking them, your anxiety disorder has virtually a 100 percent chance of returning, unless you have learned coping skills (that is, abdominal breathing, relaxation, exercise, stress management, working with self-talk, assertiveness, and so on) and made lifestyle changes that will result in long-term anxiety relief. Taking a BZ only, without doing anything else, amounts to merely suppressing your symptoms without getting at the cause of your difficulty.

A final problem with benzodiazepines is that they tend to have a blunting effect, not only on anxiety but on feelings in general. Many people report that their emotional responses are muted while they are taking these drugs (for example, they may have trouble crying or getting angry, even at times when these reactions are appropriate). To the extent that anxiety is related to suppressed and unresolved feelings, taking these drugs will tend only to alleviate symptoms rather than relieve the cause of the problem. (Some people have a paradoxical reaction to benzodiazepines, during which they actually become more emotional or impulsive, although this tends to happen infrequently.) Emotional blunting is somewhat less likely with antidepressant medications, although it may occur.
Long-term use of BZs (more than two years) is sometimes necessary in those cases of severe panic and anxiety that do not respond to any other type of medication. While it enables many people to function, long-term BZ use has several problems. Many long-term BZ users report that they feel depressed and/or less vital and energetic than they would like. It is as though the medication tends to sap them of a certain degree of energy. Often, if they are able to switch to an antidepressant medication to help manage their anxiety, they regain a sense of vitality and enthusiasm for life. Many doctors currently regard the BZs as most appropriate for treating short-term, acute anxiety and stress rather than longer-lasting conditions such as agoraphobia, post-traumatic stress disorder, or obsessive-compulsive disorder. Wherever possible, chronic, long-term anxiety disorders are most appropriately treated with SSRI antidepressants. There are, however, certain individuals who seem to need to take a low dose of a BZ over the long term in order to function.
They accept the addiction and other side effects in exchange for protection from the anxiety that they have been unable to manage using solely natural techniques or other types of medication.
If you are over fifty years old and have been taking a BZ medication for more than two years, you should periodically receive medical checkups, including an evaluation of your liver function.

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Antidepressants

SNRI antidepressants work by blocking the reuptake of two major neurotransmitters: serotonin and norepinephrine. 

At present, the three most commonly used SNRIs are: 
#1 Cymbalta (duloxetine),
#2 Effexor (venlafaxine), and 
#3 Pristiq (desvenlafaxine). 

Desvenlafaxine is the mirror-image isomer of venlafaxine, and is claimed by some to have fewer side effects than venlafaxine, though there is no systematic research on this. The SNRIs are potent medications and may be tried when response to SSRIs is insufficient. They are most commonly used to treat depression and/or generalized anxiety disorder but may be used to treat other anxiety disorders such as panic disorder or OCD.
The main advantage of SNRIs over the SSRIs is that they can stabilize both the norepinephrine and serotonin receptor systems, instead of just the serotonin system alone. So for certain people, they are more powerful anxiolytics than the SSRIs. They have the same disadvantages as the SSRIs, with side effects including dizziness, nausea, weakness, dry mouth, insomnia, and sexual dysfunction. Like the SSRIs, the dose needs to be tapered off gradually when SNRIs are discontinued. Abrupt discontinuation is associated with withdrawal symptoms.

Serotonin Modulator and Stimulator (SMS) Antidepressants 

SMS antidepressants are a relatively new class of medications that, in addition to promoting serotonin reuptake inhibition like SSRIs, also stimulate transmission at one or more serotonin receptor sites.
Viibryd (vilazodonehydrochloride), with a normal dose range of 10 to 40 mg per day, facilitates the serotonin receptor 5-HT1A, a mechanism of action it shares with the anxiolytic medication Buspar (buspirone) as well as the atypical antipsychotic medication Abilify (aripiprazole).

Viibryd was approved in early 2011 for use in the United States. In September 2011, the FDA raised questions about whether Viibryd showed any advantage over previously and commonly available SSRIs. Some users have reported good results with Viibryd, both with respect to anxiety and depression, while others have reported side effects such as nausea, diarrhea, sleeplessness, and weight gain, leading them to discontinue the drug. Viibryd was marketed as having fewer sexual side effects than other SSRIs, though results so far have shown that this benefit is not invariably reported.

