Perhaps you’ll remember from the first chapter that rumination—
the continual replaying of unpleasant thoughts—is a component in all
emotional explosions. Rumination has many forms, from the terrifying
apparitions of PTSD haunting consciousness in search of the words that will
lay them to rest, to the much more common replaying of incendiary words—
predictions of doom or assignments of blame—that fan the flames of fear,
sadness, and anger. The common element is the repetition that people
feel is out of their control. It’s possible that the automatic replay button
in the brain is in the cingulate gyrus, an area implicated in obsessive-
compulsive disorder, which is characterized by uncontrolled repetition
and treated with—you guessed it—serotonergics.
What I have observed in hundreds of patients is that these drugs
somehow make it easier to stop thinking negative thoughts. Countless
times I have relied on this property of medication to help me sneak in a
few positive thoughts edgewise. When you’re doing therapy on explosive
disorders, you need all the help you can get.
Serotonergics fall mostly into two classes.
TRICYCLICS. These are an older form of antidepressant, among the sero-
tonin norepinephrine reuptake inhibitors (SNRIs). Imipramine, the first
drug in this class, is still used to treat panic disorder. Amitriptyline is also
used. As antidepressants, tricylics have two drawbacks: They tend to be
more sedating than newer drugs, and in rare cases they can lead to heart
rhythm irregularities. The sedating part sometimes makes tricyclics espe-
cially useful in treating fear disorders.
Amitriptyline, which can be sedating enough to make a normal per-
son sleep for two days, is sometimes quite effective in taking the edge off
panic and acute anxiety without the danger of addiction. Trazadone, a
serotonin antagonist reuptake inhibitor (SARI) somewhat similar to drugs in
this class as well as to those described below, is sedating but metabolizes
more quickly. It is often prescribed as a safe sleeping aid, which is helpful
to people with fear disorders. The chief complaint that my clients have
about tricyclics is that they make them feel groggy and drugged, with a
dry cottony mouth, which comes from anticholinergic effects. Tricyclics
also have some of the same side effects as serotonin reuptake inhibitors.
These will be discussed in greater detail in the section on depression.
88 ❧Explosions into Fear