![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 26. This is the beginning of the thread.
Posted by Jasmine on September 4, 2004, at 13:08:20
Hi everyone!
I've been visiting this board for over a year now and I've posted a couple times, but usually just read everyone's advice. Anyway, I could really use some advice right now. This may be a fairly long post so I apologize in advance.I was diagnosed with severe social anxiety 5 years ago and was immediately put on medication. Since that time, I have tried so many meds and therapies and even my pdoc is saying I have pretty much run out of options, which makes me feel pretty hopeless. I'm only 22 years old and have already pushed away all of my childhood friends and am too shy to make news ones, so I am basically friendless. I just wanted to see if anyone had any other suggestions about what I could take to help myself. Here is a list of what I've tried so far...
-Paxil (Worked the best for making me social, but also made me want to sleep all day and the sexual side effects were intolerable)
-CBT (worked for getting rid of panic attacks, but I still live with the constant anxiety)
-Xanax (worked well but not something I could use for mono-therapy)
-Celexa (didn't work at all)
-Ativan (made me feel depressed)
-Prozac (didn't do anything)
-Nardil (worked pretty well but I gained 18 lbs. in 3 months and that's too much for my 5'5" frame)-Parnate (didn't work at all)
-Effexor (made me feel too "weird")
-Selegiline (made the anxiety worse and didn't help anything else)
-Ritalin + Klonopin (I'm taking this now, but it isn't making a noticable difference)So if anyone has any advice of other meds or combinations I could try, I'm open to all advice. I'm suppsoed to call my pdoc later this week to update her so I'm hoping for some ideas to pass along to her. I hate to be picky, but I don't want to deal with sexual side effects or more than 10lbs of weight gain so maybe that limits my possibilities. There must be a combination out there that can work for this. I'll take any advice anyone is willing to give me, thank you all so much!
Jasmine @-->--
Posted by pseudonym on September 4, 2004, at 18:23:03
In reply to Social Anxiety help pleeeeaase!, posted by Jasmine on September 4, 2004, at 13:08:20
I too have suffered from social anxiety for as long as I can remember. For myself, Klonopin gets rid of a good deal of the anxiety (@ 1mg/day) but it certainly does not help what I would call the sociability aspect. I imagine for you, Xanax was also helpful in a similar fashion. Both things that worked in some way for you (Xanax and Nardil), enhance the effect of GABA, a neurotransmitter. I know that pregabalin (Lyrica) will be out soon, and although it was not indicated for Generalized Anxiety, physicians may indeed find it clincally useful for that purpose. It seems clear that SSRI's do not address the social anxiety, they don't for me either. Perhaps you could try Klonopin + Cymbalta. I believe Cymbalta is weight neutral as well.
Posted by King Vultan on September 5, 2004, at 10:41:07
In reply to Social Anxiety help pleeeeaase!, posted by Jasmine on September 4, 2004, at 13:08:20
The best ones for me have been Nardil and the tricyclics. Enhancing norepinephrine transmission seems to very helpful in my case as far as increasing self confidence, but increasing NE can also raise general anxiety. I would suggest considering desipramine, which has a low incidence of weight gain (I found it to be a powerful appetite suppressant, YMMV), perhaps combined with Klonopin. If your pdoc is not crazy about desipramine, Strattera has a fairly similar pharmacologic profile but is more expensive. The Cymbalta + Klonopin suggestion might also be a good one. I also found the SSRIs and Effexor to not really address my fundamental problem, but I am hoping Parnate works out better for me than it did for you.
Todd
Posted by Michael Bell on September 5, 2004, at 23:41:51
In reply to Social Anxiety help pleeeeaase!, posted by Jasmine on September 4, 2004, at 13:08:20
Jasmine, I feel your pain. I've tried just about everything under the sun for SP, so I'll try to give you some advice on the most effective meds and combos.
1) Stuff that has worked for me, to varying degrees:
Klonopin
Nardil
Picamilon
Tramadol
Amisulpride
Adrafinil
Klonopin + Prozac + Adderall2) Meds I'll be trying in the near future:
Buprenorphine
Proglumide
TianeptineOverall, the most effective combo has probably been: Klonopin + Picamilon + Adrafinil
Posted by Jasmine on September 6, 2004, at 14:28:40
In reply to Re: some possibilities » Jasmine, posted by Michael Bell on September 5, 2004, at 23:41:51
Posted by steveb on September 6, 2004, at 14:52:52
In reply to Re: some possibilities » Jasmine, posted by Michael Bell on September 5, 2004, at 23:41:51
Michael,
I'd stay away from buprenorphine. I've taken it on and off over the past 5 years, and while it works wonders for just about everything (GAD, SP, depression and physical pain), the side effects and withdrawal symptoms are just not worth it. Buprenorphine is a powerful opiate, several times stronger as a painkiller than heroin. And like heroin, the cons far outweight the pros.
I say I've been "on and off it" because of the following recurring cycle: I forget the negatives and just remember the wonderful feeling of calm & confidence. So when I've felt really low I start taking the drug for a month or so and just put up with the side-effects (constipation, cratchy skin, pin-prick pupils, erectile disfunction, etc) until I realize, once again, that I just can't live the life of an opiate addict. So I quit, and however slowly I taper, i have to deal with the 5-10 day withdrawal. And believe me, that's just as bad as getting off heroin (I speak with experience). Then 6 months later, I'm feeling really low, and bingo I'm on the merry-go-round again.
Well, my unused Subutex tablets have been sitting in my bathroom cabinet for over a year now. I'm happy to know they're there (as a very last resort), but I'm not going anywhere near them ... for a long time I hope...
So brother, my advice to you is stay away from buprenorphine. Like all potent opioids/opiates, it's an ugly ride.
