Posted by Racer on August 13, 2007, at 2:22:00
In reply to Re: severe social phobia help desired))racer, posted by jhj on August 13, 2007, at 0:27:31
Hi, JHJ. Now that you've told us a bit more, I think I have a much clearer picture of what's going on for you. Let's see if that means I can offer something more helpful to you.
First of all, it sounds as though you've got some obsessive-compulsive symptoms going on. Your description of the ruminations involved in your anticipatory anxiety sounds an awful lot like my obsessive-compulsive routines. You're right, that sort of thing really is pretty debilitating. It also sounds as though you've got two sets of symptoms to address -- the physical symptoms, such as racing heart, sweating, etc; and the psychological symptoms. I admit I have a bias here, but I think you'll have to attack the psychological symptoms with more therapy -- drugs alone won't go very far to fix that part of it.
(By the way, I know English is not your first language. You do seem very fluent, and pretty much all the Indians I've ever met have spoken English very well. If there's something that you don't quite get, please do ask. I know that my writing isn't always as clear as I'd like it to be.)
So, what do I recommend? Well, forgive me because I think you did tell us how old you are, but I've forgotten. What I do know, though, is that you're younger than I am, and probably pretty impatient to feel better. I understand that, but it's not going to make what I have to say very welcome: I think you need to start drugs one at a time, and give them time to work before adding on another, or switching entirely. I hate hearing about doctors starting multiple drugs at one time, because that just muddies the waters so much. The biggest problem with that, though, is that it means it'll take a while to find out what will work best -- unless you luck out, which could happen.
So, paroxetine didn't do anything for you? Out of the SSRIs, fluvoxetine is considered the most sedating, which is often good for anxiety, with paroxetine coming in at a close second. Fluvoxetine is approved here in the US for Obsessive Compulsive Disorder, rather than depression, but it might be worth trying. It is worth trying sertraline or citalopram, even though the other SSRIs haven't been overwhelmingly successful. They're all different enough that it's worth trying them all. My own experience with them was that sertraline is my favorite, with fluoxetine second. But, I'm not a huge fan of any of the serotinergic drugs -- I get pretty apathetic, and have a problem with weight gain on them. The thing is, they really are pretty effective for OCD for many, many people, and what you're describing sounds a lot like OCD-related symptoms.
With all the SSRIs and SNRIs, you'll have some stomach trouble to begin with. That usually passes after a period of weeks to months, depending on the individual. Most of the serotonin produced in your body is used in the digestive tract, rather than the central nervous system, so stomach trouble is almost inevitable. But, for most people, it does pass. I've found good results with ginger beer -- have a ginger ale or ginger beer, and it'll help settle your stomach until the problems pass. Taking the acid reducers also helps.
For physical symptoms, I think you mentioned having taken propranalol? Did that help with the physical symptoms? If so, I'd suggest -- strongly, in fact -- that you try taking propranalol as needed, and then attacking the negative thoughts through therapy. Learning some relaxation techniques, learning to calm yourself, will go a long way for you. Learning some assertiveness should also help. NOT to make you stand up to everyone, just to be able to remind yourself that you have a right to be here, as much as anyone else. Verapamil is another drug which might be helpful.
I'd also suggest trying another anti-psychotic. I don't know what medications are available in India, but quetiapine is a good option, as would be risperidone. Olanzapine is also pretty successful, but causes some side effects that would worry me, so it's hard for me to recommend it. (Although I do know some people who do really well on it.)
Overall, I think you're going to have to come at these problems from a couple of different directions. Medications will only go so far, and you've got to learn to control those negative thoughts, which is what therapy can help with. Since you've tried CBT without good results, I think you'd do well to find a therapist who follows either interpersonal or psychodynamic models. As far as medications are concerned, I guess I'd attack the mood disorder separately from the physical symptoms of anxiety. Starting out with an antidepressant, and then attacking any remaining symptoms once that's stabilized.
That's actually a key to my recommendations on this: start one drug at a time, and give it time to stabilize. There are algorithms out there to show how doctors recommend making medication decisions. Mostly they say about the same thing: start with an SSRI, wait six weeks, and re-evaluate. If there has been ANY improvement whatsoever, increase the dose and check back in another four to six weeks. Again, if there's additional improvement, raise the dose again. If there are too many side effects, consider the severity: if they're too severe, try another drug; if they're tolerable, add another drug. Basically, though, you're looking at about three months on one drug, which probably won't be knocking your socks off, before you know whether a drug might be helpful or not. That's a lot of time -- but it's still less than the seven years you've been trying so far.
Also, I know you've said you had absolutely no improvement whatsoever in any of yoru symptoms. I'm not suggesting that you don't believe that -- but I will respectfully suggest that you may be feeling so down right now that you forget the improvements you did experience. For that reason, I also suggest using the Babbleometer on this site, or other self-assessment tests to see how your symptoms are doing. It may be that you've had more improvement than you're aware of. It could also be that I'm wrong, and you've never had any improvement. But a more objective measure might help you track your progress.
I hope something in there is helpful to you. Good luck.
poster:Racer
thread:775682
URL: http://www.dr-bob.org/babble/20070808/msgs/775919.html