Brintellix (vortioxetine), with a normal dose range of 5 to 20 mg per day, was introduced in the United States in late 2013. It is described as a multimodal antidepressant because it has a differential action on different types of serotonin receptors. Specifically, it has an antagonistic (inhibitory) reaction toward serotonin receptors 5-HT3A and 5-HT7, while it tends to facilitate neurotransmission at 5-HT1A and 5-HT1B receptors. It’s also a potent serotonin reuptake inhibitor like typical SSRIs.

Preliminary research indicates that these multiple effects on several different serotonin receptors may result in increased noradrenaline (as in SNRIs) and dopamine (as in mood stabilizers) as well as increased glutamine transmission. So the drug appears to have a variety of effects beyond that of simple serotonin reuptake inhibition.
Brintellix is currently being studied for potentially beneficial cognitive effects, apart from its antidepressant effects, in elderly persons.

Tricyclic Antidepressants

Tricyclic antidepressants include: 
1. Tofranil (imipramine), 
2. Pamelor (nortriptyline), 
3. Norpramin (desipramine), 
4. Anafranil (clomipramine), 
5. Elavil (amitriptyline), and 
6. Sinequan (doxepin), among others. 

These medications (especially imipramine) are sometimes used to treat panic attacks, whether such attacks occur by themselves or in conjunction with agoraphobia. Tricyclic antidepressants seem to reduce both the frequency and intensity of panic reactions for many people. They are also effective in reducing the depression that often accompanies panic disorder and agoraphobia.
While it used to be believed that Tofranil was the most effective antidepressant for treating panic, more recent evidence indicates that any of the tricyclic antidepressant medications can be helpful, depending on the individual. Anafranil tends to be specifically helpful in treating OCD.
The tricyclic antidepressants are used less these days than SSRI antidepressants because they tend to have more troublesome side effects. For example, in studies of imipramine, usually about one-third of the subjects drop out because they cannot tolerate side effects (only about 10 percent do in studies using SSRIs). On the other hand, tricyclic antidepressants are sometimes a better choice than SSRIs for certain people because most of them (other than Anafranil) modify a different receptor system in the brain (the noradrenergic system instead of the serotonin system).
As with SSRIs, tricyclic antidepressants are best tolerated by starting with a very low dose (for example, 5 mg per day of imipramine) and gradually working up to a therapeutic dose level (approximately 100 to 200 mg per day).

Advantages 

Tricyclic antidepressants, like the SSRIs, do not lead to physical dependence. They have a beneficial effect on depression as well as on panic and anxiety. They block panic attacks, even if you are not depressed. Because generic forms are available, they are inexpensive.
Drawbacks Tricyclic antidepressants (unlike SSRIs) tend to produce anticholinergic side effects, including dry mouth, blurred vision, dizziness or disorientation, and postural hypotension (causing dizziness).
Weight gain and sexual dysfunction can also occur. With imipramine, in particular, anxiety may increase during the first few days of administration. With clomipramine (effective for OCD), side effects can be particularly bothersome.

Although these side effects tend to diminish after one or two weeks, they persist for 25 to 30 percent of people who take tricyclic antidepressants after the initial adjustment period.
Like the SSRIs, tricyclic antidepressants take about three to four weeks to offer therapeutic benefits. While able to block panic attacks, these medications may not be as effective as SSRIs and benzodiazepine tranquilizers in reducing anticipatory anxiety about the possibility of having a panic attack or having to face a phobic situation.
Finally, about 30 to 50 percent of people will relapse (experience a return of panic or anxiety symptoms) after discontinuing tricyclic antidepressant medications. This is, however, a much lower relapse rate than occurs when benzodiazepines are discontinued.
MAO-Inhibitor Antidepressants If you have given SSRIs and tricyclic antidepressants a fair trial and still have obtained no benefit, your doctor may try the oldest class of antidepressant medications—the MAO-inhibitors (MAOIs). Nardil (phenelzine) is the MAOI most commonly used to treat panic, although Parnate (tranylcypromine) is sometimes used. While MAOIs are potent medications, they are frequently last in line to be tried because they can cause serious or even fatal rises in blood pressure when combined with 1) foods that contain the amino acid tyramine, such as wine, aged cheeses, and certain meats, and 2) certain medications, including some over-the- counter analgesics. If you are taking an MAOI, you should be under close supervision by your doctor.
Advantages MAOIs have a potent panic-blocking effect and are sometimes effective when other types of antidepressants have failed. There is also some research indicating that they are helpful in treating social phobia, especially generalized social phobia (a tendency to be phobic toward a wide range of interpersonal situations or encounters). They may also help severe depression that has been unresponsive to other classes of antidepressants.

