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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by BobS. on June 19, 2002, at 19:41:30
I have two teenage sons and may be presented shortly with a decision on treatment for them. I will not give them SSRIs, so please don't advise me on their role in this disorder.
Which do you consider better and why? Any thoughts would be greatly appreciated.
Regards,
BobS.
Posted by joy on June 19, 2002, at 22:21:39
In reply to Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 19, 2002, at 19:41:30
Sometimes it's trial and error. I think that Xanax is a good med, but it should not be overused. It is excellent for panic attacks or anxiety attacks. I know you are anti-SSRI, and I don't blame you, but I take Prozac [small dose] and it has a long half life and is much easier to take, and much easier to stop taking. I take generic Xanax as needed [bedtime for me] and am back on Prozac now as I was off it months. Just my humble opinion. I prefer Xanax.
Joy
Posted by Cece on June 20, 2002, at 14:25:50
In reply to Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 19, 2002, at 19:41:30
Well, I don't actually think that either xanax or klonopin are especially good for social anxiety, although as Joy said, they can be useful for generalized anxiety (which is a very different kettle of fish from social anxiety). I wonder why you have narrowed your search down to these two meds? Perhaps you could seek a second psychiatric opinion before you make a decision?
I've taken xanax and klonopin for some time, in addition to other meds, for my Bipolar II disorder (I also have generalized anxiety). They have been fairly useful for me, but I am slowly weaning off of them as they have given me memory problems and slowed cognitive functioning. Not a good side effect for teenagers studying for school- or for anyone. Also, since they both are drugs that some people use recreationally, your kids could be put in an awkward position if their friends find out and want some.
I don't mean to offend you or to challenge your parenting- obviously you care about your kids' welfare. But please at least think about seeking further professional advice, and reconsidering your prejudice re SSRI's. I have a neighbor with extreme social phobia and anxiety disorder who has been 'saved' by Paxil. And, there are probably other meds to consider that are not SSRI's or benzodiazepines.
Best of luck,
Cece
Posted by 3 Beer Effect on June 20, 2002, at 14:52:21
In reply to Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 19, 2002, at 19:41:30
Klonopin has been proven to be effective for social anxiety at doses of 2-4 mg per day (in adults), split into 3 doses/day. Several double-blind clinical trials showed a long term improvement rate of up to 85% and it is said the only thing more effacious for social phobia is the much more dangerous MAOI anti-depressant Nardil. A study on Xanax showed significantly less improvement, especially in the long term.
My own experience has been than Klonopin is not quite as good for Social Phobia as those studies would indicate since it kind of gives you a 'blah' dull feeling. It gets rid of anxiety around others but does not necessarily make you more outgoing (as does alcohol). It seems to work best for social phobia for me when taken with low doses of the psychostimulant/ADD medication Dexedrine/Dextrostat 5-10 mg 2x per day, but it seems as though the Dexedrine is doing most of the work in helping with (my) social phobia. Higher doses of Dexedrine/Dextrostat such as 10 or 20 mg 2x per day are better for ADD than for social phobia. Adderall tends to cause more anxiety than Dexedrine/Dextrostat & Ritalin generally doesn't help at all with social phobia or makes it worse.
Xanax & Valium have been the 'problem children' of benzodiazepines because they are subject to much more abuse than Ativan & especially Klonopin. Xanax & Valium have a rapid onset & peak of action, & short half lifes which tends to make them more desirable as drugs of abuse than drugs with a slow onset of action, long time to peak effect, & long half life such as Klonopin & to a lesser extent Ativan.
In contrast to Xanax & Valium, Klonopin seems to cause no euphoria. Ativan may also be a good choice, although some think it is slightly more addictive than Klonopin.If you are worried about potential abuse of these medications you might want to put them away somewhere & give your teenage sons their daily dose either the night before or the morning of, each day they are taking them. Being curious teenagers, I would be worried that they would escalate the dose or overdose if they had full access to a month's supply of benzodiazpine pills, which could cause disinhibition, incoordination, & loss of rational thinking which might get them in trouble at school or if they are of driving age, a DUI or traffic accident.
