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Rachel Udin
04-08-2013, 09:31 PM
If you *are* a mental health pro, please tell me up front, since this is the internet and I can't see your body language or degree to see if you know what you're talking about. =P Helps with misunderstandings.

I get these things are different, but for this character she seems to have both.

So the character...

She is an actress in Korea (who, historically aren't that friendly towards mental illness), about 23 years of age, average stature and weight. She had a severe episode of depression/anxiety when she was 18.

When she was 18, she was going to college, acting, had her parents divorce, and her stylist died in a car accident driving her home (She was the big emotional support in her life). She also got into a scandal when it was reported she broke up with her boyfriend while he still was in the army (a huge deal in Korea), and then it got worse when it leaked that the whole relationship was staged by her agency.

Since there was the internet, she got pummeled and attacked on several occasions (basically bullied).

She kinda has a habit of ignoring the stress building up. (Denial) And had to pretend while she was an actress the first time that she was not half, but full Korean (by her crappy agency, since there is somewhat of a stigma), which added stress since she couldn't talk about her parents' divorce in any detail to anyone except her stylist and manager (mostly to her stylist). She also tends to procrastinate on issues that would help her on her mental health. (Such as getting a new stylist, finding another psychologist, etc)

And so at 18, she had a kind of psychotic break. (I'm not sure if she attempted suicide, but I'm thinking she might have). This, of course led to a third scandal since the psychotic break was public. She was shipped off to the US for treatment, and for about 5 years, has been steadily recovering and finishing her degree.

She's returned to South Korea, since South Korea has changed a bit towards mental health and she still wants an acting career, despite the high amount of stress. (She tends to define herself through this outlet. She's been doing it since she was a child.)

She is currently on medication, but I'm not sure what.

Her manager is trying to keep her diet healthy and keep her exercising, per the last recommendation of the US Health professional. (It's not easy, since during shooting, many of the actors resort to convenience store food in Korea, which means ramyeon, rice filled balls, etc. And take out, which is mainly jjajangmyeon (not that much in vegetables) and jampon (seafood, salty soup) Also, Korea has a high culture of drinking socially to make connections and caffeine... which I understand she should stay away from...)

Ah, the depression tends to present with her not eating, or not sleeping well. Also procrastination, inaction, oversleeping, and eventually insomnia and not moving.

The anxiety tends to result in panic attacks, and presents with mostly performance and social expectations. (Which means the bullying made her anxiety much, much worse, since she tied a lot of her self image in her ability to work effectively).

Oh, not sure this is relevant, but she's tried a few times to go off her med on her own, without supervision...

As a mental health professional, what drugs would you recommend to her and what kind of treatment options would be the best? Which things would you want to try to address in her history first?

slhuang
04-08-2013, 10:00 PM
Not a MHP, but I just wanted to pop in quickly and warn that I'm pretty sure a "psychotic break" is something very specific (as in, the first psychotic episode), and using the term for your MC strikes me as incorrect. It doesn't sound from your description like she experiences psychosis.

Again, not a MHP, but I thought I'd mention it in case it warrants some checking. :)

Rachel Udin
04-09-2013, 01:45 AM
Slhaung--thanks. Ah, probably wrong terminology. I mean the thing where she would break down from stress, and not talk to anyone, not seem to respond to her environment. Basically curl in on herself and not be able to see much of what was happening. So kinda numb and break from herself. <-- wrong term? So too calm and non-responsive.

Versus an anxiety attack, where she would want to hide and be hyperventilating and hyper aware... feeling like there was a heart attack.

She gets both. Just don't know what to call the first one.

boozysassmouth
04-09-2013, 03:41 AM
MA in Forensic Psych

First thing, when is this set? You were just saying Korea for a while, which no longer exists, but then you say South Korea. Are you refering to North Korea as just Korea, or is this set before the war? That will drastically change what psychological information is available at the time.