Drawbacks

Side effects include weight gain, hypotension (low blood pressure), sexual dysfunction, headache, fatigue, and insomnia. These side effects may be most pronounced during the third and fourth weeks of treatment and then are likely to diminish.
Dietary restrictions are critical. When taking an MAOI, you need to avoid foods containing tyramine, including most cheeses, homemade yogurt, most alcoholic beverages, aged meats and fish, liver, ripe bananas, and certain vegetables. Over-the- counter cold medicines, diet pills, and certain antihistamines also need to be avoided. Prescription amphetamines and SSRI or tricyclic antidepressants should be avoided as well.

Other Antidepressants

Other antidepressant medications occasionally used with anxiety disorders include Remeron (mirtazapine), Wellbutrin (bupropion), and Desyrel (trazodone). Remeron is classified as a noradrenergic/specific serotonergic antidepressant (NaSSA), and, like Effexor, it has a dual action, increasing the levels of both norepinephrine and serotonin at the synapse. Remeron is very sedating at lower doses and may be used to promote sleep. At higher doses, it is an effective antidepressant, and may be used when Effexor is not well tolerated. Psychiatrists sometimes use it in combination with an SSRI, like Paxil or Celexa, to enhance the antianxiety and/or antidepressant effects of the SSRI, a strategy called augmentation.
Wellbutrin is often helpful for depression but can be difficult for people with anxiety disorders to tolerate, since its side effects can include anxiety and insomnia. 
On the positive side, Wellbutrin is one of the newer antidepressants that does not have sexual side effects.
Trazodone (brand name Desyrel) is an older antidepressant medication that has been around since the early 1980s. While not frequently prescribed for anxiety, it can be a highly effective sedative for many people. It has the advantage of not being addictive (unlike Restoril, Ambien, or Lunesta), and may be more potent for some people than natural sedatives like melatonin and tryptophan. Its side effects are similar to those listed for the tricylic antidepressants.
Beta Blockers Although there are several different beta-adrenergic blocking drugs (popularly called beta blockers), the two most commonly used with anxiety disorders are Inderal (propranolol) and Tenormin (atenolol). These medications can be helpful for anxiety conditions with marked body symptoms, especially heart palpitations (rapid or irregular heartbeat) and sweating. Beta blockers are quite effective in blocking these peripheral manifestations of anxiety, but are less effective in reducing the internal experience of anxiety mediated by the central nervous system. Inderal or Tenormin may be used in conjunction with a benzodiazepine tranquilizer, such as Xanax, in treating panic disorder when heart palpitations are prominent. By themselves, beta blockers are often given in a single dose (for example, 20 to 40 mg Inderal) to relieve body symptoms of anxiety (rapid heartbeat, shaking, or blushing) prior to a high-performance situation, such as public speaking, a job interview, final examinations, or a musical recital. Beta blockers are also often used to treat mitral valve prolapse, a benign heart arrhythmia that sometimes accompanies panic disorder.
Although these medications are relatively safe, they can produce side effects, such as the excessive lowering of blood pressure (causing dizziness or light-headedness), fatigue, and drowsiness.
In some people, they can also cause depression. Unlike tranquilizers, these medications do not tend to be physically addictive. Still, if you’ve been taking them for a while, it’s preferable to taper your dose gradually to avoid rebound elevations of blood pressure. Beta blockers are not recommended for people with asthma or other respiratory illnesses that cause wheezing, or for diabetics.
Buspar Buspar (buspirone) has been available for about twenty years. To date, it has been found useful in diminishing generalized anxiety but is less effective in reducing the frequency or intensity of panic attacks. Some research indicates that Buspar can be helpful in treating social phobia or in augmenting the effects of SSRI medications used to treat OCD. Some practitioners prefer it over Xanax (and other benzodiazepines) for treating generalized anxiety because it is less prone to cause drowsiness and is nonaddictive. There is little risk of your becoming physically dependent on Buspar or requiring a protracted period of time to withdraw from it. Research in recent years, however, has not found Buspar to be any more effective than SSRIs in treating generalized anxiety.
An ordinary starting dose for Buspar is 5 mg two or three times per day. It takes from two to three weeks before the full antianxiety effect of this medication is achieved. Some people with generalized anxiety respond well to Buspar, while others report side effects (lethargy, nausea, dizziness, or paradoxical anxiety).

