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Dr. Bob is Robert Hsiung, MD,
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Posted by Cairo on April 27, 2005, at 17:41:24
Just came from an intense appointment with my daughter's psychiatrist. She's been on Lexapro 10mg + Provigil 200mg for Social Anxiety for over a year with only moderate success. Higher doses of Lex cause incredible fatigue and cognitive side effects which we cannot afford b/c she has learning and language disabilities and a chronic fatigue/fibromyalgia type thing going on. CBT doesn't generalize.
A pediatric Psychiatrist we saw at UPenn last summer suggested Seroquel as an add on to Lexapro for the anxiety, but said we need someone local to follow us up. We switched to someone new who headed the Anxiety clinic at our state Medical School and who tried her on Librium and added the Provigil. Provigil helped fatigue some and thereby, I think made her more prosocial. Low dose Librium helped only a little and she balked at needing to take a pill every "frickin' time I want to talk to someone". Increasing the dose is not an option and MAOIs aren't either.
We pressed him on the Seroquel and he said absolutely no way due to sedation, which is the last thing we need in her as she is underaroused and he hasn't heard of Seroquel being used for social anxiety. He wants to switch her to Zoloft, which I'm game to try, but I'm afraid we'll get only a partial response to that too. Dosing may be an issue as she's sensitive to side effects.
We'll give Zoloft a whirl, but after that we need referral to a pediatric clinic that specializes in social anxiety. Who is the best? Are there any places that do intensive CBT specifically for pediatric SP? Research on atypicals as adjuncts for SP?
BTW, he won't consider discussing Pregabalin when it's released as it's "new". What's the latest news on ocinaplon?
Thank you for any help you can give!
Tired, worried, and confused,
Cairo
Posted by zeugma on April 28, 2005, at 17:36:11
In reply to Re: Seroquel and Social Anxiety, posted by Cairo on April 27, 2005, at 17:41:24
> Just came from an intense appointment with my daughter's psychiatrist. She's been on Lexapro 10mg + Provigil 200mg for Social Anxiety for over a year with only moderate success. Higher doses of Lex cause incredible fatigue and cognitive side effects which we cannot afford b/c she has learning and language disabilities and a chronic fatigue/fibromyalgia type thing going on. CBT doesn't generalize. >>
I take 200 mg Provigil along with nortriptyline, clonazepam and buspirone for narcolepsy, depression, ADD, and anxiety both social and generalized. I also have some learning disabilities. I tried CBT for five months and it didn't generalize for me either. I don't have fibromyalgia, but I do have chronic pain in the form of IBS, and the nortriptyline is very good for that, and so is clonazepam. Unfortunately, Provigil worsens my IBS and it also worsens my anxiety at the dose at which it becomes an effective stimulant (200 mg) although less so than Ritalin. Has your daughter tried a TCA or clonazepam? the sedation from the benzo dissipates over time, although not completely, and I've also found it effective for IBS-triggered pain, probably because it lowers the anxiety that pain normally provokes.
>
> A pediatric Psychiatrist we saw at UPenn last summer suggested Seroquel as an add on to Lexapro for the anxiety, but said we need someone local to follow us up. We switched to someone new who headed the Anxiety clinic at our state Medical School and who tried her on Librium and added the Provigil. Provigil helped fatigue some and thereby, I think made her more prosocial. Low dose Librium helped only a little and she balked at needing to take a pill every "frickin' time I want to talk to someone". Increasing the dose is not an option and MAOIs aren't either.>>Clonazepam is fairly long acting though i have to take it twice a day.
>
> We pressed him on the Seroquel and he said absolutely no way due to sedation, which is the last thing we need in her as she is underaroused and he hasn't heard of Seroquel being used for social anxiety. He wants to switch her to Zoloft, which I'm game to try, but I'm afraid we'll get only a partial response to that too. Dosing may be an issue as she's sensitive to side effects.
>
> We'll give Zoloft a whirl, but after that we need referral to a pediatric clinic that specializes in social anxiety. Who is the best? Are there any places that do intensive CBT specifically for pediatric SP? Research on atypicals as adjuncts for SP?
>I have heard of seroquel for SP, in fact I've considered it myself because my SP is so severe. But I'm afraid of sedation too. The thing about CBT is that it is supposed to generalize. I suspect that those with CBT-resistant SP are also those with various comorbidities (such as fibro or narcolepsy or even ADD) that interfere with the learning process, not at the cognitive level, but at the 'automatic' level. CBT is a very top-down approach. It works well for those whose nervous systems are not in a state of disarray at lower than conscious levels. It made my anxiety worse because the failure to generalize was itself ego-dystonic because I was perfectly aware that something was going wrong at a level I could not control- and my CBT practitioner denied that there was anything I could not control. I am not aware of pediatric SP as a specific diagnosis- I had SP beginning at age five or so, in much the same form I have now (mid-to-late thirties).
