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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by psychobot5000 on August 14, 2007, at 14:35:01
Hi,
So here's a question: I've got a friend who's being medicated for social anxiety. She doesn't need anything too dramatic, but something to help frequent attacks at work or class without causing sedation (SSRIs and SNRIs make her very drowsy, and benzos make her feel drugged. Wellbutrin was not helpful.). Her provider, a psychiatric nurse practitioner, is one of these SSRI-brainwashed types with nothing more to offer beyond those options (zoloft and lexapro first, then cymbalta, then, reluctantly, wellbutrin and lorazepam). Everything (except the wellbutrin) worked very well, but the problem is the sedation (or druggy feeling with the lorazepam)--she'd nap a quarter of the day on zoloft or lexapro--a little less on cymbalta.
Now her provider wants to start over with zoloft or cymbalta because "we've tried everything people usually try." She apparently seems very self-satisfied that the non-SSRI alternatives didn't work.
Any suggestions for alternative social-anxiety meds? My thought was that she could try a tricyclic (a less sedating one), but unfortunately she has some -very slight- suicidal tendencies. Does anyone know a good alternative, or a way to make a tricyclic workable (she might need only a low dose, and thus not much medication on hand)? Some other popular antidepressants like Remeron or trazadone seem to me too sedating to be useful, but I thought there might be something else she could try.
Might a different (short-acting) benzo feel less druggy than lorazepam? Or maybe modafinil might help the drowsiness side-effects of the SSRIs? Is there something else altogether to try?
Any suggestions or comments would be very helpful!
Thanks everyone,
Psychbot5000
Posted by Phillipa on August 14, 2007, at 22:20:59
In reply to Friend needs alternative to SSRI/benzo for anxiety, posted by psychobot5000 on August 14, 2007, at 14:35:01
Why not an extremely low dose of a benzodiazepam cutting the pills into little pieces once I was only on .125 of xanax every other day and it worked fine. That was all. Love Phillipa
Posted by med_empowered on August 15, 2007, at 2:40:07
In reply to Re: Friend needs alternative to SSRI/benzo for anxiety » psychobot5000, posted by Phillipa on August 14, 2007, at 22:20:59
i think a tricylclic is a bad call; they're not that great for anxiety. MAOIs, however, are; my first choice would be Parnate, maybe plus an as-needed benzo, then the EMSAM patch (again, with an as-needed tranquilizer for at least a little while) and then Nardil.
Sometimes upper/downer combos work. For example: Klonopin is good for social phobia, and sometimes adding Wellbutrin, Provigil, or low-dose Ritalin helps alot, too. I would think clonazepam would be better than lorazepam if there's a need for day-long sedation; most of the dose can be taken at nite.
Posted by SometimesBlue on August 15, 2007, at 10:02:47
In reply to Friend needs alternative to SSRI/benzo for anxiety, posted by psychobot5000 on August 14, 2007, at 14:35:01
The only suggetion i can offer is, from my experience, Provigil/Modafinil helped to counteract the drowsiness/tiredness when i was on Zoloft, then Lexapro (depression & anxiety).
When I was on it at first with the Zoloft, it did aggrivate my anxiety, and so I switched to Lexapro with the Provigil and the anxiety was relieved.
Hope that helps some.
-blue
Posted by fuzz54 on August 17, 2007, at 13:00:12
In reply to Friend needs alternative to SSRI/benzo for anxiety, posted by psychobot5000 on August 14, 2007, at 14:35:01
A few suggestions... Some SSRIs can be activating and others the reverse, so she might be wise to give Prozac or Paxil a try. I wouldn't assume that all SSRIs will be sleep inducing just yet. Also, an herbal supplement that works for myself and my girlfriend for times of very high anxiety / panic is Suntheanine. There are many different manufacturers of Suntheanine, so just pick one. It is the only herbal supplement that I have ever used and found it to do anything for anxiety without causing sleepiness. Valerian root works for anxiety too, but it makes me sleepy. Suntheanine only works when my anxiety is high though, not when it is just a little bit higher than normal. It is a mild drug, just like most herbal supplements are, but it does actually do something for me and works a lot better for my girlfriend. She swears by the stuff when she needs to take the edge off of panic / anxiety while teaching in front of 30 middle schoolers.
Posted by blueboy on August 18, 2007, at 8:36:11
In reply to Friend needs alternative to SSRI/benzo for anxiety, posted by psychobot5000 on August 14, 2007, at 14:35:01
Okay, please don't take this the wrong way. I have to say this even though I don't know how to do it without sounding a bit like a jerk, but: make sure she has exhausted CBT possibilities. I'm a believer in meds when needed, but still, it's better if you can get by without taking anything.
