Chapter Text
Beck was unconsciously tapping his leg, while seated in the waiting room, anticipating his name being called out. He knew sometimes Liz ran late with her appointments, and he wasn’t in any hurry.
Over the past few months, Beck had noticed he was having panic attacks more frequently. He had become accustomed to experiencing them once or twice a month after he had moved into the RV and had felt a lot more in control of his anxiety. However, over the last two months, he had had three to four each month, sometimes a week apart, other times closer to ten days apart. He couldn’t pinpoint any specific triggers or anything in his life that was causing him enough undue stress that would be resulting in his attacks increasing this much.
He had managed to – with some difficulty – keep it from Jade just how frequently they were now occurring. He was starting to become anxious about the attacks, and how they could occur whenever he least expected it. It meant he had been a bit more on edge when speaking to his friends, and he and Jade had more petty arguments – why did it take you an hour to text back? I was worried! Or Why are you so late?! We’re going to miss class! – between them than was usual.
But he was starting to get worried about how often they were occurring, and just how much it was affecting him. He was sick and tired of how wound up about them he was, not to mention the exhaustion that lasted for days, particularly after the really bad ones. So, he had brought forward his next appointment with his psychiatrist.
Elizabeth called out for Beck and gestured for him to come into her office. “Beck, how have you been?” Liz asked, as Beck walked in.
“Hi, Liz. I’m alright, how are you?” Beck responded politely but on autopilot.
“I’m doing well.” Liz paused, raising an eyebrow at his response to her, and gently asked again, “How have you really been, since the last time I saw you?”
By now, Beck had been seeing Liz for the greater part of almost two years and they had developed decent rapport between each other. He knew very well that there was no point in attending if he wasn’t expressive with how he truly was doing.
“I’ve been having the attacks a lot more, lately. It’s why I rescheduled our appointment to today, instead of in a couple weeks’ time,” Beck explained, not beating around the bush.
“How frequently? Have you been keeping a diary, like I initially suggested?” Liz asked, referring to her advice that the more the attacks occurred, the better it was he write down when it happened, where, how often and what was going on beforehand, along with what symptoms he experienced, and his thoughts at the time.
Beck shook his head. “No, not really. Not the way you suggested it, anyways. I did write down when it happened into my phone, so I could keep track of how often they are, but not with as much detail as you asked. I did note anything I could remember, but most of them seemed to happen either at school or when I was on my own in the RV, and I only got the chance write it down after I had slept it off, so I didn’t always remember much.”
Liz held out her hand, requesting the phone. Taking the phone, she spoke, “Recording anything is good. For the next while, even if you record it on your phone, try to include the details, as much as possible. Try to also include how you felt you handled it. Whether you were able to employ any of the techniques I’ve shown you, or if there’s anything else that you’ve found that helps ground you. And if you can, try to write it out before you sleep it off. I know it’ll most likely be difficult, I know how exhausted you are after them, but you most likely will remember key details which could help isolate if there is a trigger.”
She was silent for a few moments as she read briefly through what he had recorded. She handed back his phone, “This gives me a good idea of how often they’re occurring, but it isn’t enough to see if there’s a common theme across them. Has anything happened or changed in the last few weeks? Or a reoccurring thought that’s been bothering you?”
“No, not really. Nothing I could pinpoint,” Beck sighed, annoyed. “I’ll try to keep more detailed entries then. I’ve tried to think of what could be causing it, but honestly, I can’t work it out. I figured once I moved into the RV, and the anxiety improved, that was it. I don’t understand why it’s getting worse.”
Liz could hear the underlying frustration in Beck’s voice. “Beck, unfortunately it isn’t as easy as always being able to remove the trigger and expecting yourself to not be anxious at all. Yes, removing triggers can improve it, but it is possible there are other triggers, but we just haven’t linked them to your attacks.”
Beck sighed but nodded. They had discussed this before, especially in the months after he had moved out; he had been somewhat surprised he had still been experiencing panic attacks.
“Would you say you’re experiencing any undue stress? School? Friends? Jade?” Liz enquired. “Like we’ve discussed before, stress can come in so many different forms. Sometimes, it could just be that you’re already on edge, and a classmate or a teacher says something you don’t like, and if you find yourself just suppressing that ‘annoyance’, it can fester to where the presence of that person starts stressing you out. I’m not saying this is what’s happening with you, but not everyone realises that sometimes it’s the smaller things we may consider insignificant but that do bother us.”