-z
Posted by Cairo on April 29, 2005, at 13:19:41
In reply to Re: Seroquel and Social Anxiety » Cairo, posted by zeugma on April 28, 2005, at 17:36:11
> I take 200 mg Provigil along with nortriptyline, clonazepam and buspirone for narcolepsy, depression, ADD, and anxiety both social and generalized. I also have some learning disabilities. I tried CBT for five months and it didn't generalize for me either. I don't have fibromyalgia, but I do have chronic pain in the form of IBS, and the nortriptyline is very good for that, and so is clonazepam. Unfortunately, Provigil worsens my IBS and it also worsens my anxiety at the dose at which it becomes an effective stimulant (200 mg) although less so than Ritalin. Has your daughter tried a TCA or clonazepam? the sedation from the benzo dissipates over time, although not completely, and I've also found it effective for IBS-triggered pain, probably because it lowers the anxiety that pain normally provokes.
She's only tried Lexapro, Celexa prior to that and the Librium 5mg prn. Prozac was tried years ago for "irritability", but not much change seen; social anxiety not noticed then. Imipramine (5mg???) years ago caused tachycardia. No other TCAs tried. The doc doesn't seem to want to go any route other than SSRIs as she's a partial responder to the Lex. He said no to MAOIs, atypicals, and higher doses of Librium. Didn't really discuss other benzos . I agree that we should give Zoloft a try. BTW, Strattera induced depression in her and all the stims caused social withdrawal and anxiety. I would love to see what Neurontin would do for her (except for the cognitive side effects and fatigue), but maybe Pregabalin might work. Could you see Lyrica as as an adjunct to SSRIs to keep doses lower to avoid SE? Also, I've heard about Pindolol as an adjunct to SSRIs for depression, but what about for anxiety? Also seen a case using Topamax for social phobia. Have you tried Larry Hoover's favorite, niacinamide? I forgot...she tried Desyrel 50mg. for sleep. Helped her fall asleep and she was happier and more social , but that was at the same time she started Lexapro. I think it was the Lex. They’re now recommending that we try Melatonin now to help her fall asleep (both a Neuropsych and a Neurologist).It’s interesting that Provigil worsens your IBS and anxiety. Your system must be highly sensitive to any stimulation. Do you respond that way to any stimulants such as caffeine, chocolate, light, noises, smells, etc.? When I’m in a flare, I can’t even drink decaf coffee without waking up at night and lights bothering me. We need sensory deprivation.
Maybe we ought to revisit the Librium. He is totally against raising the dose (she’s at 5mg prn) and prescribed Librium due to the higher dopamine component (I think???). Why Klonopin over Librium? Any news about ocinaplon?
Regarding, pediatric SP, she was labeled “selectively mute” at age 3, though she had severe language delays and auditory processing problems which I know contributed to the problems. But selective mutism is a form of social phobia. The psychologist diagnosed her back then along with ADHD and all her other issues, but the developmental pediatrician we saw was a disaster and she has so many issues that it was hard to sort things out. Even so, what do you do with a 3 year old that you think has social phobia? We live in a very backwards area in that regard.
> I have heard of seroquel for SP, in fact I've considered it myself because my SP is so severe. But I'm afraid of sedation too. The thing about CBT is that it is supposed to generalize. I suspect that those with CBT-resistant SP are also those with various comorbidities (such as fibro or narcolepsy or even ADD) that interfere with the learning process, not at the cognitive level, but at the 'automatic' level. CBT is a very top-down approach. It works well for those whose nervous systems are not in a state of disarray at lower than conscious levels. It made my anxiety worse because the failure to generalize was itself ego-dystonic because I was perfectly aware that something was going wrong at a level I could not control- and my CBT practitioner denied that there was anything I could not control. I am not aware of pediatric SP as a specific diagnosis- I had SP beginning at age five or so, in much the same form I have now (mid-to-late thirties).
I totally agree about the top down approach of CBT. But I suspect that there is a medication out there somewhere that can help open up the “automatic” level. You hear of people here and there that this happens to with Neurontin or other weird meds. My Rheumatologist is into this and constantly telling me that the current drug armamentarium is hitting the problem ‘downstream’ and you’ve got to get to the prefrontal cortex (?) or whatever (my attention span is gone with my FMS) . She speaks of stress and anxiety changing the genes from one generation to the next until you see something like my family where my mom had FMS, I have earlier and worse FMS and my daughter has even earlier and even worse symptoms.
If we need to go beyond our current psychiatrist, what centers and doctors are the best CLINICALLY in the country for social anxiety/phobia? She’s 16 and a half. We can take her anywhere if need be.
I would greatly appreciate any advice. I myself am having difficulty sleeping and anxiety dealing with this and other things. But mom’s got to keep it together. Namaste’
Cairo
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