Other Medications Used to Treat Anxiety

When antidepressant medications and/or BZ tranquilizers are ineffective or not fully effective in treating panic disorder, psychiatrists may try other medications such as: 
1. Depakote (valproic acid), 
2. Neurontin (gabapentin), 
3. Gabitril (tiagabine), or 
4. Lyrica (pregabalin). 

Although such medications are often used to treat seizure disorders or bipolar disorder, they also have an antianxiety effect. 

It’s thought that they work by increasing levels or activity of the neurotransmitter GABA in the brain. (Tiagabine is actually a selective GABA reuptake inhibitor.) 

Certain clients, most often those with generalized anxiety disorder, seem to benefit from one or another of these medications, taken either alone or with an SSRI antidepressant. Effective dose ranges for Depakote are 700 to 1500 mg per day; Neurontin, 300 to 1800 mg per day; Gabitril, 4 to 10 mg per day; and Lyrica, 150 to 300 mg per day.
The advantage of these medications is that they work rapidly, are nonaddictive, and are not associated with sexual side effects. Numerous people receive genuine help from these drugs. On the downside, some people report that Neurontin or Gabitril makes them feel tired, lethargic, or occasionally nauseated. Depakote is generally well tolerated but has been associated with liver problems in certain people (so it needs monitoring). If you have not had a good response to antidepressants and want to avoid the addictive problems associated with benzodiazepines, these medications are worth trying.

The Choice to Use Medication: What to Consider

The decision to include medication in your effort to recover from anxiety involves many considerations.
First and foremost, it’s always a decision to be made in consultation with your physician.
Your doctor, preferably a psychiatrist, should be knowledgeable and experienced in treating anxiety disorders and should work with you in a collaborative (not authoritarian) way. Second, your decision depends on a number of personal factors, including: 

1) the severity of your problem with anxiety, 

2) your personal outlook and values regarding medication, and 

3) your patience, which may be tested in those situations where several medications need to be tried before the right one for you can be found.

Be wary of pat answers and simple generalizations when you consider undertaking a course of medication. The following twelve vignettes illustrate the complex range of situations that might lead a person to decide for or against taking medication.

1. A busy physician has numerous duties at work, at home, and in his community. He takes time to meditate, jog, express feelings, and work with self-talk, but still has debilitating panic attacks. He finds that an SSRI antidepressant helps him to sleep better and carry out his round of daily responsibilities with less anxiety.

2. A mother who has been housebound with agoraphobia for a long time has a difficult time beginning exposure therapy. She finds that taking an SSRI medication helps her to get started. After one year of exposure, she is confident enough to continue without medication.

3. A secretary who has been taking medication for mixed anxiety and depression for a year discovers she is pregnant. She stops her medication and puts up with intensified symptoms for nine months in order to have a healthy baby.

4. A husband going through a divorce has a heart attack followed by mixed anxiety and depression. Although he has been opposed to taking medication up to this time, he decides to rely on a benzodiazepine medication to help him negotiate this severe crisis.

5. A woman who has just been promoted to a more demanding job learns her mother has died. She elects to take medication for a period of several months to handle her stressful life circumstances.

6. A chiropractor who teaches classes in nutrition and is heavily involved in alternative health practices has obsessive-compulsive disorder. He finds that he needs to take an SSRI antidepressant in order to handle his work.

7. A student who decides to enroll in a certificate program to be an acupuncturist has a strong desire, despite her panic attacks, to embrace only natural methods (such as herbs, nutrition, tai chi, and meditation) to handle her anxiety. She decides not to use medication.

8. A man who has been taking various SSRI antidepressants for panic disorder over five years wants to evaluate how he might do without medication. He discontinues it over a period of two months and does well.

9. A long-term user of benzodiazepines feels they are causing her to be depressed and decides she would rather have some anxiety and emotional intensity in her life than feel numbed or de-energized by a tranquilizer. She discontinues her use of BZs.

10. A minister with panic disorder is unable to tolerate any antidepressant medication. He finds he is best able to function taking a low dose of a tranquilizer every day over the long term.