All the best.
> Jasmine, I feel your pain. I've tried just about everything under the sun for SP, so I'll try to give you some advice on the most effective meds and combos.
>
>
> 1) Stuff that has worked for me, to varying degrees:
> Klonopin
> Nardil
> Picamilon
> Tramadol
> Amisulpride
> Adrafinil
> Klonopin + Prozac + Adderall
>
> 2) Meds I'll be trying in the near future:
> Buprenorphine
> Proglumide
> Tianeptine
>
> Overall, the most effective combo has probably been: Klonopin + Picamilon + Adrafinil
Posted by Philidor on September 7, 2004, at 16:46:13
In reply to Social Anxiety help pleeeeaase!, posted by Jasmine on September 4, 2004, at 13:08:20
OK, my dear. Here's something you might try. I have SP myself PLUS ADHD.
I was taking until last week dexedrine plus klonopin(2mg, twice daily).
Twopoints here. The Klonopin helped a lot with the SP; enables me to do things I could never do, like smile back at an attractive woman who smiles at me, instead of looking down as I used
to. (Oh, the nights I've wasted!)But it's not enough. Once the fear is controled by the Klonopin, you gotta make yourself get out there and start TESTING it:socializing as the new, less bashful, more smiling Jasmine, in situations where you couldn't.
That's the only way you'll really know the stuff is working, because you don't usually feel any kind of effects from clonazepam, as you would with, say, 3 belts of Jack Daniels.
Some people find that Dexedrine plus Klonopin is super-duper as an SP cocktail, the one lowers your fear, and the other gives you that extra boost to your confidence to go out and mingle. Here's one guys review from another board:
http://www.remedyfind.com/review_long.asp?id=5052&review_id=9939
Some say dexedrine, has more of a socializing effect than Ritalin, which is more ("focusing".)
Of course, everybody's different. So I'd say:1)Ask your doc to switch you from Ritalin to Dexedrine and
2) "Test" your Klonopin in your most feared social setting to make sure you're taking an adequate dose.Best of luck,
Philps I had to quit the dex because it fizzled out.
Posted by mattw84 on September 7, 2004, at 18:03:52
In reply to Re: Social Anxiety help pleeeeaase!, posted by Philidor on September 7, 2004, at 16:46:13
That is great info phil, thanks much! My current dx is ADHD/Dep./SP and I have pretty much been my pdoc's guinea pig as far as meds go it seems.
My current meds:
Wellbutrin xl 300mg daily
Adderall 10mg 3x dailyAs of last week I had a real "breakdown" and the doc wants me to add Paxil too, and continue with the wellbutrin at the same time. She also gave me 8 0.5 mg Xanax pills to get me through the "brunt" of this past weeks woes. I have to admit I feel so much more at ease and my SP seems to disappear for a while after taking a xanax. I see the doc again on weds and would like to ask to continue the xanax, but I suspect she is going to want to continue with the SSRI's even though we've tried about 10 others. I am worried that if I directly ask for them she will think I am looking to abuse them, cuz she already warned me that they are easily abused and addictive. I have never been addicted to anything nor abused any meds, and she knows this. I guess my point is, did your doc suggest the klonopin or did you have to ask for it?
Thanks
Posted by Jasmine on September 8, 2004, at 0:57:53
In reply to Re: Social Anxiety help pleeeeaase!, posted by Philidor on September 7, 2004, at 16:46:13
Thank you Phil! :) I think I'm going to definitely ask my doctor about this. Here's how I feel about my Ritalin + Klonopin combo so far.... I can only take .25mg of the Klonopin in the morning and .5mg at night because otherwise it just makes me sluggish. I'm not sure if I'm just sensitive to this med or if it's because I only weigh about 100 lbs. At .25mg I find it to be the most effective so I can actually walk around my university campus and not freak out if I "accidentally" make eye-contact with someone walking by. As far as the Ritalin, it's definitey time for a switch. I'm not sure if it's because it's generic ritalin, but it only really helps me for an hour max while my doctor says it should be at least 4 hours. I was shocked to find a stimulant didn't make me more anxious or happy really, but I would say it makes me "smiley" (or so I've been told). I'm used to walking around with a grumpy face so people won't want to approach me.
I can just imagine how great it would be if it was stronger (as maybe the dexedrine will) and if it lasted a bit longer. Today in my university lecture class I actually had the urge to raise my hand and ask a question in front of everyone which I never ever thought I'd do. But soon after that, I could feel the med crashing and I retreated back into my shell. It's a disappointing feeling, ya know.
I would like to add something more stable to my cocktail to keep me a little more "even" between doses. Maybe a little bit of Paxil or Zoloft but not too much so as to try and avoid as many side effects as possible.
But thank you for your reply and sorry if I rambled on a bit, but it's nice to get advice from someone who understands where I come from instead of most people who just think i'm making it all up in my head.
I'm sorry the dexedrine pooped out on you, I wish you the best in finding something to equal its effect.
Take Care!
Jasmine (aka. Tiffany :))
Posted by Philidor on September 8, 2004, at 19:07:11
In reply to Re: Social Anxiety help pleeeeaase! » Philidor, posted by mattw84 on September 7, 2004, at 18:03:52
Greetings matt,
I would say, having used it, yes indeed Xanax is great for social anxiety AND is well-known to also have an antidepressant effect for many.BUT it is NOT approved as a stand-alone treatment for depression, and it's almost unheard of for doctors to use it so except an an adjucnt to an established AD, which they often do.