Beck nodded slowly, taking in what she was saying. “I probably am stressed, but I can’t pinpoint why, exactly. A lot of things have been annoying me where they normally wouldn’t. I just kind of put it down to being tired from the attacks, to be honest.”
“I think we might have some more insight at your next session, if you’ve been able to note down what I asked.” Liz then asked, “How have you been handling the panic attacks this frequently?”
Beck ran a hand through his hair, as he replied, “Like I said, I’m tired a lot more now. Sometimes, I only feel like I’m myself for a couple days before I have another one, and it’s been really draining.” He paused, then continued, “I’m worried it will start affecting my schoolwork and performances.”
“Has it been affecting you in other ways, as well?” Liz prompted. “When our body is rundown or tired, it can start affecting our mood and how we handle day to day things that annoy or irritate us.”
“I have been a bit more on edge than normal… I feel like Jade, and I have been having more stupid arguments as well. And I know most of it is because of me, but sometimes I can’t hold my tongue and she’s not exactly one to sit there and take it,” He chuckled, sadly.
At the mention of Jade’s name, she raised an eyebrow, sceptical. “Have you told Jade about the attacks happening more often?”
Beck looked away for a moment, before meeting Liz’s eyes, confirming her suspicions. “No, I haven’t.” Not waiting for Liz to prompt him, he added, “At first, I didn’t realise, and I wasn’t hiding them from her, exactly… they just happened when she wasn’t present. After a while though, it was just never a good time to mention it. If she was around, she would make me take a Valium or Xanax almost straight away, and by the time I woke up, I would still be exhausted, and just didn’t want to worry her.”
Liz looked at him thoughtfully, “And you don’t think she would want to know? Even if she is worried? You’ve told me before that she wants to help you with the attacks, and that you’re comforted by her presence. So, why are you trying to deprive her of the opportunity to be there for you, and yourself of her comfort?”
“I just – she’s already been there for me for so much of it. I don’t want to keep adding to it, if I don’t need to. I don’t want to worry or upset her.” He attempted to divert the subject from Jade. “It’s why I changed our appointment, to see if there was… a medication we could consider. I know initially you mentioned something to take regularly, and I told you I wouldn’t take it. I’m willing to consider taking it, if you can tell me more about it.”
“We’ll discuss that in a few moments. Let’s go back to what you said about not wanting Jade to be worried or upset. She already knows. She has already proven she wants to be there for you. Beck, by not telling her, you’re taking away the choice from her.” She stopped for a moment, taking note that he was avoiding eye contact with her, and clearly wasn’t willing to agree on this. “With your attacks happening more frequently, has anyone around you noticed? I know one of your biggest concerns is other people finding out.”
A worried look entered his eyes, but he answered, “I don’t think anyone’s noticed. But it’s been making me a lot more worried, because I don’t know when or where they’re going to happen and I’m anxious a lot of the time. What if I have one in front of strangers, or even my friends, other students, even teachers?! I don’t want them to know about this. I don’t even know what I could even say, I don’t even know why they’re happening!” Beck rushed out.
Liz took exaggerated deep breaths and gestured to Beck to do the same. She counted out his breaths, how long to hold his breath for and how long to exhale for. After a few minutes, Beck was more relaxed, but still concerned.
“Beck, I know we’ve previously discussed others finding out, so for the time being, we’re not going to get into it. But I just want to remind you, that there is nothing wrong or shameful” (repeating a word Beck had used in the past to describe the attacks, and himself) “with you for suffering through these. Okay?”
Beck nodded, unconvinced, but wanting the topic to drop.
“First, I just want you to remember that isolating yourself from your friends, and particularly Jade, isn’t going to help your anxiety. It’s going to feed into it, and it might even be some of what’s causing these attacks to trigger as much as they are. If you’re getting worked up about the thought of having another attack, it could start, if it hasn’t already, triggering another attack, and it just becomes a vicious cycle. Does that make sense, Beck?”
Beck looked thoughtful, not having thought of that. “Yeah, it does. You’re saying that because I’m worried about not knowing when I might have an attack, the anxiety could be triggering another attack.” He looked up at her, asking, “So, what do I do?”
“Well, like you mentioned earlier, there are medications. In terms of regular medications… what we discussed briefly before was a class of medications called ‘selective serotonin reuptake inhibitors,’ or SSRIs. We’ve spoken about serotonin before, and how it’s responsible for balancing out emotions like happiness. The way these medications work is to stop the reuptake of serotonin into the cells, meaning it extends the duration of its action in you. These are tablets you need to take as close to the same time each day. But there are side effects, Beck, especially when you first start using the medication.”