You're describing a lot of symptoms there. I can pick out pieces of anxiety disorders, but not a specific one from what you've written. I would want to know if she is afraid of having more panic attacks and if this has reduced her ability to function in anyway. I would also want to know if her fear of social situations rise to the point of being irrational, and if they do, if she's aware of that. Look into panic disorder and social phobia.

As for the depression and psychotic break. You can have depression that's so severe that it's accompanied by psychotic symptoms (hallucinations or delusions, generally).
But it sounds like you're describing nothing more than severe depression. If it were catatonia (which is a psychotic symptom), she's be completely unreachable and either immovable or actually pose-able, as in you move her arms an she says in that pose for hours.

Just being curled in a ball and voluntarily shutting the world out, is just deep depression. Layman would probably call it a nervous breakdown, but that term doesn't exist, psychologically speaking. She could eventually become psychotic, especially if her depression continues to get worse, but I don't think based on what you said, she got to that point. Psychosis is very severe.

In terms of her depression, I'd want to know how many depressive episodes she's had (you need at least one to qualify as having major depressive disorder), how long they've lasted, what treatment she's been given in the past and what has worked and what hasn't, and if she's ever been hospitalized. Most of that applies to the anxiety symptoms as well.

As for treatment, drugs would be antidepressants and anxiolytics. Antidepressants come in three classes: Tricyclics, MAOIs, and SSRIs. SSRIs are the newest, and probably have the fewest side effects (sorry, can't remember), so they'd probably try those first. The only anxiolytics I remember are benzodiazepines, but I think they use some antidepressants now as well.

As for therapies, there's different schools of thought for treating depression. If it was severe, they'd definitely try drugs. Extremely severe cases in which people don't respond to drugs, they may try ECT (electroconvulsive therapy), as this has show some success with these types of cases. It's not the barbaric procedure that you're thinking, the technique is much improved. There are a lot of talk therapies that can be tried, and these would depend on the doctor treating her, and what's been successful in the past.

For the anxiety, aside from meds, it would depend on her disorder. If she can't be diagnosed with a specific anxiety disorder, then it may just be a talk therapy similar to what she'd get for depression, rather than a specific anxiety disorder therapy (like exposure therapy).

Also remember that only psychiatrists can prescribe meds, and from what I understand they aren't usually as well versed in non-drug treatments as psychologists. Though it isn't uncommon to find psychologists and psychiatrists in practice together.

The other thing I should add is that this is American psychology. I don't know anything about North or South Korean psychology.

My memory for treatments is not so good, so someone else please comment and add/correct!

Rachel Udin
04-09-2013, 05:33 AM
Thank you very much! I'll try to answer as much as I can so I can hammer out a better treatment plan than she has currently (which is pretty much nothing.)


MA in Forensic Psych

First thing, when is this set? You were just saying Korea for a while, which no longer exists, but then you say South Korea. Are you refering to North Korea as just Korea, or is this set before the war? That will drastically change what psychological information is available at the time.

South Korea, the first major episode, I think would be circa, 2005-ish? Civil rights took a sharp upturn from that point.

The National Human Rights Commission of the Republic of Korea was established in 2001, so they wouldn't have much clout over this. (The first film to promote human rights was in 2003)



You're describing a lot of symptoms there. I can pick out pieces of anxiety disorders, but not a specific one from what you've written. I would want to know if she is afraid of having more panic attacks and if this has reduced her ability to function in anyway. I would also want to know if her fear of social situations rise to the point of being irrational, and if they do, if she's aware of that. Look into panic disorder and social phobia.

I think it's more social phobias dosed with a large part of denial of a problem too. Mainly performance anxieties, such as being able to meet people's expectations of her in social situations. When she either feels like she will fail those expectations, or does fail those expectations she tends to shut down into either a panic attack or a major depressive episode. (At least, I'm thinking that's her major trigger.)

As for fear of future episodes--not sure... since she tends to live a lot in denial land and put off treatment options. I wouldn't know how to put that... if someone is denying their fear, is that fear at all? Because she tends to deny her anxieties and fears tend to build up, so it hits her hard. (Denial cycle... if she ignores it, it will go away, because she's afraid to face the reality and that builds more fear, etc.)