Yes, I had to ask my doctor up-front for the Klonopin, when the Lexapro she gave me didn't do the job. She politely declined. I showed her the evidence that when it comes to SP, the SSRI's are grossly overrated, and that Klonpin has proved far superior. (You'll find some here):
www.socialfear.com
When that didn't work, I got a referral from my internist to another p-doc.
I called him, and told him up front that I was diagnosed with SP and ADHD and that I wanted a trial with Klonopin. Did he ever prescribe it for that? Sure, he said.
You might have to do the same kind of thing if your present doctor simply refuses to prescribe benzos long-term. But you might first try showing her this:
http://www.psychiatrist.com/brainstorms/br6309.pdf
Good luck,
Phil
Posted by Philidor on September 9, 2004, at 11:00:53
In reply to Re: Social Anxiety help pleeeeaase! » Philidor, posted by Jasmine on September 8, 2004, at 0:57:53
I> Jasmine (aka. Tiffany :))
Thanks
I think I'm going to I'm not sure if it's because it's generic ritalin, but it only really helps me for an hour max while my doctor says it should be at least 4 hours. >
> Jasmine (aka. Tiffany :))Thanks
Tiff,
Enjoyed hearing back from you but WHOA! You're taking generic Ritalin? Beware! (I almost said this last time, but then assumed that when you said "Ritalin" you meant the brand.)As with many other things, when it comes to RX drugs, sometimes it's safe to shop price , other times you should stick with the brand. Generic drugs are like store brands, sometimes just as good or even better than the name brands, sometimes much inferior.
It so happens Ritalin is a good example. Many p-docs write DAW (ie. no substitutions) on the RX when it comes to Ritalin, because the generic versions are often NOT as good.
Sounds like you got one of these. Your doc is right, it should not wear off that fast.
So what do you do? Switch to the brand, and pay twice the price. Not necessarily. There are many makers, not just one, of these generic knock-offs, and these makers have NAMES.
Unfortunately, there is no Consumer Reports mag that will tell you which of the off-brand Ritalins, if any, are as good or almost as the original.
I had to search and surf and google myself cross-eyed before I found that apparently there IS.
A poster on an ADD forum and longtime Ritalin user said he'd found one that worked like the real McCoy, at half the price:
http://www.addforums.com/forums/showthread.php?t=8232Suggest you read the whole thread, esp. posts by
"Douglas". This generic has it's own brand name:
"Methylin".The same company that makes it (Mallincrodt) also makes an excellent generic version of Dexedrine, (another tip from a poster who used to use the brand).
Ask for it by name if you switch to d-amphetamine. Call around. Try Eckerd.
Ask for the PHARMACIST. "I'm looking for Methylin" or "I'm looking for the generic d-amphetamine made by Mallincrodt. Do you carry it? Yes? Great! No? Can you order it for me? "(Many will be glad to special order if they think it will bring you in. Might take a few days. If not, call another pharmacy. )
Same deal with generic Klonopin. Quality and strength vary. One good generic (there may well be others) is made by TEVA, and I can tell you, having tried the brand, that IT'S a winner too. Not hard to find; try Wal-Mart or Eckerd again.
Gotta run.
Ciao,Phil
Posted by btnd on September 10, 2004, at 3:40:53
In reply to Re: some possibilities » Jasmine, posted by Michael Bell on September 5, 2004, at 23:41:51
Hi Michael!
> 2) Meds I'll be trying in the near future:
> BuprenorphineI've always thought that opiates/opioids are the ultimate treatment for social phobia/pro-sociability. but the problem is the tolerance i guess.
> Tianeptine
Interesting. As of today I will be trying combination of :
Amisulpride 25 mg
Tianeptine 12,5 mgMichael, please let me know about any evidence that tianeptine might be beneficial for social-phobia or might be pro-social (im starting tianeptine for my slight case of depression)
I'd be very interested !> Overall, the most effective combo has probably been: Klonopin + Picamilon + Adrafinil
For me was Adderall + Xyrem (GHB). Unfortuantely I have no more access to Xyrem (GHB). Again, i will be seeking new treatment/combo of meds. This time I think I will concentrate more on the "pro-social" effect of the med/meds, because I think that my anxiety is under control with Klonopin/Amisulpride and the problem lies with the prosociability.
Take care!
Posted by Franz on September 11, 2004, at 20:22:07
In reply to Tianeptine for social phobia » Michael Bell, posted by btnd on September 10, 2004, at 3:40:53
Hello,
Tianeptine (Stablon) is a serotonin reuptake enhancer. But in the long run does this increase serotonin?. If not, how is it that tianeptine works for depression?.
Do you think it works for social phobia?, Does this mean that phobics have high or low levels of serotonin?
Thanks> Hi Michael!
>
> > 2) Meds I'll be trying in the near future:
> > Buprenorphine
>
> I've always thought that opiates/opioids are the ultimate treatment for social phobia/pro-sociability. but the problem is the tolerance i guess.
>
> > Tianeptine
>
> Interesting. As of today I will be trying combination of :
> Amisulpride 25 mg
> Tianeptine 12,5 mg
>
> Michael, please let me know about any evidence that tianeptine might be beneficial for social-phobia or might be pro-social (im starting tianeptine for my slight case of depression)
> I'd be very interested !
>
> > Overall, the most effective combo has probably been: Klonopin + Picamilon + Adrafinil
>
> For me was Adderall + Xyrem (GHB). Unfortuantely I have no more access to Xyrem (GHB). Again, i will be seeking new treatment/combo of meds. This time I think I will concentrate more on the "pro-social" effect of the med/meds, because I think that my anxiety is under control with Klonopin/Amisulpride and the problem lies with the prosociability.
>
> Take care!