Liz stopped to see how Beck was absorbing this information. Most of it she had already mentioned to him, but it had been some time since, and she wanted to make sure he understood. She knew that teenagers especially struggled with adherence to taking regular medication – Beck had already slipped multiple times and told her that when he was experiencing a panic attack, it was most often Jade who made him take either Valium or Xanax. If left to his own devices, Beck usually didn’t reach for the medications, making her think it had been the same as of late, if Jade wasn’t aware of the attacks increasing.
“Side effects can include mood changes. These can be slight, but can also be quite abrupt or aggressive, compared to what temperament you usually are. There can be disruption to sleep, irritability, reduced sexual appetite, an increase in seeking out danger and self-harm.” She paused, looking at Beck carefully. “Now, I know that all of this sounds fairly concerning. Most of these are only until you stabilise on the medication, which can take up to 6 weeks, sometimes less. It also doesn’t mean you will experience all of these, or even some of them. It’s a possibility that you will, nothing more.”
Beck looked a bit overwhelmed, so she stopped to ask him, “Beck? I need you to explain to me your concerns, so that I can address them, before going into more detail.”
Liz had mentioned several side effects that Beck was now worried about, and wondering if the medication was even worth the trouble if it could cause all of this. “I could become aggressive?”
“Not necessarily, but it is a possibility, Beck. The medication causes mood swings, while it takes time to stabilise those emotions in your body. If you’re already aggravated, yes it could cause you to become aggressive. But you could also experience real low moments, instead. It means your emotions may be a lot more varied than you’re used to. Usually with mood changes, along with some of the other side effects such as self-harm and risk-seeking activities, I generally encourage my patients to tell at least one person that they’re taking the medication, so they can look out for you. A lot of the time, some of these things you may not recognise in yourself, but someone who is around you constantly will be able to.”
Beck wasn’t sure if he wanted to tell Jade if he did decide to start the medication. He felt embarrassed that he was feeling so out of control that he was resorting to it, and even though Jade had been nothing but supportive, she didn’t need this. She had plenty on her plate already.
“Beck, if you do decide to go ahead with taking SSRIs, I want us to discuss who you would be comfortable to tell that you’re taking it. I think it would be good for you, and that person can help support you. But first, what other concerns do you have with the side effects I’ve mentioned?”
Liz already knew Beck did occasionally self-harm. “You mentioned self-harm. Would I want to do it more than I already do sometimes?”
Liz explained gently, “When you first start taking the medication, your body needs time to adjust to the medication before it can regulate serotonin to where it will benefit you. During that time, which can be somewhere between 4-6 weeks, most commonly, you may feel some of your symptoms worsen. Mood changes can also be really low ‘lows’, or your anxiety could peak, and it could lead you to self-harming, maybe differently to how you normally want to. Normally, it’s because it breaks you out of the cycle of anxiety, right?”
At Beck’s nod, she continued, “Well, you might lean towards it because you’re feeling really sad or upset, instead. Because you have previously self-harmed, you are more likely to reach for that coping mechanism, especially if you don’t have any other coping strategies in place.” She realised he wasn’t entirely reassured, but she was proud he had raised it himself. It was usually her that raised the topic of self-harm in their sessions, except the first time he had admitted to it.
“Have you been finding yourself wanting to self-harm recently? Especially with the spike in attacks?”
Beck replied, “Yeah. I don’t always realise I’m doing it, but after the past few attacks I’ve noticed marks on my palm. Even when sometimes I feel myself itching for it, to calm the uneasy feeling down, I can’t always do much anyways. If I’m with my friends, or with Jade, I know she’ll get worried, and stop me.”
Liz nodded but reiterated, from a previous session, “I’m happy that you’re less inclined to because you know it would concern Jade but try out some of the techniques we’ve been through. Self-harm is a coping mechanism your mind has let you take on to distract you from the anxiety you’ve been experiencing. If we can replace it with other coping mechanisms, it will help you to not be so quick to self-harm.”
“For the time being though, like I’ve mentioned, there is a possibility you’ll lean towards self-harming more than usual. Try to go for a run, spend time with Jade, or your friends, or use a stress-ball over the next few weeks to help distract yourself. You have my personal number, Beck. Don’t be afraid to use it, if you need me to talk you down, or you’re struggling, or just need to talk,” Liz advised. “Do you have any other concerns, Beck?”
Beck shook his head, then looked up, slightly flushed. “You said it could affect my sexual appetite?” He voiced in a low tone.