Mainly, I think she would be afraid of it being public again (i.e. leaking), especially with the stigma still out there. The prejudice is still real in South Korea.



As for the depression and psychotic break. You can have depression that's so severe that it's accompanied by psychotic symptoms (hallucinations or delusions, generally).
But it sounds like you're describing nothing more than severe depression. If it were catatonia (which is a psychotic symptom), she's be completely unreachable and either immovable or actually pose-able, as in you move her arms an she says in that pose for hours.

Catatonia... was looking for that. Wasn't sure if it was the right term. Basically, unresponsive to anything outside, doesn't hear anyone, does not respond. Shuts down. Won't speak or voluntarily eat. From what I know she was like this for about a year after her major break down at 18. She may have been presenting symptoms before that. Not like a panic attack, though, since her thoughts tend to shut down as well, and her breathing stays steady.

Out of body experience?



Just being curled in a ball and voluntarily shutting the world out, is just deep depression. Layman would probably call it a nervous breakdown, but that term doesn't exist, psychologically speaking. She could eventually become psychotic, especially if her depression continues to get worse, but I don't think based on what you said, she got to that point. Psychosis is very severe.

Not sure if it's voluntary since it's triggered by stress???



In terms of her depression, I'd want to know how many depressive episodes she's had (you need at least one to qualify as having major depressive disorder), how long they've lasted, what treatment she's been given in the past and what has worked and what hasn't, and if she's ever been hospitalized. Most of that applies to the anxiety symptoms as well.

She was hospitalized for a whole year after the incident, in the US. First major break down is probably 18. She's had smaller episodes after that, but has been largely managed.

Since I'm not 100% sure how long term hospitalization goes these days, I'm not sure what US treatments would be given to her.

She has had minor panic attacks. Though not major. Mostly in social situations about work performance. Also when she's felt she was "losing friends".

I haven't seen any auditory hallucinations in her yet, but that may because I haven't really gotten much into the specifics of her past.

Most of her treatment has been the US. (which I will joke that Korean dramas often say is better for medicine anyway...)

Not sure how she'll take the transition to South Korean approaches, but it seems to be similar in many instances, though I'm guessing certain approaches may be different since the hardcore drug culture isn't present in South Korea. (South Korea is like Japan--enough drugs to get you functional, but not feeling well.)



As for treatment, drugs would be antidepressants and anxiolytics. Antidepressants come in three classes: Tricyclics, MAOIs, and SSRIs. SSRIs are the newest, and probably have the fewest side effects (sorry, can't remember), so they'd probably try those first. The only anxiolytics I remember are benzodiazepines, but I think they use some antidepressants now as well.

As for therapies, there's different schools of thought for treating depression. If it was severe, they'd definitely try drugs. Extremely severe cases in which people don't respond to drugs, they may try ECT (electroconvulsive therapy), as this has show some success with these types of cases. It's not the barbaric procedure that you're thinking, the technique is much improved. There are a lot of talk therapies that can be tried, and these would depend on the doctor treating her, and what's been successful in the past.

For the anxiety, aside from meds, it would depend on her disorder. If she can't be diagnosed with a specific anxiety disorder, then it may just be a talk therapy similar to what she'd get for depression, rather than a specific anxiety disorder therapy (like exposure therapy).

Also remember that only psychiatrists can prescribe meds, and from what I understand they aren't usually as well versed in non-drug treatments as psychologists. Though it isn't uncommon to find psychologists and psychiatrists in practice together.

The other thing I should add is that this is American psychology. I don't know anything about North or South Korean psychology.

My memory for treatments is not so good, so someone else please comment and add/correct!

I hope that narrows the field a bit. I'm trying to get her into talk therapy again, ^^;; But the character is resisting me by denying there is a problem once she feels better.

Also, how do you talk someone out of trying to reduce their meds on their own?

boozysassmouth
04-09-2013, 08:50 PM
2005 is pretty recent, but whatever you choose, you might want to double check with someone who's been in the field since at least then.