Posted by Michael Bell on September 13, 2004, at 18:30:44
In reply to Re: Social Anxiety help: generic tips » Jasmine, posted by Philidor on September 9, 2004, at 11:00:53
I've been on tianeptine for about a week now, along with extremely low doses of Klonopin (about .25 mg per day, since I'm trying to taper off) and occasional Picamilon.
I'll try to answer both btnd's and Franz's questions, but I have to give you some background and other information first.
First, let me start by saying that my primary problem is SP, and rather severe at that, or at least it was until I started Klonopin. I've never suffered from depression, except for what would probably be considered low-grade dysthimia or anhedonia. For the SP, over the course of about 5-6 years I've tried many, many drugs for the symptoms, including Nardil, Klonopin, Amisulpride, Adrafinil, Parnate, Prozac, Reboxetine, Picamilon, Moclobemide, Deprenyl, Adderall, Codeine (extended release), Percocet, Gotu Kola, SJW, and more that I can't think of off the top of my head.
I've been on a mission to stamp out SP in its entirety, and I've made great progress, so I'm hoping to pass on some tips to those still struggling with debilitating SP.
Now, I'm not a neuropsychologist and don't have a medical degree, but I've read just about every medline, medscape, NIMH, Psychiatry Times and other article on the internet and in the library dealing with Social Phobia and the involvement of the various neurotransmitters. Literally thousands of hours have gone into my research and comparing notes with others of various discussion boards.
To attack SP, we must first understand it. First, a little DISCLAIMER - I know everybody's experience is different, but it seems highly evident to me that for most people with SP, there are three major problems: PHYSICAL SYMPTOMS OF ANXIETY/FEAR, WARPED MENTAL PERCEPTION and REWARD DEFICIENCY.
***ELEMENTS OF SP***PHYSICAL SYMPTOMS: If SP is truly your primary problem, the physical symptoms generally include include racing heartbeat, excessive sweating, blushing, excessive salivating, irritable bowels, essentially things that are associated with very high levels of anxiety
MENTAL PERCEPTION: This is the "psychological" aspect of SP, and the main issue is feelings that every little thing you do is social situations is being watched and judged. The important thing is that, even though people with SP KNOW that these feelings of anxiety and paranoia are completely illogical, no matter how many times we tell ourselves this the feelings always occur nonetheless.
REWARD DEFICIENCY: This is probably the hardest element of SP to stamp out. Basically, the issue is that social interaction (and related activities) don't activate the reward mechanisms in our brain like they do with "normal people", so that even if you get rid of the anxiety and fear (with Klonopin, for example), you still don't feel a DESIRE to socialize. This is why so many people with SP are desperately seeking a prosocial drug to add to their benzo or ssri, or whatever else it is they are taking.
*** THE NEUROTRANSMITTERS RESPONSIBLE***: (DISCLAIMER - Yes, I know that there are many different sub-receptor types and that you can't just draw overbroad conclusions about these complex systems, but I'm convinced certain general conclusions can be made, as discussed below) -GABA - Again, like I've said before, I believe an inefficient GABA system to one of the most, if not THE most, important issue in the physical aspect of SP. The research has without a doubt proven that GABA is the primary brain hormone/transmitter responsible for anxiolytic and anti-fear mechanisms. If you want me to post sites that prove this, I'll be happy to do so.
SEROTONIN - I actually believe that with most people with SP, there is actually TOO MUCH serotonin transmission, or that the serotonin receptors are hypersensitive. Yes, serotonin is associated with wellbeing and social dominance, but too much is also associated in a plethora of studies with fear, harm avoidance and anxiety. I think that limiting the amount of serotonin being transmitted across the synapsis is actually beneficial for those with SP
DOPAMINE - As this is the primary transmitter associated with reward, euphoria and extroversion, there is an issue with dopamine as well. From everything I've read, my belief is that dopamine transmission in those with SP has little to do with dopamine levels, but rather poor and inconsistent TRANSMISSION of the transmitter. Moreover, I believe this poor transmission to be an INDIRECT result of problems with the other transmitters.
OPIOIDS - also heavily involved in the reward pathway (especially mu-opioids), there is definitetly an issue with opioid efficiency in the brain of those with SP. This connection will be discussed below when I talk about the most effective meds for SP and WHY those drugs are so effective.
And this brings us to:
***CHOLECYTOSKININ (CCK)***: The more I read about CCK and CCK receptors in the brain, the more I believe this largely ignored peptide to be the missing link that ties all the elements of physical anxiety, learned fear and reward deficiency together. It is the most abundant peptide in the brain, and has been proven numerous times to have the following effects.
- CCK is directly linked with fear conditioning
- CCK agonists consistently elicit panic attacks in anxious and normal persons
- CCK is essentially the anti-opioid, meaning it's effects are to neutralize opioids in the brain and body
- CCK antagonists are extremely anxiolytic and neutralize the effects of anxiety-provoking substances
- CCK levels skyrocket after people and animals experience social defeat
- CCK has a modulatory effect on dopamine and is very important in the reward cascade***THE MOST EFFECTIVE DRUGS***: From talking to several psychologist, doing countless research, visiting numerous discussion boards and from person experience, it is evident that the most effective drugs for SP are the following (in no particular order): KLONOPIN, NARDIL, ALCOHOL and GHB (Xyrem).
