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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by jhj on August 12, 2007, at 0:41:05
I am 29 years old male from India. I am suffering from severe social phobia right from the childhood.I started treatment before around 7 years because previously i had heard nothing about social anxiety disorder.My phobia is so severe that i can not talk to anybody unless i am forced to except with my mom.I do not talk to my father and brother either unless it is necessary.I have tried following drugs so far.Paroxetine
fluoxetine
escitalopram
alprazolam
clonazepam
diazepam
clobazam
chordiazepoxide
venlafaxine
amisulpride
pregabalin
gabapentin
buspirone
lamotrigine
tiagabineIn addition to that i have also tried CBT.These all drugs have only given me terrible side effects.I am ready to tolerate these side effects too,if there is any benifits from these drugs.My symptoms have not improved by even one percent.I want your advise on the drugs that i have not tried so far and should try.I will appreciate your help because i am frustrated now.
Posted by Racer on August 12, 2007, at 2:36:09
In reply to severe social phobia help desired, posted by jhj on August 12, 2007, at 0:41:05
I guess I asked this before, but what sorts of side effects were you experiencing with these drugs? And what specific symptoms are you seeking help with? It's hard to know what to suggest, despite your list -- it would be easier if there were some clues, such as "paroxetine was too sedating," or "fluoxetine increased my anxiety," etc.
It might also help to know things like, "the symptoms I most need help with include sweating and racing heartbeat/intrusive thoughts/negative ruminations/whatever it is."
See, the thing is, everyone has a different need, even with the same disorder. If that wasn't the case, we wouldn't need all these drugs. So, especially for anxiety related disorders, it really helps to know if your problem is more akin to, say, obsessive compulsive disorder, or atypical depression, or whatever. It would help a lot in making suggestions.
Also, although I know right now it feels that way, but are you *certain* you've never experienced *any* benefit of any kind on any of these drugs? Only the adverse effects? I ask because I often find that when I'm in the depths of whatever bad feeling I've got, it feels as though nothing has ever been better, and no drug has helped, etc. Right now, though, I'm fairly functional on these meds, so I know that I have received benefits from them, even if they weren't perfect. I wonder if your perspective on this might be a little skewed right now?
Good luck.
Posted by girlnterrupted78 on August 12, 2007, at 7:45:37
In reply to severe social phobia help desired, posted by jhj on August 12, 2007, at 0:41:05
I notice you haven't tried Citalopram (Celexa).
Citalopram worked wonderful for me for social anxiety and depression. Why not give it a try?
Escitalopram didn't work for me at all (even though it's so similar to Citalopram), and neither did Paroxetine.
Clonazepam and Alprazolam might work if you use them in specific situations, and along with an antidepressant that WORKS.
When I was taking Citalopram, I used Alprazolam for severe situations (like public speaking or meetings) and it helped a lot. But just by itself it didn't help. If I'd take it everyday, it'd only made me sleepy, so I only took it when the situation would be very severe.
Were you abused as a child? Did someone harass you, abuse you, or bully you when you were growing up? When did you start having these problems?
Give us more details please, so we can come up with more info for you.
Best wishes
Posted by steel on August 12, 2007, at 9:19:06
In reply to severe social phobia help desired, posted by jhj on August 12, 2007, at 0:41:05
>
> I am 29 years old male from India. I am suffering from severe social phobia right from the childhood.I started treatment before around 7 years because previously i had heard nothing about social anxiety disorder.My phobia is so severe that i can not talk to anybody unless i am forced to except with my mom.I do not talk to my father and brother either unless it is necessary.I have tried following drugs so far.
>
> Paroxetine
> fluoxetine
> escitalopram
> alprazolam
> clonazepam
> diazepam
> clobazam
> chordiazepoxide
> venlafaxine
> amisulpride
> pregabalin
> gabapentin
> buspirone
> lamotrigine
> tiagabine
>
> In addition to that i have also tried CBT.These all drugs have only given me terrible side effects.I am ready to tolerate these side effects too,if there is any benifits from these drugs.My symptoms have not improved by even one percent.I want your advise on the drugs that i have not tried so far and should try.I will appreciate your help because i am frustrated now.I agree that a benzo will be the icing on the cake ONCE you have found a drug to help.
