Posted by 3 Beer Effect on June 26, 2002, at 6:04:41
In reply to Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 19, 2002, at 19:41:30
I have one of the newer textbooks on Social Phobia & Dr. Liebowitz appears to be one of the leaders in his field in research on this often neglected & chronic condition & I think along with (Dr. Davidson?) is even considered a "celebrity" by Social Phobics for helping to shed light on proper treatment of this condition & for conducting clinical trials of clonazepam, alprazolam, & SSRIs that show (numerically) the amount of symptom improvement for each on the LSAS- Liebowitz Social Anxiety Scale.
My 2 questions to Dr. Leibowitz are:
1. Is a double-blind trial of Ativan (lorazepam) going to be performed, or has one already been done? Since there are conflicting reports with some (such as Prentice Hall Nurse's Drug Guide 2002) saying that Ativan is the strongest of the benzodiazpines (with the obvious exception of IV only Versed), I wonder if Ativan might be superior to Klonopin for Social Phobia in clinical trials or have a different side effect profile (e.g. more or less sedation/memory impairment at equivalent doses).2. Also, has anyone looked at the potential value of Dexedrine/Dextrostat (dextroamphetamine) for treating social phobia? I have found that, unlike other ADD psychostimulants, in low doses (such as 10-15 mg/day) dextroamphetamine is effective for Social Phobia even by itself,
but more importantly I discovered by accident that the combination of dextroamphetamine & Klonopin (in the standard Social Phobia dose of 2-4 mg/day) is one the most effective treatments for Social Phobia. For many this combo is as effacious (or more so) than SSRIs but with a lower incidence of side effects (especially sexual side effects & Prozac/Zoloft insomnia). Thus, for those who can't tolerate SSRIs, have Social Phobia without Depression, or have ADD w/ Social Phobia, the dextroamphetamine/clonazepam could become an valuable treatment option especially since the MAOI Nardil is rarely prescribed anymore.
If Social Phobia double-blind clinical trials & LSAS reduction scores on these medications have not been done before I wonder if Dr. Liebowitz could use his influence to get university funding & someone (such as a psychopharmacology resident or doctoral student for his thesis) to do a double-blind clinical trial on the both the effectiveness of dextroamphetamine for Social Phobia, & more importantly a double-blind clinical trial for
THE COMBINATION OF: dextroamphetamine (low doses=10,15mg/day & ADD doses=20, 30 OR 40 mg/day) WITH clonazepam (in the standard social phobia dose of 2-4 mg/day in 2 to 3 divided doses).
-My own experience with Dextrostat & Klonopin-----My own experience with Klonopin by itself at 3 mg/day: 1 mg breakfast, 1 mg lunch, 1 mg at sunset has been somewhat dissapointing, especially when compared to alcohol, which for me has in the past had unparalleled efficacy for Social Phobia (although I haven't drank since Sept. 11th). Unlike moderate doses of Alcohol (2-3 drinks), Klonopin does not appear to make you more outgoing/confident at 2-3 mg daytime dose, or even 4 mg split into 3 doses (1 breakfast, 1 lunch, 2 at bedtime) although it does alleviate general anxiety to some extent. I have switched a few days ago to a dose I am hoping will be more effective: 4 mg/day in the daytime: 2 mg @ breakfast & 2mg either at lunch (4 hours later) OR 6 hours later (not sure which time of 2nd dose will be best yet). To improve sleep I now take Ambien 10 mg because unlike Benzodiazepines, Ambien does not supress the important stages 3 & 4 (deep sleep), is much more bioavailable (70%) than Sonata (30%) & has been shown to maintain efficacy for up to 6 months with little evidence of tolerance (source: G & G's Pharmalogical Guide to Therapeutics 2001).
Obviously, over a period of time the risks of alcohol often outweigh the benefits especially in people self-medicating for Social Phobia or Anxiety disorders.
By accident, however, I discovered a wonderful combination which is almost as effacious as Alcohol for Social Phobia.