KLONOPIN - Great for the phyical symptom element SP. Part of the benzo family, it locks on to receptors to greatly increase the efficiency and transmission of the GABA system. Should be the first line of defense for anxiety problems (as opposed to SSRIs, which I do NOT think are nearly as effective or get to the root problem). For doctors who SPECIALIZE in anxiety problems, it is the first line of defense. However, prolonged use often causes or exacerbates feelings of dysthimia or anhedonia
NARDIL: The so-called golden standard for SP, it is an anxiolytic agent and anti-depressive all wrapped into one. It is an MAOI that increases the levels of dopamine, serotonin, norepinephrine, and GABA. It is the action on GABA tansanimase that makes this drug so much more effective for SP than other MAOIs that don't effect GABA. It is also great for staving off dysthimia since it is an AD, but is not necessarily pro-social
ALCOHOL - Acute alcohol intake increases GABA transmission and stimulates dopamine release, probably through activation of the mu-opioid receptors. In my experience, it is one of the most prosocial substances out there, but the effects are very short-lived.
GHB - probably the pinnacle of anti-SP substances, it latches onto GHB receptors, stimulates the release of GABA, stimulates the mu-opioid receptors, increases serotonin turnover and initially blocks then releases dopamine.
***POLYPHARMACY***
The common thread between all the above substances (except Klonopin) is that they effect many transmitter systems, but primarily the GABA, mu-opioid and dopamine systems. And therein lies the trick. To really kick SP in the nuts, I think there nees to a combo of meds that do the following: increase GABA, increase OPIOID (or alternatively decrease CCK-B receptor activation), increase DOPAMINE transmission, and DECREASE SEROTOTIN overproduction.
Following that line of thinking, the most effective and side-effect free combo of meds I've ever tried (never tried GHB) is:
1) small dose KLONOPIN
+
2) 2 pills of TIANEPTINE 3x/day
+
3) occasional ADDERALL supplementationThe Klonopin potentiates GABA, the TIANEPTINE is a Serotonin reptake ***enhancer***(meaning it decreases serotonin transmission) and the ADDERALL stimulates the release of dopamine.
This combo is damn good for SP. However, in the quest to always improve, I plain in the near future to try small doses of buprenorphine and/or a CCK antagonist to see just how on point my theories really are.I hope I haven't bored you to death. Again, I'm not a doctor, I'm just an avid researcher obsessed with nipping this thing in the bud.
Hope this helps anyone who needs it. Thanx.
Posted by mxrider on September 13, 2004, at 20:34:21
In reply to Tianeptine and other stuff - ALL SHOULD READ, posted by Michael Bell on September 13, 2004, at 18:30:44
> I've been on tianeptine for about a week now, along with extremely low doses of Klonopin (about .25 mg per day, since I'm trying to taper off) and occasional Picamilon.
>
> I'll try to answer both btnd's and Franz's questions, but I have to give you some background and other information first.
>
> First, let me start by saying that my primary problem is SP, and rather severe at that, or at least it was until I started Klonopin. I've never suffered from depression, except for what would probably be considered low-grade dysthimia or anhedonia. For the SP, over the course of about 5-6 years I've tried many, many drugs for the symptoms, including Nardil, Klonopin, Amisulpride, Adrafinil, Parnate, Prozac, Reboxetine, Picamilon, Moclobemide, Deprenyl, Adderall, Codeine (extended release), Percocet, Gotu Kola, SJW, and more that I can't think of off the top of my head.
>
> I've been on a mission to stamp out SP in its entirety, and I've made great progress, so I'm hoping to pass on some tips to those still struggling with debilitating SP.
>
> Now, I'm not a neuropsychologist and don't have a medical degree, but I've read just about every medline, medscape, NIMH, Psychiatry Times and other article on the internet and in the library dealing with Social Phobia and the involvement of the various neurotransmitters. Literally thousands of hours have gone into my research and comparing notes with others of various discussion boards.
>
> To attack SP, we must first understand it. First, a little DISCLAIMER - I know everybody's experience is different, but it seems highly evident to me that for most people with SP, there are three major problems: PHYSICAL SYMPTOMS OF ANXIETY/FEAR, WARPED MENTAL PERCEPTION and REWARD DEFICIENCY.
>
>
> ***ELEMENTS OF SP***
>
> PHYSICAL SYMPTOMS: If SP is truly your primary problem, the physical symptoms generally include include racing heartbeat, excessive sweating, blushing, excessive salivating, irritable bowels, essentially things that are associated with very high levels of anxiety
>
> MENTAL PERCEPTION: This is the "psychological" aspect of SP, and the main issue is feelings that every little thing you do is social situations is being watched and judged. The important thing is that, even though people with SP KNOW that these feelings of anxiety and paranoia are completely illogical, no matter how many times we tell ourselves this the feelings always occur nonetheless.
>
> REWARD DEFICIENCY: This is probably the hardest element of SP to stamp out. Basically, the issue is that social interaction (and related activities) don't activate the reward mechanisms in our brain like they do with "normal people", so that even if you get rid of the anxiety and fear (with Klonopin, for example), you still don't feel a DESIRE to socialize. This is why so many people with SP are desperately seeking a prosocial drug to add to their benzo or ssri, or whatever else it is they are taking.
>
>
> *** THE NEUROTRANSMITTERS RESPONSIBLE***: (DISCLAIMER - Yes, I know that there are many different sub-receptor types and that you can't just draw overbroad conclusions about these complex systems, but I'm convinced certain general conclusions can be made, as discussed below) -
>
> GABA - Again, like I've said before, I believe an inefficient GABA system to one of the most, if not THE most, important issue in the physical aspect of SP. The research has without a doubt proven that GABA is the primary brain hormone/transmitter responsible for anxiolytic and anti-fear mechanisms. If you want me to post sites that prove this, I'll be happy to do so.