Thanks for sharing that is not a race card thing,or even a hemisphere thing,from india to a kid in the "western pop world" these demons do more than harm,they slowly torture it seems.
Reading your list,and well know it doesent look good comming from a strong moai user,or least a advid ssri anti advocate,id say i dident notice any of the common maois there,parnate,nardil,deprenyl,etc.
I can imagine india must have different meds avaialbale,does this in anyway work out to your benifit too?Any meds unconventional here you might find there?
I have heard of people from my way lol getting there meds from india,so something is lost in translation.
Regardless keep on trying,its something to know just because locals might not show it,there are people all the way to the U.S waking in the morning to the same live in jail cell.Best wishes.
Posted by Phillipa on August 12, 2007, at 11:54:21
In reply to Re: severe social phobia help desired, posted by steel on August 12, 2007, at 9:19:06
Just a thought you say you've had this since age seven? or was it seven years and you have suffered since childhood . Could it be some sort of ADD or ADHD since it started in childhood. Reason your're aware of you can't talk to your father or other family? Love Phillipa ps do you see a pdoc or a regular doc?
Posted by med_empowered on August 12, 2007, at 16:47:29
In reply to Re: severe social phobia help desired, posted by steel on August 12, 2007, at 9:19:06
if your social phobia is rooted in a deep-seated fear of something/someone, or some sort of urge to withdraw, it may not respond too well to drugs until you address other factors.
Its odd that you didn't respond to benzos. How high did you push the dose? Generally speaking, if you're still anxious on a benzo, you just need a higher dose, unless there's something else going on with you, like depression or some sort of psychosis.
Have you tried opiates? Or an anticonvulsant, like oxcarbazepine? Or a stimulant? Weirdly enough, some socially phobic people do well with an upper (like modafinil, amphetamine, methylphenidate, etc.) plus a downer (clonazepam, diazepam, etc.). Even using bupropion plus a benzo-type tranquilizer can be a really good combo, or Parnate plus a benzo.Anyway, do keep trying.
Posted by jhj on August 13, 2007, at 0:27:31
In reply to Re: severe social phobia help desired, posted by Racer on August 12, 2007, at 2:36:09
Thanks for your reply.
I can not say specifically about particular drug's side effect because i was always on combination of drugs.But,I can say that SSRI gave me severe stomach pain and stomach acidity.Venlafaxine and Mirtazapine constipation and all the banzo made me feel drowsy and i felt like sleeping for 24 hours.But,I can tolerate these adverse effects if they are accompnied by symptoms improvements.
The exact symptoms are as described below.
When I meet any person,the first thought comes to my mind is that I am inferior person and he is superior to me.I feel like the other person is observing my every movement and I feat that either he is laughing at me,he will humiliate me or he will insult me or if he is person of some authority he will get angry with me.When I am supposed to go to anybody's home,I start thinking about that "frightning" moment and i keep on thinking about the same thing till i go to person's home.I am not able to think anything else during that period.I mean the anticipatory anxiety is very tough.I feel like I am "on the edge".This is the feeling when person feels that some imminent danger is near.Many times,my hands tremble just before meeting or during meeting also.Well,I am not in the depths of bad feeling.The phobia has not become worse right now then it was before.I mean it is horrible definitely but it is same as it always was and not increased right now.And,I can say very confidently that none of the drugs or combination of drugs has any positive impact whatsoever. I have neve said doctor that there is even small improvement in my symptoms.I hope i have made myself more clear.Thanks once again.