Diagnosing mental illness when it's as mixed as your protagonist is very difficult, and with a person like that, it could take years to get an accurate diagnosis. The same applies to establishing a therapeutic regimen that works.

When you say "out of body experience" that describes dissociation, which is not the same as psychotic symptoms. That's a completely different category of disorders.

My advice to you is if her treatment and recovery aren't your plot, to simplify what you have in mind for her, because you're already pulling from four different diagnostic categories now. And you won't need that much detail anyway. If her treatment and recovery are your plot, I would suggest either calling around to local psychologist/psychiatrists in the field who are currently treating patients, and see if one would be willing to help. Or write the book as a laymen, and give it to a psychologist/psychiatrist to tweak when you're done.

Even if I had every single detail you have in your head about her, I don't know that I could diagnose accurately. I'm just an MA and I don't practice. And I don't know enough about treatments to establish a regimen.

I would also mention that her doctors over here should have knowledge of South Korean culture. Ethical guidelines require it.

Going off meds is pretty common from what I understand, and I imagine it's like convincing a person to do anything else they don't like. You'd have to appeal to her individually, it's more about your character than it is psychology. If all else fails, figure out what will give her the proverbial kick in the pants.

Good luck.

Rachel Udin
04-10-2013, 07:52 PM
Thanks. I was thinking mainly the base causes to be moderate to severe depression and social anxiety. The dissociation, (as it was clarified through discussion) and other problems would be peripheral to those two base causes. (As a coping mechanism for the depression and social anxiety).

Since she's worked on it for 5 years by the start of the story, I don't think I need to 100% focus on her treatment??? (Am I wrong?)

Mostly she needs to be realistic in managing it.

Isn't anxiety and depression often mixed in real life? How is it usually treated?

I'm kinda fishing for a drug(s) to chase after so I can look up side effects and the best way to treat her in talk therapy. I don't need her to be "cured" by the end... but I do need it to be a serious obstacle for her to function and be used against her.

Also, thanks for the heads up on the South Korean culture knowledge thing. I didn't know that.

No insult to boozysassmouth (http://www.absolutewrite.com/forums/member.php?u=70689), but to highlight what was said, Are there MHP around that have a good medical knowledge of treatment and management of social anxiety related to performance and depression combined with a peripheral possibility of dissociation as a coping mechanism for the previous? (I'm thinking maybe related more to the anxiety)

archetypewriting
04-11-2013, 07:58 AM
Me: PsyD in clinical psychology, with particular expertise in mood disorders

First, I'm totally on board with everything boozysassmouth (http://www.absolutewrite.com/forums/member.php?u=70689) has told you, so you're lucky to be getting such good help from her.

One piece of advice I typically give writers is to pick one or two disorders max. More than that and you have a complicated clinical picture. And you have to portray that complicated clinical picture accurately, which can be tough to do, especially consistently throughout a novel. Also, people with complicated mixes of disorders are much harder to help, because they're buried under the weight of so many problems.

Typically it's not just the disorder that's causing the problem, either. It's the snowball effect -- just two examples: the impact on friends, including the ability to get social support; and work, including the ability to earn money and stay employed. Someone with severe depression and severe social anxiety might even be on disability. People with one (or especially both) of these disorders cost employers billions of dollars a year in missed days.

Depression and anxiety are often treated similarly, both in terms of medications and in terms of therapy. If you add psychosis, though, you've got a whole new can of worms.

I think, like boozy said, that you actually meant a "nervous breakdown" rather than a "psychotic break." What's a nervous breakdown? Also as boozy said, it's not a clinical term. Whenever people brought that term up in therapy, I had them explain what they mean. To some people it means they exploded in anger. To some it means they got so emotionally exhausted or stressed out that they stopped being able to get out of bed and face the day. Some mean they started crying and couldn't stop for a long time. It's fine to use the term in your novel...just not by the therapist!