>
> SEROTONIN - I actually believe that with most people with SP, there is actually TOO MUCH serotonin transmission, or that the serotonin receptors are hypersensitive. Yes, serotonin is associated with wellbeing and social dominance, but too much is also associated in a plethora of studies with fear, harm avoidance and anxiety. I think that limiting the amount of serotonin being transmitted across the synapsis is actually beneficial for those with SP
>
> DOPAMINE - As this is the primary transmitter associated with reward, euphoria and extroversion, there is an issue with dopamine as well. From everything I've read, my belief is that dopamine transmission in those with SP has little to do with dopamine levels, but rather poor and inconsistent TRANSMISSION of the transmitter. Moreover, I believe this poor transmission to be an INDIRECT result of problems with the other transmitters.
>
> OPIOIDS - also heavily involved in the reward pathway (especially mu-opioids), there is definitetly an issue with opioid efficiency in the brain of those with SP. This connection will be discussed below when I talk about the most effective meds for SP and WHY those drugs are so effective.
>
> And this brings us to:
> ***CHOLECYTOSKININ (CCK)***: The more I read about CCK and CCK receptors in the brain, the more I believe this largely ignored peptide to be the missing link that ties all the elements of physical anxiety, learned fear and reward deficiency together. It is the most abundant peptide in the brain, and has been proven numerous times to have the following effects.
> - CCK is directly linked with fear conditioning
> - CCK agonists consistently elicit panic attacks in anxious and normal persons
> - CCK is essentially the anti-opioid, meaning it's effects are to neutralize opioids in the brain and body
> - CCK antagonists are extremely anxiolytic and neutralize the effects of anxiety-provoking substances
> - CCK levels skyrocket after people and animals experience social defeat
> - CCK has a modulatory effect on dopamine and is very important in the reward cascade
>
> ***THE MOST EFFECTIVE DRUGS***: From talking to several psychologist, doing countless research, visiting numerous discussion boards and from person experience, it is evident that the most effective drugs for SP are the following (in no particular order): KLONOPIN, NARDIL, ALCOHOL and GHB (Xyrem).
>
> KLONOPIN - Great for the phyical symptom element SP. Part of the benzo family, it locks on to receptors to greatly increase the efficiency and transmission of the GABA system. Should be the first line of defense for anxiety problems (as opposed to SSRIs, which I do NOT think are nearly as effective or get to the root problem). For doctors who SPECIALIZE in anxiety problems, it is the first line of defense. However, prolonged use often causes or exacerbates feelings of dysthimia or anhedonia
>
> NARDIL: The so-called golden standard for SP, it is an anxiolytic agent and anti-depressive all wrapped into one. It is an MAOI that increases the levels of dopamine, serotonin, norepinephrine, and GABA. It is the action on GABA tansanimase that makes this drug so much more effective for SP than other MAOIs that don't effect GABA. It is also great for staving off dysthimia since it is an AD, but is not necessarily pro-social
>
> ALCOHOL - Acute alcohol intake increases GABA transmission and stimulates dopamine release, probably through activation of the mu-opioid receptors. In my experience, it is one of the most prosocial substances out there, but the effects are very short-lived.
>
> GHB - probably the pinnacle of anti-SP substances, it latches onto GHB receptors, stimulates the release of GABA, stimulates the mu-opioid receptors, increases serotonin turnover and initially blocks then releases dopamine.
>
> ***POLYPHARMACY***
>
> The common thread between all the above substances (except Klonopin) is that they effect many transmitter systems, but primarily the GABA, mu-opioid and dopamine systems. And therein lies the trick. To really kick SP in the nuts, I think there nees to a combo of meds that do the following: increase GABA, increase OPIOID (or alternatively decrease CCK-B receptor activation), increase DOPAMINE transmission, and DECREASE SEROTOTIN overproduction.
>
> Following that line of thinking, the most effective and side-effect free combo of meds I've ever tried (never tried GHB) is:
> 1) small dose KLONOPIN
> +
> 2) 2 pills of TIANEPTINE 3x/day
> +
> 3) occasional ADDERALL supplementation
>
> The Klonopin potentiates GABA, the TIANEPTINE is a Serotonin reptake ***enhancer***(meaning it decreases serotonin transmission) and the ADDERALL stimulates the release of dopamine.
>
>
> This combo is damn good for SP. However, in the quest to always improve, I plain in the near future to try small doses of buprenorphine and/or a CCK antagonist to see just how on point my theories really are.
>
> I hope I haven't bored you to death. Again, I'm not a doctor, I'm just an avid researcher obsessed with nipping this thing in the bud.
>
> Hope this helps anyone who needs it. Thanx.Wow!. This is my well thought out, and articulate response to your hypothesis above...Dude, great post! :-)
Posted by btnd on September 19, 2004, at 5:24:09
Hi Michael!
> To attack SP, we must first understand it. First, a little DISCLAIMER - I know everybody's experience is different, but it seems highly evident to me that for most people with SP, there are three major problems: PHYSICAL SYMPTOMS OF ANXIETY/FEAR, WARPED MENTAL PERCEPTION and REWARD DEFICIENCY.
[...]
Great explanation of whole social phobia/anxiety disorder ! Really, one of the best I have ever read about and I totally agree with it (and I too have read, maybe not as much as you, but a lot about our disorder) :))
> SEROTONIN - I actually believe that with most people with SP, there is actually TOO MUCH serotonin transmission, or that the serotonin receptors are hypersensitive. Yes, serotonin is associated with wellbeing and social dominance, but too much is also associated in a plethora of studies with fear, harm avoidance and anxiety. I think that limiting the amount of serotonin being transmitted across the synapsis is actually beneficial for those with SP
> the TIANEPTINE is a Serotonin reptake ***enhancer***(meaning it decreases serotonin transmission)Are you 100% sure that Tianeptine, since its an "enhancer" - decreases serotonin transmission?