Posted by jhj on August 13, 2007, at 1:00:09
In reply to Re: severe social phobia help desired » jhj, posted by girlnterrupted78 on August 12, 2007, at 7:45:37
Thanks for your wishes.You are right I have not tried either citalopram or sertraline.Do you really think there is any difference between citalpram and escitalopram.In case of sertraline also,can it be successfull if other SSRI have failed? You are saying about taking alprazolam or clonazepam along with antidepressant that "WORKS".But,So far i have not found any antidepressant that works even remotely.I have GAD,dyshymia,IBS and Avoidant personality disorder also in addition to social phobia but these problems started much later than social phobia.My problems started right from when i was 7-8 years old.I used to confine myself to one room whenever any guest came to our place.I was not abused or harrased by anyone.My parents are great and they have raised me with lot of love and care.I have never faced any harrassment from anybody else also.You can say that I have normal childhood like anybody else in terms of treatment given to my by various people around me.I can not even speak to another person let alone speaking in public or meetings.Even that thought is frightning me.thanks again.
Posted by jhj on August 13, 2007, at 1:12:03
In reply to Re: severe social phobia help desired, posted by Phillipa on August 12, 2007, at 11:54:21
I have these problems since childhood but I did not know there is anything like mental disorder in this world.I knew all along that i am abnormal and weird person.It is only before seven years that i started seeing doctors.I have seen only "pdoctors" and they are many.After that i was diagnosed with GAD,dyshymia,IBS na AVPD also.The reason i am not able to speak to my father is may be i am afraid of him but i do not know why? Because he has raised me with lot of care and given lot of sacrifices along the way.The other reason may be because since i developed chronic deperssion i remain sad and do not like speaking to anybody.Also,Because my father and other family members except my mom are refusing to believe that any such things like depression,anxiety etc. exists.Thanks.
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.
Posted by jhj on August 13, 2007, at 2:43:27
In reply to what's going on in your life?, posted by med_empowered on August 12, 2007, at 16:47:29
I have gone up to 2 mg/day of clonazepam but my phobia is also accompnied by chronic depression(Dyshymia).Opiates are controlled substance in India and is not approved for any mental disorder.Among anticonvulsants,i have tried lamotrigine and gabapentin. Among stimulant,i have tried modafinil.Bupropion+benzo(Clobazam),i am currently trying but there is no improvement.As far as pernate is concerned,no pdoctor here considers MAOI as option because they think they are dangerous drugs.But,i have heard that after taking MAOI several people have become very talkative.If that is the case then i have to force my pdoctor to try this option.Thanks for suggestions.
Posted by Sigismund on August 13, 2007, at 17:12:01
In reply to Re: severe social phobia help desired))racer, posted by jhj on August 13, 2007, at 0:27:31
>When I meet any person,the first thought comes to my mind is that I am inferior person and he is superior to me.I feel like the other person is observing my every movement and I feat that either he is laughing at me,he will humiliate me or he will insult me or if he is person of some authority he will get angry with me.
You do come from a culture that has a distinct sense of heirarchy, of relative status.
Perhaps you are very sensitive to this?
Posted by jhj on August 14, 2007, at 2:26:08
In reply to Thanks for the details, they help -- very long » jhj, posted by Racer on August 13, 2007, at 2:22:00
Thanks Racer for your detailed reply.I am impatient well atleast, for reduction in symptoms if not elimination.
Well, you are right i have not tried either citalopram or seartraline.All the antipsychotics you have mentioned are available in India.By the way,I am 29 years old.I will tell you something about why i am impatient.My culture is such that when person reaches some age(around 25),he(or she)is expected to get married othewise,all the family members put lots of pressure as i am subjected to.Nobody knows anything about anything like "social phobia".Also,a person needs to take care of parents partly because of lack of social security and partly because of joint family system.My parents are coming to stay with me from December and i can not even take care of myself.You have suggested psychotherapy but,there are not many good psychotherepist around and i do not think i took CBT from right person because hardly few CBT therepists exist in my country. Also,here i can not freely give suggestions to pdoctor because he or she would fill offended because i am hurting doctor's ego and self prescribing inspite of knowing nothing.
These are the reasons no pdoctors would take me seriously if i say i want to start with say monotherapy.As per my stomach problems,well,i already have GERD and gastritis and drugs make them worse.