Thanks. I was thinking mainly the base causes to be moderate to severe depression

Chronic low-grade to moderate depression may be dysthymia. There don't tend to be ups and downs with dysthymia, and the person is supposed to have had it for 2 years to be diagnosed with it.

Severe depression is a major depressive disorder, and it tends to wax and wane some. People will occasionally go up to "normal" and then plunge back down into the depression.

Someone with a "double depression" (colloquialism, not an official diagnosis) has both. They are down in the abyss of major depression, but when they come up, they only come up as far as dysthymia, and then go back down.


and social anxiety.

Social anxiety is different from other anxiety disorders. Social anxiety is like a phobia, and would require exposure-based treatments and some cognitive therapy. By contrast, if you meant something like generalized anxiety disorder (constant anxiety with no apparent cause), cognitive therapy still makes sense, but exposure therapy doesn't. (What would you expose someone who's afraid of nothing they can identify to?)


The dissociation, (as it was clarified through discussion) and other problems would be peripheral to those two base causes. (As a coping mechanism for the depression and social anxiety).

Dissociation is not typical of depression or anxiety, and it's (arguably) not so much of a coping mechanism as an escape. Dissociation means you wall off an experience or a part of yourself, either very mildly (you're paying attention to your phone conversation rather than to where you're going and you accidentally find yourself heading towards work) or very severely (for example, with a fugue, where someone develops autobiographical amnesia for some event or information and travels away from home, sometimes unconsciously making up a new identity along the way).

With that having been said, someone who has extremely painful bouts of depression or who's having panic attacks may depersonalize or derealize, which are forms of dissociation. Depersonalization means you disconnect from yourself and feel like you're not entirely real; derealization means you disconnect and feel like the world's not entirely real. This is the time-slows-down-and-everything-feels-surreal thing and is common with car accidents and other traumas. In someone with unbearable depression, the person may just sort of walk around disconnected, apathetic, and numb. In someone with anxiety, the dissociation tends to happen during panic attacks.


Isn't anxiety and depression often mixed in real life? How is it usually treated?

Yes, anxiety disorders and depression are often comorbid. Again, cognitive treatments are usually very effective. (If you want something to look up, try Rational Emotive Behavioral Therapy.) Other theoretical approaches could also be relevant based on why the character has the disorders she has (e.g. Interpersonal Therapy, IPT).

I could spend pages explaining what cognitive therapy looks like. I always hesitate to direct people to The Writer's Guide to Psychology, just because it's a personal plug, but it also seems silly not to direct you someplace where I've already spent many pages explaining in extreme detail how all of this would look in therapy, including exactly how a therapist would interact with and theorize about someone who has these problems, as well as how things like Rational Emotive Behavioral Therapy work and which meds you'd use. (There's also very detailed inside information on ECT in there. Most docs who do ECT won't talk to people who don't also do ECT, but I found a back door.)


I'm kinda fishing for a drug(s) to chase after so I can look up side effects and the best way to treat her in talk therapy. I don't need her to be "cured" by the end... but I do need it to be a serious obstacle for her to function and be used against her.

You'd start with SSRIs, which include things like Prozac, Zoloft, Lexapro, Celexa, etc. and/or possibly (for a severe depression) an SNRI, which would be Cymbalta or Effexor. The SSRIs also are effective with anxiety disorders, because dep. and anx. impact the same neurotransmitters (brain chemicals).

I don't know what you mean by "used against her," but if someone starts these meds and then goes cold turkey on them, she can have a nasty "discontinuation syndrome." In other words, she goes into withdrawal. Cymbalta and Effexor withdrawal in particular can make someone look and feel like they're coming off a much heavier-duty drug. Withdrawal also usually includes relapse into the depression.

Typically the psychiatrist weans you off of an SSRI over time, but Effexor and Cymbalta can be troublesome even when you take that approach.

For anxiety, you could also add something like Buspar or benzodiazepines (Valium, Xanax), though you have to be really careful with benzos because they're enormously addictive. Also, if you are dealing with social anxiety, benzos in particular can interfere with treatment.