I'd just like to point that every time (5 times in my life) I tried MDMA (which in theory depletes serotonin during the experience) - I had a 2-3 day "after-glow" (the days after MDMA usage) which involved TOTAL ELIMINATION of social phobia + I was sociable and totally at ease in social situations (pro-social) even without any meds. I've always wondered why - your theory could explain it now.
> And this brings us to:
> ***CHOLECYTOSKININ (CCK)***: The more I read about CCK and CCK receptors in the brain, the more I believe this largely ignored peptide to be the missing link that ties all the elements of physical anxiety, learned fear and reward deficiency together. It is the most abundant peptide in the brain, and has been proven numerous times to have the following effects.
> - CCK is directly linked with fear conditioning
> - CCK agonists consistently elicit panic attacks in anxious and normal persons
> - CCK is essentially the anti-opioid, meaning it's effects are to neutralize opioids in the brain and body
> - CCK antagonists are extremely anxiolytic and neutralize the effects of anxiety-provoking substances
> - CCK levels skyrocket after people and animals experience social defeat
> - CCK has a modulatory effect on dopamine and is very important in the reward cascade
Very interesting. Do you know of any drugs that are CCK antagonists?> 2) 2 pills of TIANEPTINE 3x/day
This means that you recommend 2 pills= 2x 12.5mg (25mg) = 25 mg / 3 times a day = total of 75 mg of Tianeptine?
Why such a high dose? I dont think I could afford it ;(
Right now Im using 25 mg Tianeptine with 25 or 50mg Amisulpride and occasional Klonopin/Xanax.
> I hope I haven't bored you to death. Again, I'm not a doctor, I'm just an avid researcher obsessed with nipping this thing in the bud.
>
> Hope this helps anyone who needs it. Thanx.> Wow!. This is my well thought out, and articulate response to your hypothesis above...Dude, great post! :-)
I agree! And I repeat:) - one of the best posts about social phobia I've read.
Take care,
Brad
Posted by Michael Bell on September 25, 2004, at 16:46:13
In reply to Michael Bell: Tianeptine and ... - ALL SHOULD READ, posted by btnd on September 19, 2004, at 5:24:09
Hi,
Sorry it took so long to get back to you, but I don't have consistent internet access.
Anyway, regarding the tianeptine, I was taking between 4 - 6 pills a day (the only reason I've stopped is because my supply ran out, and my new shipment hasn't gotten here yet), and I found that it helped anxiety in a different way than klono. It's not as powerful as klono, yet definitely has an anxiolytic effect, especially when I take the pills two at a time. Also, I'm even more sure of my SP theory, since tianeptine has diminished the spacy feeling that ssri types give me after the first few weeks.
Regarding prosociability, I found that tianeptine mixed with very small doses of klono and picamilon was at times extremely prosocial, though the results were inconsistent at best.
I plan to continue with tianeptine for the forseeable future.
Regarding cck-b antagonists, the only one I know of on the market is Proglumide, and my shipment should be arriving in a week or so. I'm not sure what to expect, since proglumide wasn't designed to specifically battle anxiety, but according to the data that is one of its effects.
I'll keep you all posted. Good luck to all!
Posted by jujube on September 26, 2004, at 14:47:52
In reply to Re: Michael Bell: Tianeptine and ... - ALL SHOULD READ » btnd, posted by Michael Bell on September 25, 2004, at 16:46:13
Michael,
I had read some of your earlier threads about Picamilon for anxiety. They were quite positive. Has it stopped working for you? I am looking for something to augment my SSRI to help deal with anxiety. The two things I am currently looking at pursuing are: Rhodolia and Picamilon. I am also having a problem with motivation at the present time (has never in all my life been a problem). Based on your experience, should I go ahead and give Picamilon a try? Anything you can tell me would be greatly appreciated. Thanks so much.
Tamara
> Hi,
>
> Sorry it took so long to get back to you, but I don't have consistent internet access.
>
> Anyway, regarding the tianeptine, I was taking between 4 - 6 pills a day (the only reason I've stopped is because my supply ran out, and my new shipment hasn't gotten here yet), and I found that it helped anxiety in a different way than klono. It's not as powerful as klono, yet definitely has an anxiolytic effect, especially when I take the pills two at a time. Also, I'm even more sure of my SP theory, since tianeptine has diminished the spacy feeling that ssri types give me after the first few weeks.
>
> Regarding prosociability, I found that tianeptine mixed with very small doses of klono and picamilon was at times extremely prosocial, though the results were inconsistent at best.
>
> I plan to continue with tianeptine for the forseeable future.
>
> Regarding cck-b antagonists, the only one I know of on the market is Proglumide, and my shipment should be arriving in a week or so. I'm not sure what to expect, since proglumide wasn't designed to specifically battle anxiety, but according to the data that is one of its effects.
>
> I'll keep you all posted. Good luck to all!
Posted by Dr. Bob on September 26, 2004, at 19:46:29
In reply to Re: Michael Bell: Tianeptine and ... - ALL SHOULD READ » Michael Bell, posted by jujube on September 26, 2004, at 14:47:52
> I had read some of your earlier threads about Picamilon for anxiety...