THE COMBINATION: a fairly low dose of either 5mg Dexedrine or 10 mg Dextrostat tablets (both are dextroamphetamine) 2x or 3x per day COMBINED with the 'standard' Social Phobia dose of Klonopin 2-4 mg/day split into 2 or 3 doses. Those with both Social Phobia & ADD will benefit from higher doses= Dextrostat of up to a maximum of 40 mg/day divided into 2-3 doses, although the higher doses required for ADD cause a bit more anxiety in some.I have tried all of ADD psychostimulants & found out that the old neglected drug Dexedrine/Dextrostat has all the advantages of mental stimulation that occur with Ritalin or Adderall but without the increased social/general anxiety that accompanies those two drugs.
Ritalin seems to be the worst offendor for causing shyness/social inhibition/nervousness around others & studies in Rats have come to the same conclusion that Ritalin is anxiogenic. Adderall causes MUCH less social anxiety than Ritalin, shares many of the same positive effects as Dexedrine/Dextrostat such as increased talkitiveness & self-confidence & may have some utility for Social Phobia if it is combined with a high-potency benzodiazepine. But since Adderall contains the peripheral side-effect causing l-isomer of amphetamine it is less selective for dopamine than Dex, & most importantly it affects/releases Norepinephrine to a greater degree. One of the most popular theories implicates Norepinephrine as a significant contributor to anxiety in Social Phobia while increased availability of Dopamine & Serotonin seem to improve the condition (which could be why SSRIs & possibly Dexedrine/Dextrostat can be effective for Social Phobia, while Wellbutrin SR & Desipramine are not.
Right now I am going through a one-month trial of Adderall 30 mg 2x per day & you can actually feel/notice the peripheral (l-isomer of amphetamine) side effects of increased heart & breathing rate, anxiety, nervousness & somewhat disturbing lack of appetite (After all Adderall was originally the amphetamine diet pill Obetrol). There seems to be different stages of Adderall & the first one is euphoric (probably since Adderall is 1/4 Dexedrine) but some of the other stages feel somewhat or even downright dysphoric & feel somewhat like the Ephedrine Hcl found in Primatene Asthma Tablets (Synthetic Ephedrine Hcl is a potent CNS stimulant, but is probably the strongest anxiogenic/nervousness & dysphoria causing medication I have ever taken).
Anyways, Dexedrine/Dextrostat in low to moderate doses (15-25 mg/day) combined with Klonopin 2-4 mg/day seems to be an ideal treatment for Social Phobia. Klonopin gets rid of (general) anxiety & social anxiety if people approach you/ask you a question or your opinion, but most of the time seems to give a non-euphoric/blah/somnolent feeling.
Dexedrine, however, even by itself, makes you much more outgoing/talkative & less inhibited (& combined with Klonopin is about as close as you can get to 1-2 drinks of alcohol but without the cognitive impairment). Dexedrine increases confidence, immediately alleviates even severe depression (although only for 5 hours per dose), & changes ones' attitude to one of healthy optimism (the glass is instantly half-full instead of half-empty). Not only that but work & mental performance even in those without ADD can sometimes improve markedly, procrastination becomes a thing of the past, & all this is accomplished with a remarkably low level of anxiety (nonexistant in my case).
The bottom line is that seems that it gets rid of timidity/fear of failure which is a major barrier to success in life for social phobics & also (temporarily) lifts the mood which the benzodiazepines fail to do. All this is done without the oftentimes ridiculous side effects of the SSRI anti-depressants. I found Zoloft 100mg to be the greatest thing since alcohol for Social Phobia, but its significant sexual side effects can be doubly frustrating- you talk to & end up dating more women, but your doubts about your ability to perform b/c of SSRI anorgasmia or ridiculously delayed time to ejaculation (1 to 1 1/2 hours even though I was 23 at the time & before without medication lasted 15-30 minutes). I couldn't even begin to imagine the negative impact this all-to-common SSRI side effect would have on a married middle-aged male.
Thank you.
poster:3 Beer Effect
thread:110299
URL: http://www.dr-bob.org/babble/20020617/msgs/110794.html