11. A woman who belongs to a religious group that espouses that prayer and right living are the answer to life’s difficulties has a strong philosophical belief that medications are unnecessary for her recovery. She elects not to use medication for her panic attacks.

12. A recovering alcoholic with two years’ sobriety begins taking Xanax to manage his anxiety. Within two months, he starts escalating the dose. Both his doctor and his 12-step program friends advise him to discontinue the medication. In the interest of maintaining a commitment to a substance-free lifestyle, he does so.

Whether you’re considering starting medication or thinking about stopping medication you’ve been taking for a while, the two most important factors to look at in making a decision for yourself are your own personal values and the severity of your condition. Each of these is considered below.
Personal Values What are your personal values about medication? Are you open to including medication as a part of your recovery program, or do you feel strongly about adhering to natural methods alone? While your symptoms may warrant trying medication and while your doctor might encourage you to do so, the decision is ultimately your own. If you happen to be committed to the ideal of natural healing without the aid of medication, that is a perfectly legitimate option. Many people can recover from anxiety disorders by natural methods alone if they have sufficient motivation, persistence, and diligence in practicing natural methods, such as those outlined in this book. At the opposite extreme, there are people who lack sufficient interest or motivation to put in the time and effort involved in practicing relaxation, exercise, exposure, and cognitive skills on a daily basis. They seek immediate relief of symptoms through taking a drug. In many cases, this is also a viable choice. It is not for anyone to judge a person’s decision to seek relief from anxiety disorders through medication. Medications certainly do provide a great deal of relief for many people.
In making a choice about whether to rely on medication, it’s important to have all the information that you need to make the most informed and enlightened decision possible. Such a decision should not be based solely on impulse—for example, a desire to take a high dose of medication to eliminate all symptoms of anxiety as soon as possible. Nor should it be based upon fear or avoidance of medication because you have a phobia of it. The purpose of this chapter is to give you as much information as possible so that you can make the optimal decision for yourself.

Severity of Your Condition

Apart from your personal values, the next thing to look at in considering medication is the severity of your symptoms. As a general rule, the more severe your problem, the more likely you will benefit from a trial of medication. Severity can be defined in two ways: your ability to function and your level of distress. Use the following questions to evaluate the severity of your own condition.

First, does your problem with anxiety significantly interfere with your ability to function in your everyday life? Are you having a hard time working, or are you unable to work at all? Is your ability to raise your children or be responsive to your spouse impaired by your anxiety? Do you have a hard time organizing your thoughts to complete basic tasks, such as cooking or paying bills? 

Second, does your problem with anxiety cause you considerable distress, to the point that you have two or more hours every day during which you feel very uncomfortable? Is it hard for you just to make it through each day? Do you wake up each morning in a state of dread? If your answer to any of these questions is yes, you may want to consider medication.

Another factor in considering medication is depression. Significant depression accompanies anxiety disorders in up to about 50 percent of cases. The highest association is with generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD), while the lowest association is with specific phobias. There is also a syndrome—mixed anxiety and depression—that has received attention in recent years. Criteria for depression include lack of energy, continuous low mood or apathy, loss of appetite, disturbed sleep, frequent self-criticism, difficulty concentrating, and possibly suicidal thoughts. If you are depressed, antidepressant medication can be especially helpful because it tends to restore the motivation and energy you need to practice the skills promoted in this book, such as abdominal breathing, relaxation, exercise, cognitive restructuring, and graded exposure. If you have had suicidal thoughts, your doctor will most certainly recommend medication.
In addition to severity of symptoms, chronicity—how long you’ve had your problem—is another important factor to consider. If your anxiety is of recent origin and a response to stressful circumstances, it may pass when you learn stress-management techniques and work through whatever problem instigated the stress. On the other hand, if you’ve been suffering for more than a year—and especially if you’ve tried cognitive behavioral therapy and have not yet received the benefit you wanted—a trial of medication may be helpful. To conclude, the more severe and/or the more chronic (long-standing) your condition, the more likely you may be to respond favorably to medication.