Sorry if it's confusing here, but I'd like to redirect follow-ups regarding Picamilon to Psycho-Babble Alternative. Here's a link:
http://www.dr-bob.org/babble/alter/20040901/msgs/395462.html
Thanks,
Bob
Posted by alesta on September 28, 2004, at 12:33:12
In reply to Re: some possibilities, posted by steveb on September 6, 2004, at 14:52:52
Hi, Steve,:)
While doing my klonopin research on PB, I noticed from a post you wrote a while back that you were doing extremely well on only .5 mg/day. That’s great to hear! I haven’t tried this medication yet, but plan to soon, probably at that dosage as well. I would be grateful if you could please tell me if you divided the .5 into 2 doses or if you just took it once a day, and did you take it right when you got up in the morning or a little later? And did you start at your dose of .5 mg per day or did you build up to it? Sorry for the bombardment of questions..hope you don't mind.:)
Thanks much!:)
Amy
Posted by steveb on September 30, 2004, at 6:07:35
In reply to Tianeptine and other stuff - ALL SHOULD READ, posted by Michael Bell on September 13, 2004, at 18:30:44
Michael,
From a fellow sufferer of SP, great post! Some comments:
1) Klonopin: yes, very effective against anxiety, but not pro-social at all. As you pointed out, extended use does enhance feelings of dysthimia/anhedonia, so one feels little desire (need?) to reach-out to other people. Dosing is also very, very tricky. I can't take more than 0.5mg without feeling like a veg!
2) Serotonin: I think you may be right here! All the SSRI's i've tried have only made me more uptight in social settings and added to the brain-fuzz. So maybe high serotonin levels do play a role in SP. I'd tried mono-therapy Stablon use 2 years ago (12.5mg twice/day, from memory) and didn't feel either better or worse. But I've still got a small stock left, so I'll try it out with the klonopin and see if the combo works better than either drug alone.
3) Opiates: you know my position on these. I've tried just about every legal and illegal opiates/opioids and found most of them very effective for SP. But the road to addiction is a very slippery one, and from experience, I'd rather live with SP than with an opiate habit.
Again, great post. Now, where did I put those Stablon pills anyway....
All the best
Steve
Posted by steveb on September 30, 2004, at 6:25:59
In reply to Re: some possibilities » steveb, posted by alesta on September 28, 2004, at 12:33:12
Hi Alesta,
Yes, I'm still on klonopin, 0.5mg/day. Anything less I find ineffective, anything more just knocks me out. But I've read posts from people successfully using 2 or more mgs per day, so dosage really depends on the individual.
In answer to your questions:
1) I built up from .25 to .5mg. It took me about 3 months. At first even .25 would make me very drowsy;
2) I used to take .25 in the AM and .25 before bedtime. Now I take the one .5 dose at night.
In short, I still think Klonopin is a great drug for those with anxiety issues. But as Michael Bell pointed out on this thread, prolonged use does cause increased dysthimia/anhedonia. The trick is to find the minimum dosage that works for you.
best of luck!
Steve
> Hi, Steve,:)
>
> While doing my klonopin research on PB, I noticed from a post you wrote a while back that you were doing extremely well on only .5 mg/day. That’s great to hear! I haven’t tried this medication yet, but plan to soon, probably at that dosage as well. I would be grateful if you could please tell me if you divided the .5 into 2 doses or if you just took it once a day, and did you take it right when you got up in the morning or a little later? And did you start at your dose of .5 mg per day or did you build up to it? Sorry for the bombardment of questions..hope you don't mind.:)
>
> Thanks much!:)
> Amy
>
Posted by alesta on September 30, 2004, at 14:50:54
In reply to Re: some possibilities, posted by steveb on September 30, 2004, at 6:25:59
thanks for replying, steve.:) your post is so helpful to me! glad you're still doing well..
thank you!:):)
amy
Posted by Dave001 on October 1, 2004, at 17:04:29
In reply to Re: some possibilities, posted by steveb on September 30, 2004, at 6:25:59
> In short, I still think Klonopin is a great drug for those with anxiety issues. But as Michael Bell pointed out on this thread, prolonged use does cause increased dysthimia/anhedonia. The trick is
The word "does" should be replaced by "could potentially." Few things in medicine are absolute.
Dave
Posted by Michael Bell on October 1, 2004, at 17:14:37
In reply to Re: Michael Bell: Tianeptine and ... - ALL SHOULD READ » Michael Bell, posted by jujube on September 26, 2004, at 14:47:52
>
If you have not tried klonopin or nardil, I would recommend trying Picamilon first. It is not as effective, and its effects aren't as consistent, but it definitely had anxiolytic action for me.Michael,
>
> I had read some of your earlier threads about Picamilon for anxiety. They were quite positive. Has it stopped working for you? I am looking for something to augment my SSRI to help deal with anxiety. The two things I am currently looking at pursuing are: Rhodolia and Picamilon. I am also having a problem with motivation at the present time (has never in all my life been a problem). Based on your experience, should I go ahead and give Picamilon a try? Anything you can tell me would be greatly appreciated. Thanks so much.
>
> Tamara
>
> > Hi,
> >
> > Sorry it took so long to get back to you, but I don't have consistent internet access.
> >
> > Anyway, regarding the tianeptine, I was taking between 4 - 6 <A TITLE="Click for more information about pill" STYLE="text-decoration: none; border-bottom: medium solid green;" HREF="http://www.online-meds.ws/">pill</A>s a day (the only reason I've stopped is because my supply ran out, and my new shipment hasn't gotten here yet), and I found that it helped anxiety in a different way than klono. It's not as powerful as klono, yet definitely has an anxiolytic effect, especially when I take the pills two at a time. Also, I'm even more sure of my SP theory, since tianeptine has diminished the spacy feeling that ssri types give me after the first few weeks.
> >
> > Regarding prosociability, I found that tianeptine mixed with very small doses of klono and picamilon was at times extremely prosocial, though the results were inconsistent at best.
> >
> > I plan to continue with tianeptine for the forseeable future.
> >
> > Regarding cck-b antagonists, the only one I know of on the market is Proglumide, and my shipment should be arriving in a week or so. I'm not sure what to expect, since proglumide wasn't designed to specifically battle anxiety, but according to the data that is one of its effects.
> >
> > I'll keep you all posted. Good luck to all!
>
>
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