3 Beers........
Posted by BobS. on June 20, 2002, at 21:13:54
In reply to Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 19, 2002, at 19:41:30
Thanks for the responses. As to SSRIs, I have various anxiety disorders and was prescribed Prozac and Paxil. The thread above on the "SSRIs and the open wound" sums up my feelings on them. They are fundamentally a marketing ploy in "pure" anxiety disorders. It took me 3 years to successfully withdrawal from Paxil. That's why I want to stick to BZD monotherapy.
3 beer,
I read the study you reference on Klonopin. Liebowitz was one of the authors. The doctor I am seeing is a colleague of Liebowitz. I am looking for personal anecdotal experience. My plan is to use a range of therapies, talk, medication (very little) and general support. Beer works the best, I know, been there done that. My hope is a reasonable medication approach will prevent self medication with alcohol and a little relief will help them lead fuller lives.
Regards,
BobS.
Posted by johnj on June 21, 2002, at 9:23:58
In reply to Re: Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 20, 2002, at 21:13:54
Hi Bob,
Could you link that study you were talking about? I would be interested in hearing more about Dr. Liebowitz. I am interested in a similiar approach that you have. I just can't seem to find any type of meds that let me relax and get a good nights sleep lately. I have depression with my anxiety and my current pdoc just isn't aggressive enough for me. Thanks
johnj
Posted by JonW on June 21, 2002, at 16:39:22
In reply to Re: Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 20, 2002, at 21:13:54
Hi,
I'm currently a patient of Dr. Liebowitz and he is very excited about the combination of CBT and medication -- at least in my case. He says that they are finding that it is more effective than either alone. He also says that Nardil is the single most effective drug for SP. I doubt either of these ideas would surprise anyone, but it's nice to hear an expert reiterate them.
Jon
> 3 beer,
> I read the study you reference on Klonopin. Liebowitz was one of the authors. The doctor I am seeing is a colleague of Liebowitz. I am looking for personal anecdotal experience. My plan is to use a range of therapies, talk, medication (very little) and general support. Beer works the best, I know, been there done that. My hope is a reasonable medication approach will prevent self medication with alcohol and a little relief will help them lead fuller lives.
> Regards,
> BobS.
Posted by JonW on June 21, 2002, at 16:43:21
In reply to Re: Klonopin or Xanax f(BobS), posted by johnj on June 21, 2002, at 9:23:58
Hi John,
If you are unhappy with your doctor -- get a new one now! I'm currently a patient of Dr. Liebowitz and it has made all the difference in the world! Have you ever tried Nardil, it may be a good choice for your symptoms. Although, you would likely experience some insomnia initially.
Good Luck,
Jon> Hi Bob,
>
> Could you link that study you were talking about? I would be interested in hearing more about Dr. Liebowitz. I am interested in a similiar approach that you have. I just can't seem to find any type of meds that let me relax and get a good nights sleep lately. I have depression with my anxiety and my current pdoc just isn't aggressive enough for me. Thanks
> johnj
Posted by BobS. on June 21, 2002, at 18:29:02
In reply to Re: Klonopin or Xanax f(BobS), posted by johnj on June 21, 2002, at 9:23:58
Here is the Medline link to the article I referenced. I have the article as a pdf file if anyone needs it by email.
As I mentioned above, my goal is BZD monotherapy for a reduction in anxiety and all then any therapy that will help my sons learn. I don't expect a cure, rather an improvement in their lives.
Please let me know if anyone wants the pdf file.
Posted by BobS. on June 21, 2002, at 18:32:10
In reply to Re: Klonopin or Xanax for Social Anxiety?? » BobS., posted by JonW on June 21, 2002, at 16:39:22
Posted by BobS. on June 21, 2002, at 18:33:37
In reply to Re: Klonopin or Xanax for Social Anxiety?? (nm), posted by BobS. on June 21, 2002, at 18:32:10
Posted by JonW on June 21, 2002, at 22:32:40
In reply to JonW. Is Liebowitz, MR your doctor? (nm), posted by BobS. on June 21, 2002, at 18:33:37
Hi Bob,
Yes, I'm seeing Dr. Liebowitz right now. Hey, was your reply to my last post supposed to have a message because it's posted with no message.