In addition to the cognitive therapy (eg REBT) I mentioned above, a therapist may work with someone with social anxiety on social skills, first individually and then in a group.

I started out recommending you pick one or two disorders. I think the major depression and social anxiety hang together just fine, but I'd personally hesitate to throw in the wrenches of dissociation or psychosis. Definitely not both. That feels like a lot to manage to ME in a story, and I've seen very complicated disorder combinations in the therapy room. If you needed something else, I'd add intermittent suicidality.

Hope most of that makes sense and that some of it is helpful!

boozysassmouth
04-13-2013, 03:18 AM
First, I'm totally on board with everything boozysassmouth (http://www.absolutewrite.com/forums/member.php?u=70689) has told you, so you're lucky to be getting such good help from her.

Thanks, I'm actually kind of relieved someone with more expertise than I commented. It's great information that you included.

And I will definitely be passing your website and book info onto other writers I know. :)

archetypewriting
04-14-2013, 07:14 AM
Thanks, I'm actually kind of relieved someone with more expertise than I commented. It's great information that you included.

And I will definitely be passing your website and book info onto other writers I know. :)

Yep, I think you gave great information. And I appreciate you sharing my book info, too! :D

Rachel Udin
04-25-2013, 09:42 PM
Me: PsyD in clinical psychology, with particular expertise in mood disorders

First, I'm totally on board with everything boozysassmouth (http://www.absolutewrite.com/forums/member.php?u=70689) has told you, so you're lucky to be getting such good help from her.

One piece of advice I typically give writers is to pick one or two disorders max. More than that and you have a complicated clinical picture. And you have to portray that complicated clinical picture accurately, which can be tough to do, especially consistently throughout a novel. Also, people with complicated mixes of disorders are much harder to help, because they're buried under the weight of so many problems.

Typically it's not just the disorder that's causing the problem, either. It's the snowball effect -- just two examples: the impact on friends, including the ability to get social support; and work, including the ability to earn money and stay employed. Someone with severe depression and severe social anxiety might even be on disability. People with one (or especially both) of these disorders cost employers billions of dollars a year in missed days.

Depression and anxiety are often treated similarly, both in terms of medications and in terms of therapy. If you add psychosis, though, you've got a whole new can of worms.

I think, like boozy said, that you actually meant a "nervous breakdown" rather than a "psychotic break." What's a nervous breakdown? Also as boozy said, it's not a clinical term. Whenever people brought that term up in therapy, I had them explain what they mean. To some people it means they exploded in anger. To some it means they got so emotionally exhausted or stressed out that they stopped being able to get out of bed and face the day. Some mean they started crying and couldn't stop for a long time. It's fine to use the term in your novel...just not by the therapist!



Chronic low-grade to moderate depression may be dysthymia. There don't tend to be ups and downs with dysthymia, and the person is supposed to have had it for 2 years to be diagnosed with it.

Severe depression is a major depressive disorder, and it tends to wax and wane some. People will occasionally go up to "normal" and then plunge back down into the depression.

Someone with a "double depression" (colloquialism, not an official diagnosis) has both. They are down in the abyss of major depression, but when they come up, they only come up as far as dysthymia, and then go back down.



Social anxiety is different from other anxiety disorders. Social anxiety is like a phobia, and would require exposure-based treatments and some cognitive therapy. By contrast, if you meant something like generalized anxiety disorder (constant anxiety with no apparent cause), cognitive therapy still makes sense, but exposure therapy doesn't. (What would you expose someone who's afraid of nothing they can identify to?)



Dissociation is not typical of depression or anxiety, and it's (arguably) not so much of a coping mechanism as an escape. Dissociation means you wall off an experience or a part of yourself, either very mildly (you're paying attention to your phone conversation rather than to where you're going and you accidentally find yourself heading towards work) or very severely (for example, with a fugue, where someone develops autobiographical amnesia for some event or information and travels away from home, sometimes unconsciously making up a new identity along the way).