How Long to Continue Medication

For anyone who is considering trying or is presently taking a prescription medication, how long to take it is a very important issue. Unfortunately, there is no simple answer. The length of time you need to take medication depends on at least three different factors: 

• What type of medication (for example, tranquilizer or antidepressant) 

• What type of anxiety disorder (for example, panic, social phobia, or obsessive-compulsive disorder) 

• Your motivation and commitment to utilize natural approaches (as a committed program of nonmedication approaches may help you to stop relying on medication or else reduce your dose) What Type of Medication Some types of medication, such as tranquilizers or beta blockers, can be used on an as-needed basis only. That is, you only use the medication when dealing with an acute, anxiety-provoking situation, such as confronting a phobia. Tranquilizers can also be used over a period of a few weeks to help you get through a particularly difficult situation, such as the death of a loved one or taking the bar exam. For a period of one to two years, tranquilizers may be useful if you are unable to take any type of antidepressant medication for anxiety. Long-term use of tranquilizers (more than two years), while having certain problems, may even be justified in some cases (see the previous section on benzodiazepine tranquilizers).

Antidepressant medications are usually taken on a daily basis for a minimum of six months.
In my experience, they are most effective in treating anxiety disorders when taken for a period of one to two years. Risk of relapse once you discontinue the antidepressants is lower if you’ve taken them for this length of time. For some people, long-term use of antidepressant medication (that is, more than two years), at a maintenance dose level, offers an optimal quality of life.
What Type of Anxiety Disorder If you have a fairly mild case of agoraphobia, you may need to take medication (a tranquilizer or an antidepressant) only up to and during the early stages of graded exposure to your phobic situation. Then, during later stages, you may wean yourself off the medication and work through your exposure hierarchies on your own. Being able to do so without the use of medication will enhance your sense of mastery over your phobia. On the other hand, if you are having frequent panic attacks and/or are practically housebound, you may benefit from taking medication for a longer time. For SSRI antidepressant medications, the one-to two-year period mentioned above is optimal. Long-term maintenance on a low dose of antidepressant medication may be necessary in some cases.
For social phobia, you may take an antidepressant (SSRI or SNRI antidepressant) or a benzodiazepine, especially if you suffer from generalized social phobia (anxiety in a wide variety of social situations). One to two years on the medication will likely optimize your treatment. Long-term maintenance at a low dose, as with agoraphobia, may be necessary in some cases.
With obsessive-compulsive disorder, long-term use of an SSRI medication at a higher dose is often the best strategy. After two years, you can try lowering the dose to see what is the minimum you need to correct the neurobiological problem associated with OCD. On the other hand, some people with OCD are able to manage their problem with cognitive behavioral strategies alone—sometimes from the outset and sometimes after a year or two on medication. (See the book Brain Lock by Jeffrey Schwartz, listed at the end of this chapter.) Generalized anxiety disorder will require medication only in moderate to severe cases or in situations where you are unmotivated or unwilling to make the behavioral and lifestyle modifications that can help.
Finally, post-traumatic stress disorder may frequently be helped by antidepressant medication in conjunction with cognitive behavioral therapy; severe cases may need a long-term maintenance dose.
Your Motivation and Commitment to Utilize Natural Approaches In many cases, it’s possible to eliminate or at least reduce your need for medication over the long term, if you maintain a committed program of natural approaches. The brain has an inherent ability to heal from the stress-induced imbalances that may have led to your original need for medication.
While it may take your brain somewhat longer to recover than would be the case for a broken bone or a torn ligament, the brain can regain, with proper cognitive, behavioral, and lifestyle modifications, much or all of its natural integrity over time. Your very belief that you can recover from anxiety and eventually wean yourself off medication will help make it more likely that you do. The popular idea of “mind over matter” is not an idle notion. Any of the approaches suggested in this book will help you to heal yourself naturally. The more of these approaches you are able to implement on a regular basis, the sooner and more powerfully you will be able to foster a state of natural health in body and mind.

Discontinuing Medication

If you’ve decided that you want to stop relying on prescription medications, observe the following guidelines: 1. Be sure you’ve gained some level of mastery of the basic strategies for overcoming anxiety and panic presented in this book. In particular, it would be a good idea to have established a daily practice of deep relaxation and exercise, along with skills in using abdominal breathing and countering fearful self-talk to overcome anxiety symptoms. If you plan to withdraw from Xanax or a BZ tranquilizer, these skills will serve you well in dealing with possible recurrences of anxiety during the withdrawal period, as well as over the long run.
Be assured that any resurgence of high anxiety during withdrawal from a tranquilizer is temporary and should not persist if you proceed through your withdrawal in a sufficiently gradual manner.