“It is possible. But it may also only affect you, if it affects you, during the first few weeks, and when your body adjusts to the medication, it may wear off. If not, we can always switch to a different type of medication, instead.” She answered, professionally, in a sensitive manner; it was evident Beck was quite embarrassed to be discussing this. When Beck nodded in acknowledgement, she then asked, “Are you willing to try an SSRI out?”
Beck hesitated. “It’ll reduce the panic attacks?”
Liz replied gently, “The aim is to reduce your anxiety overall, and hopefully how frequently you’re experiencing the panic attacks. I do need to warn you, Beck, that these types of medications are not a ‘one fit for all’.” She was observing Beck, checking to see how much he was absorbing the information.
Liz went on, cautioning, “Just because this medication may have worked for another patient, doesn’t mean it will for you. Or it could work, but you decide you can’t tolerate the side effects. Or we may just need to play around with the dose. But yes, that’s our aim.”
Beck took a deep breath, and then agreed, “Okay, I’ll try it out.”
“It’s important with these medications that you don’t stop cold turkey, Beck. The side effects can be a lot worse, as your body would have had time to become accustomed to the medication helping you regulate serotonin and stopping abruptly throws that all out of sync. So, even if at the start you want to stop taking it, or further down the track you want to stop, please let me know. We can take you off it slowly so that you don’t have a bad experience coming off it, okay?” Liz reassured.
Beck nodded.
“Okay, now, back to who you are going to tell you’re taking this. Who would you be comfortable with knowing this, and is around you enough that they can watch out for you, and support you?” Liz asked, lightly. She was hoping she could get past his reluctance and have him agree to confide in someone.
Beck had gotten comfortable telling Liz the truth. “I don’t know if I do want to tell anyone,” He admitted, leaning back into his seat.
“Beck, I explained why I suggested you do so. I can’t force it, but can you explain to me why you don’t want to?”
“The only person who I could consider is probably Jade. But she has enough on her plate. She’s got a lot going on at home, and I don’t want to cause her extra stress or worry. I should be looking after her, she shouldn’t need to always have to look after me.” Beck said, quietly.
Liz had noticed over the course of their sessions that Beck had hinted at Jade’s family life. The impression she had been left with was that it wasn’t at all pleasant, and that she had suffered quite a bit. Liz had some suspicions, but nothing concrete. She didn’t know too much; she knew of the members of Jade’s family, her parents’ divorce and the partners.
But even when it had some relation to what Beck was going through, Beck remained tight-lipped about Jade. Liz had managed to get him to open-up enough to know there were insecurities in their relationship, and she had addressed some of those with Beck, but even though she suspected some of Jade’s insecurities, Beck refused to touch on anything that he considered ‘personal’ to Jade, even where it affected Beck.
“Beck, that’s not how a relationship works. You both are there to help and support each other. It doesn’t matter if at times one person needs a bit more support than the other, especially if they’re willing to give it. It’s give and take. If you don’t let Jade support you, you’re isolating yourself inside of your relationship. Without communication and trust, your relationship can’t be successful.” Liz reminded him gently of what they had discussed a few instances in the past, especially soon after he would close off if they touched at any of Jade’s ‘personal’ topics.
“I’ll think about telling her,” Beck relented a little, but Liz was unconvinced he would do so.
“Like I said, I can’t force you, but I do think you should.” Liz said. “I’ll give you the script for the SSRI. It’s called sertraline (or Zoloft), and you’ll be starting on 50mg daily. It does come in 100mg tablets, too, so we can increase the dose if need be.” She went to her desk, to print out the prescription, along with a patient information leaflet containing general information such as side effects to reiterate what she had already gone through with him. Beck followed her over to the desk, standing on the other side of it. “Here. There’s the script, and an information leaflet. It mentions the side effects we’ve discussed, along with some of the rarer things, as well. Keep in mind, just because it is listed there, it doesn’t mean it will happen to you.”
She eyed him carefully, concerned about his decision. “Beck, especially since you aren’t telling anyone, I would like you to make fortnightly appointments with me so we can check in and see how you’re going.”
Beck nodded but looked a little worried at the thought of starting the medication. He got up, parting with, “Thanks, Liz, I will,” and started heading out of her office.
“Oh, and Beck?” As he turned to look at her, she reiterated, “Don’t forget, you can always call me at any time, okay? If you can’t talk to Jade or anyone else, you can always contact me, okay?”
Beck shot her a grateful smile and left. He made his next couple of appointments two weeks apart and entered them into his phone calendar so he wouldn’t forget.