With that having been said, someone who has extremely painful bouts of depression or who's having panic attacks may depersonalize or derealize, which are forms of dissociation. Depersonalization means you disconnect from yourself and feel like you're not entirely real; derealization means you disconnect and feel like the world's not entirely real. This is the time-slows-down-and-everything-feels-surreal thing and is common with car accidents and other traumas. In someone with unbearable depression, the person may just sort of walk around disconnected, apathetic, and numb. In someone with anxiety, the dissociation tends to happen during panic attacks.



Yes, anxiety disorders and depression are often comorbid. Again, cognitive treatments are usually very effective. (If you want something to look up, try Rational Emotive Behavioral Therapy.) Other theoretical approaches could also be relevant based on why the character has the disorders she has (e.g. Interpersonal Therapy, IPT).

I could spend pages explaining what cognitive therapy looks like. I always hesitate to direct people to The Writer's Guide to Psychology, just because it's a personal plug, but it also seems silly not to direct you someplace where I've already spent many pages explaining in extreme detail how all of this would look in therapy, including exactly how a therapist would interact with and theorize about someone who has these problems, as well as how things like Rational Emotive Behavioral Therapy work and which meds you'd use. (There's also very detailed inside information on ECT in there. Most docs who do ECT won't talk to people who don't also do ECT, but I found a back door.)



You'd start with SSRIs, which include things like Prozac, Zoloft, Lexapro, Celexa, etc. and/or possibly (for a severe depression) an SNRI, which would be Cymbalta or Effexor. The SSRIs also are effective with anxiety disorders, because dep. and anx. impact the same neurotransmitters (brain chemicals).

I don't know what you mean by "used against her," but if someone starts these meds and then goes cold turkey on them, she can have a nasty "discontinuation syndrome." In other words, she goes into withdrawal. Cymbalta and Effexor withdrawal in particular can make someone look and feel like they're coming off a much heavier-duty drug. Withdrawal also usually includes relapse into the depression.

Typically the psychiatrist weans you off of an SSRI over time, but Effexor and Cymbalta can be troublesome even when you take that approach.

For anxiety, you could also add something like Buspar or benzodiazepines (Valium, Xanax), though you have to be really careful with benzos because they're enormously addictive. Also, if you are dealing with social anxiety, benzos in particular can interfere with treatment.

In addition to the cognitive therapy (eg REBT) I mentioned above, a therapist may work with someone with social anxiety on social skills, first individually and then in a group.

I started out recommending you pick one or two disorders. I think the major depression and social anxiety hang together just fine, but I'd personally hesitate to throw in the wrenches of dissociation or psychosis. Definitely not both. That feels like a lot to manage to ME in a story, and I've seen very complicated disorder combinations in the therapy room. If you needed something else, I'd add intermittent suicidality.

Hope most of that makes sense and that some of it is helpful!
Thanks so much.

I think I was fishing for these two things:


Severe depression is a major depressive disorder, and it tends to wax and wane some. People will occasionally go up to "normal" and then plunge back down into the depression.

With that having been said, someone who has extremely painful bouts of depression or who's having panic attacks may depersonalize or derealize, which are forms of dissociation. Depersonalization means you disconnect from yourself and feel like you're not entirely real; derealization means you disconnect and feel like the world's not entirely real. This is the time-slows-down-and-everything-feels-surreal thing and is common with car accidents and other traumas. In someone with unbearable depression, the person may just sort of walk around disconnected, apathetic, and numb. In someone with anxiety, the dissociation tends to happen during panic attacks.
But as I have no medical knowledge, only instinct, I didn't know how to express it.

Which means I'm on the right track... which was what I was hoping for.

Cognitive Therapy looks about right and also I'll take a look at the SSRIs.

Just to clarify on the backlash, it's a cultural problem. In South Korea, there is a severe backlash against those who have mental illnesses. As late as 2007 (according to WHO), more people committed suicide than went into mental hospital care, with the majority in mental hospital care there after a major episode, such as suicide. So she'd suffer from a lot of personal judgment for having a public anxiety attack.

Both of you have been extremely helpful. Thank you again.