Jon
Posted by Alan on June 22, 2002, at 0:48:41
In reply to Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 19, 2002, at 19:41:30
> I have two teenage sons and may be presented shortly with a decision on treatment for them. I will not give them SSRIs, so please don't advise me on their role in this disorder.
>
> Which do you consider better and why? Any thoughts would be greatly appreciated.
> Regards,
> BobS.
============================================There is no way of knowing without clinical trials. Try one and then the other and see what their reaction is. It could be different for either of them. Short trials are practical with these types of meds. Of course at least a couple of weeks on each for the initial sedation to wear off to see if the anxiolytic effect is sufficient....that's when one knows if to keep or increase the dosage. It's hard to distinguish between the sedating effects and the anxiolytic effects at first. That's why some over react when an initial arbitrary dose needs to be escallated a bit over the first few weeks of therapy. The incidence of wanting to acheive a "high" is rare and you'll have to be on the level with them on how to distinguish between that and just feeling normal enough to just feel "themselves". It involves a lot of trust.
I personally tried all of them and after the ssri "good", BZD "bad" corporate line I got from 2 psychiatrists, I fired them and went to a 3rd that actually listened to what I was telling them.....that BZD's are much more effective. I had the same "discontinuation syndrome" with Paxil as you did by the way and many "ahlf assed" responses to all the other AD's. They are not for pure anxiety disorders IMO. No matter what the drug co's say. It's one of the biggest frauds perpetrated on the doctors and patients in medicine today. Especially with the cover up or downright misleading of Paxil and others being "non habit forming (implying BZD's hold that distinction exclusively).
But back to the BZD's...there is no one size fits the disorder for ANY BZD. Individual responses vary to a much greater degree than statistical (or anecdotal) evidence for any disorder. That's the bottom line.
I've ended up taking Klonopin as maintainence and ativan PRN for breakthrough. More stable that way.
Length of half life of a BZD has absolutely nothing to do with it's "potential" for addiction. That comes from the individuals reaction themselves - their personal reaction to the med.
Alan
Posted by judy1 on June 22, 2002, at 1:48:07
In reply to Klonopin or Xanax for Social Anxiety??, posted by BobS. on June 19, 2002, at 19:41:30
I applaud your decision with SSRI use in anxiety disorders- they simply aren't the drug of choice. I have panic disorder and PTSD and do very well with klonopin 2mg tid, xanax prn and therapy. I also wanted to emphasize the role of therapy, especially with younger people. My shrink has had great luck in weaning off his anxiety patients from meds by teaching good coping skills and therapy to increase self-esteem. I wish you and your children all the best- judy
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.
Posted by BobS. on June 26, 2002, at 20:23:46
In reply to JonW or BobS- can you ask Dr Liebowitz a ? for me?, posted by 3 Beer Effect on June 26, 2002, at 6:04:41
FYI,
I am trying Xanax with my 17 y/o son. Just started 6/25/2002. As you note, Klonopin works, but not to the level of SSRIs, Nardil, etc. If you read Liebowitz, the trial for Xanax was on a small population. I don't think it was adequately tested.My pdoc, the colleague of Liebowitz, is an SSRI guy, but is not afraid to help with Xanax if a patient prefers it to the "zonking" effect of an SSRI. He has no opinion on which will work between the two, but thinks that overall Xanax is a superior medication. So time will tell. If and when, PET helps us move to better drugs and decisions on what drugs, SSRIs are out.
My son is not seriously impaired, but just needs some relief to help him grow psychologically. If you are more seriously affected, why not go see Liebowitz himself. He may treat you anecdotely based on what you have found.
I'll post back my experience/experiment in a couple of months.
Regards,
BobS.
This is the end of the thread.
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