I have two situations in which I use Klonopin. First, I will take 2.5-3 mg at night to relieve anxiety-induced insomnia and restless leg syndrome; the effect lasts all the next day. (I am a big guy and somewhat overweight.) This does cause some drowsiness but wow, what a relief to break an anxiety cycle.
However, I sometimes take 1 mg before I go out in the evening, which causes me absolutely no drowsiness but definitely relieves social anxiety. So 1/3 of the "normal" dosage for my body, that is, the dose that fully relieves GAD, has a marked temporary effect of relieving social anxiety. (Sometimes I will just put the pill in my pocket in case I start freaking out, withdrawing, etc.)
I should also say, I have an addictive personality, so I pick and choose my occasions carefully. I'm in a "club" where some members think I shouldn't take it at all.
> Hi,
>
> So here's a question: I've got a friend who's being medicated for social anxiety. She doesn't need anything too dramatic, but something to help frequent attacks at work or class without causing sedation (SSRIs and SNRIs make her very drowsy, and benzos make her feel drugged. Wellbutrin was not helpful.). Her provider, a psychiatric nurse practitioner, is one of these SSRI-brainwashed types with nothing more to offer beyond those options (zoloft and lexapro first, then cymbalta, then, reluctantly, wellbutrin and lorazepam). Everything (except the wellbutrin) worked very well, but the problem is the sedation (or druggy feeling with the lorazepam)--she'd nap a quarter of the day on zoloft or lexapro--a little less on cymbalta.
>
> Now her provider wants to start over with zoloft or cymbalta because "we've tried everything people usually try." She apparently seems very self-satisfied that the non-SSRI alternatives didn't work.
>
> Any suggestions for alternative social-anxiety meds? My thought was that she could try a tricyclic (a less sedating one), but unfortunately she has some -very slight- suicidal tendencies. Does anyone know a good alternative, or a way to make a tricyclic workable (she might need only a low dose, and thus not much medication on hand)? Some other popular antidepressants like Remeron or trazadone seem to me too sedating to be useful, but I thought there might be something else she could try.
>
> Might a different (short-acting) benzo feel less druggy than lorazepam? Or maybe modafinil might help the drowsiness side-effects of the SSRIs? Is there something else altogether to try?
>
> Any suggestions or comments would be very helpful!
>
> Thanks everyone,
> Psychbot5000
Posted by psychobot5000 on August 18, 2007, at 15:04:43
In reply to Re: Friend needs alternative to SSRI/benzo for anxiety, posted by fuzz54 on August 17, 2007, at 13:00:12
Thanks for the idea on the SSRIs--I'll suggest she give Prozac (or maybe Luvox) a try, as I've heard it's the most activating of them. Thanks also for the theanine suggestion--I'm also a bit of a fan of it. Unfortunately, it happens that it doesn't seem as effective for her (she tried it on my suggestion), but I do think it's a fine, inoffensive thing to try before things like benzos. Glad other people are on to it.
Thanks for your suggestions!
Posted by fuzz54 on August 21, 2007, at 22:35:01
In reply to Re: Friend needs alternative to SSRI/benzo for anx » fuzz54, posted by psychobot5000 on August 18, 2007, at 15:04:43
> Thanks for the idea on the SSRIs--I'll suggest she give Prozac (or maybe Luvox) a try, as I've heard it's the most activating of them. Thanks also for the theanine suggestion--I'm also a bit of a fan of it. Unfortunately, it happens that it doesn't seem as effective for her (she tried it on my suggestion), but I do think it's a fine, inoffensive thing to try before things like benzos. Glad other people are on to it.
>
> Thanks for your suggestions!Rosavin is another herb similar in efficacy to Suntheanine for me. It just relaxes me in general. It's perhaps a bit milder than Suntheanine, but might work for your friend to make things just a little better.
Posted by psychobot5000 on August 23, 2007, at 1:03:37
In reply to Re: Friend needs alternative to SSRI/benzo for anxiety, posted by blueboy on August 18, 2007, at 8:36:11
> Okay, please don't take this the wrong way. I have to say this even though I don't know how to do it without sounding a bit like a jerk, but: make sure she has exhausted CBT possibilities. I'm a believer in meds when needed, but still, it's better if you can get by without taking anything.
>Good point--usually best to hit all sides of the problem, if possible. She appreciated being reminded about CBT--good of you to mention it, since it often is hard to talk about that without seeming like a 'jerk,' as you put it. She is doing therapy, by the way.
ALso, very much appreciate the dose recommendation on the benzodiazepine--one of the options she's going to try is small doses like that, to avoid sedation, but she wasn't sure how much less to use. Thanks!
Psychbot
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