2. Consult with your doctor to set up a program for gradually tapering off the dosage of your medication.
This is especially important if you’ve been taking a BZ tranquilizer (the tapering-off period is dose-dependent but may need to be as long as six months or even longer). A tapering-off period (usually a month or two) also needs to be observed if you’re curtailing your use of an antidepressant medication like Paxil or a beta blocker such as Inderal.

Generally, the longer you’ve taken a medication, the longer and more gradual the tapering period should be.

3. For many people, benzodiazepine tapering can be difficult. The nervous system adapts to these drugs, and it may take you quite some time to readapt to living without them. Often psychiatrists prescribe an SSRI antidepressant, or other nonaddictive antianxiety medication such as Neurontin, during and after the BZ tapering-off process in order to ease withdrawal symptoms. For people unable to tolerate these prescription medications, sometimes high doses of the amino acids tryptophan, theanine, GABA, taurine, and glycine—administered either intravenously or orally—can be helpful both during and for some time after the tapering-off period. There are two approaches to withdrawing from the benzodiazepines. One is to reduce the dose very slowly over a period of several months—preferably with the aid of a nonaddictive antianxiety medication, as previously described. Alternatively, drug rehabilitation programs do a more rapid tapering off over a period of two to three weeks and use an alternative (long half-life) benzodiazepine, such as Valium, or else phenobarbital, in lieu of the high-potency benzodiazepine (such as Xanax or Klonopin) that is being withdrawn. After withdrawal from the secondary drug, an antidepressant or other nonaddictive antianxiety medication may be used to assist adjustment for several months after the tapering off is finished. For more detailed information on benzodiazepine tapering, see the resources by C. Heather Ashton listed at the end of this chapter.

4. Be prepared to increase your reliance on the strategies described in this workbook during your tapering-off period. Especially important are abdominal breathing, relaxation, exercise, coping strategies for anxiety, and countering negative self-talk.
Your withdrawal from medication is an opportunity to practice and improve your skills at using these strategies.
You’ll gain increased self-confidence by learning to use self-activated strategies to master anxiety and panic without having to rely on medication.

5. Don’t be disappointed if you need to rely on medication during future periods of acute anxiety or stress. Stopping regular use of a medication doesn’t necessarily mean that you might not benefit from the short-term use of that medication in the future. For example, using a tranquilizer or sleep medication for two weeks during a time of acute stress due to a traumatic experience is appropriate and unlikely to lead to dependence. If you’re subject to seasonal affective disorder, you may stand to benefit from taking an antidepressant medication during the winter months. Don’t consider it a sign of weakness or a lack of self-control if you occasionally need to rely on prescription medications for a limited period of time.

Given the stress and pressures of modern life, there are quite a few people who occasionally use prescription medications to help them cope.
Working with Your Doctor The purpose of this chapter has been to provide a balanced view of the role of medications in treating anxiety. There are certainly a variety of situations where the benefits of prescription drugs outweigh their associated risks and drawbacks. It’s important, however, that before taking any medication you become fully aware of all of its potential side effects and limitations. It is your doctor’s responsibility to: 

1) obtain a complete history of your symptoms, 

2) inform you of the possible side effects and limitations of any particular drug, and 

3) obtain your informed consent to try out a medication. 

It’s your responsibility not to withhold information your doctor requests in taking your medical history, as well as to let him or her know, should he or she fail to ask, whether: 

1) you have allergic reactions to any drugs, 

2) you are pregnant, 

3) you are taking any other prescription or over-the- counter medications, or 

4) you are taking any natural supplements.

Once this exchange of information has taken place between you and your physician, both of you will be in a position to make a fully informed and mutual decision about whether taking a particular prescription medication is in your best interest. If your doctor is unwilling to take a collaborative rather than authoritarian stance, or to allow for your informed consent, seek out another doctor who will. Medications may enable you to turn the corner in recovering from your particular problem, but it is essential that they be used with the utmost care and responsibility.

Note: The Internet offers websites that distribute various antianxiety medications, especially tranquilizers, without a prescription. It’s best to avoid these sites, as they may take your money without sending you anything, send you the wrong medication, or send you an inferior or toxic version of the medication you ordered. It is worth your time and money to consult with an experienced physician or psychiatrist when you are in need of medication, and to utilize reputable pharmacies that require a prescription.