I will try babbleometer but i am not feeling much down as i had said earlier.My depression mostly remain constant because i have dysthymia(minor chronic depression).I have heard very good things about nardil's effectivenyss in social phobia.Is not it worth trying?
Posted by cumulative on August 17, 2007, at 0:08:56
In reply to Re: Thanks for the details, they help -- racer, posted by jhj on August 14, 2007, at 2:26:08
Yeah. Do a search for nardil + "social phobia". Very, very effective. The gold standard.
www.socialphobia.com
Posted by jhj on August 18, 2007, at 4:13:42
In reply to Re: Thanks for the details, they help -- racer, posted by cumulative on August 17, 2007, at 0:08:56
Hi cumulative
Thanks for the information.I too have read at several places about the efficacy of Nardill in Social phobia.But,i have heard that its side effects are horrible.The other thing is that here in India,it is extremely difficult to pursuade any pdoctor to prescribe andy MAOI.But,i think i would give it a try.surely.
Posted by cumulative on August 18, 2007, at 21:05:59
In reply to Re: what about side effects cumulative?, posted by jhj on August 18, 2007, at 4:13:42
IMO (or at least, for me -- someone who cannot stand any degree of cognitive impairment) if you can follow the diet and be strict about it the side effects are nothing compared to SSRIs or benzodiazepines, especially after a while.
I understand the difficulty you have. I volunteered in a little village in South India for three months, end of last year.
There's a lot of conservatism and ignorance, frankly. But there's also a great deal of goodness and enlightenment -- I wish you luck in finding some help.
In the village I was in we were constantly exposed to trash fires and choking smog -- the products of unregulated globalization hitting home. I am fairly sure the level of toxic metals/fumes etc. that the people in Sivakasi were regularly exposed to is going to have an effect on mood/mental functioning, especially with time. Call it a hunch.
I once saw a group of children dancing around a trash fire full of burning plastic. Sucks.
Again, good luck man.
Peace,
cumulative
Posted by jhj on August 19, 2007, at 0:17:43
In reply to Re: what about side effects cumulative?, posted by cumulative on August 18, 2007, at 21:05:59
It is nice to read from a person who has closely seen real India because real India leaves in Villages.Your concerns about people of Sivakasi are right then in making fire crackers child labours are also used.But currently we are facing the problem of choosing between either environment and child labour or employment and livelyhood.Very tought.
But,i have a problem regarding NARDIL.i have come to know from somebody that no MAOI is approved in India.If i still want to have NARDIL can i import it from online pharmacy on the basis of pdoctor's prescription or can he get it imported? I do not know the procedure.Thanks
Posted by fuzz54 on August 22, 2007, at 12:17:31
In reply to Re: how to get Nardil in India?-cumulative, posted by jhj on August 19, 2007, at 0:17:43
I haven't tried a MAOI, but everything I have ever read about extreme anxiety and especially social anxiety is that Nardil is the way to go. It's only avoided by some doctors / countries because they don't understand that it is a safe drug for the majority of people if the dietary restrictions are followed.
As for India ignoring that mental illness exists, my therapist agreed to some degree. She came from India to get her degree here (USA) and then went back to India to do what she could to improve the situation.
jhj, I find that I am relating to the problems you describe and to your life more than I do with most people. I can't quite explain why, except that I had dysthymia, anhedonia, social anxiety and GAD for at least 3 or 4 years and it was almost more than I could handle. And before that my whole life was spent with high anxiety, although not to your extent. Just know that I understand a little about what it's like to have your diagnosis and I sympathize. I have to think that someday you will get some relief. The world still has a long long way to go towards treating mental illness and we are going to see some big changes in treatments in our lifetime.
Posted by jhj on August 23, 2007, at 0:38:09
In reply to Re: how to get Nardil in India?, posted by fuzz54 on August 22, 2007, at 12:17:31
Thanks dear for all your sympthies.It is really nice post and i appreciate it.Thanks again.
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