In Conclusion

Appropriate use of medication does not conflict with holistic values or a natural lifestyle. There is a time and place for the use of medication in treating anxiety disorders, and not to use them at those times is equivalent to not taking good care of yourself. The real question to ask, in my opinion, is this: What is the most compassionate thing you can do for yourself? In some cases, the answer may be to wean yourself off medication—especially if you have become overly dependent on or addicted to a drug for several years without having evaluated how you might fare without it. In some cases, the answer may be to use medication for a period of several months (up to a year) to get through a difficult time or to jump-start your motivation to utilize cognitive behavioral and other natural approaches. In other cases, long-term use of medication (particularly the SSRIs), in conjunction with the full spectrum of cognitive, natural, and lifestyle changes suggested in this book, may be the most compassionate response you can have for yourself.
There are few set answers when it comes to the subject of medication. Getting all the information you can, working with a competent physician whom you can trust, and then listening to your own intuition is the best you can do.
The Use of Natural Supplements Since this chapter is about prescription medications, it doesn’t include detailed information on natural substances that can be useful in the treatment of anxiety problems. Full descriptions of all of the natural supplements used to treat anxiety and depression may be found in the section “Supplements for Anxiety” in chapter 15.
There are two classes of such substances. Natural tranquilizers include herbs such as kava, valerian, passionflower, and chamomile, as well as amino acids such as theanine and GABA.
Natural antidepressants, which can have an anxiety-reducing effect as well, include the herb Saint-John’s- wort,
S-adenosylmethionine (abbreviated as SAM-e), and the amino acids tryptophan and tyrosine. You may find any of these supplements at your local health food store or online. Any one or a combination of them may be quite helpful as an alternative to prescription drugs in treating your problem with anxiety or depression. The key consideration in deciding to try natural supplements is whether you consider your anxiety problem to be in the mild to moderate range of severity. If anxiety is more of a nuisance—a discomfort or inconvenience in your life—and not a debilitating or highly distressing condition, you might want to consider natural supplements first before consulting with a psychiatrist about prescription drugs. If you are already taking an SSRI antidepressant or BZ tranquilizer, do not try natural supplements without first consulting with a doctor well versed in combining prescription medications with supplements.

Summary of Things to Do

1. Review this chapter to provide yourself with an overview of the various types of medications used to treat anxiety disorders. Be familiar with the benefits and limitations of those medications that may have relevance for your particular issue.
If you are not currently taking medication but wonder if you could benefit from doing so, contact a psychiatrist who is knowledgeable about anxiety disorders to discuss your options. The Anxiety and Depression Association of America offers a “Find a Therapist” link on their website, adaa.org, that may assist you in finding a specialist in your local area (see appendix 1).
If you are currently taking a medication and would like to stop, consult your prescribing physician to discuss the appropriateness of doing so. If you and your physician jointly decide that you are ready to discontinue the medication, follow the guidelines in the section “Discontinuing Medication.” Remember, it’s preferable to stop medication only after you’ve gained some mastery of the skills discussed in chapters 4 through 15 of this book. If you wish to withdraw from a benzodiazepine medication that you have been taking for more than a month, prepare to take some time tapering off the dose gradually, possibly over a period of several months. Consult the website benzo.org.uk and The Ashton Manual for assistance.

2. If you feel your problem with anxiety is relatively mild (if it’s more of an inconvenience or nuisance than a debilitating or highly distressing condition), consider trying natural supplements, as described in chapter 15, before resorting to drugs. You may also want to take a look at the books Healing Anxiety Naturally by Harold Bloomfield or my book Natural Relief for Anxiety.

Further Reading 

1. Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw. Boston: Benzodiazepine Awareness Network, 2002. (See the website benzo.org.uk, where you can download The Ashton Manual.) Bloomfield, Harold. Healing Anxiety Naturally. New York: HarperPerennial, 1999.

2. Bourne, Edmund, Arlen Brownstein, and Lorna Garano. Natural Relief for Anxiety. Oakland, CA: New Harbinger Publications, 2004.

3. Norden, Michael. Beyond Prozac. Revised and updated edition. New York: HarperPerennial, 1996.

4. Preston, John, John H. O’Neal, and Mary C. Talaga. Handbook of Clinical Psychopharmacology for Therapists. Sixth edition. Oakland, CA: New Harbinger Publications, 2010.

5. Schwartz, Jeffrey. Brain Lock: Free Yourself from Obsessive-Compulsive Behavior. New York: Regan Books / HarperPerennial, 1997.

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