Question: Dr. Jones
My son is 14 yrs. old and has been diagnosed with bipolar more depression than mania. ADHD and Anxiety. He is on 150 mg of Lamitical, and he is starting 36mg of Concerta, and is currently on 80mg. of Prozac. My son has severe social anxiety and performance anxiety. He is a select basketball player and baseball player. He has dropped all sports due to anxiety. The only thing he does now is ride bikes with his dad and works out at the gym. We are looking at also having to home school him due to his condition. He is very smart, talented in music and sports, but locked up with anxiety. Can you please help. We have also tried Xanax, Propanolol (for Physical symptoms) Nothing we have tried has helped the anxiety. Anxiety and panic attacks run in my family. Most of my family are taking Effexor XR. What do you think about my 14 year old son trying this medication. Please help!!
This anxiety is so crippling. Thanks so much for your help!

Answer from Dr. Jones:

Social Anxiety Disorder is the most common anxiety disorder, affecting 16% of people to some degree.  Most patients are somewhat comforted by knowing there is a strong genetic factor.  Studies of pregnant women monitoring the pulse of the fetus with a loud noise or acute stimulation show that those that will have a shy temperament have a much stronger reaction in terms of increased heart rate and their heart rate stays up much longer.  I have found that many people with social anxiety are also ADHD so that is common.  Also, being diagnosed with bipolar is not unusual because all three of these conditions involve the dopamine system of the brain. 

Stimulants are often helpful, although my experience has been that the Adderall Vyvanse, Dexedrine type of medications are often the best.  One of the reasons they are helpful and one of the paradoxical things we find is that stimulants decrease anxiety because they help us to think of one thing at a time and can help with more easily ignoring distractions.  Especially with Social Anxiety distractions come from all directions, mind, body, and other people  -  what if this?, what if they don’t like me?, what if I say the wrong thing?, and what if I draw a blank?.  They may feel their heart racing, or their throat gets tight, or they feel hot or flushed.  Any negative stimulation in the environment affects them.  There can be a thousand people in the room and if somebody yawns when they are talking, they think, “oh no, they think I’m boring”.  Or somebody laughs and they think they are laughing at them, which makes it very hard to stay on track and the anxiety keeps escalating. 

Propranolol is helpful for some types of symptoms as long as asthma is not a problem.  But it has to be the right dose for the individual.  It is especially good for racing heart, shaking muscles, quivering voice and tremor.  It is not particularly good for sweating and blushing but a lot of patients take it along with one of the tranquilizers at least for situational things like giving a talk or being in class if that’s what the problem is.  Xanax is good for anxiety but the tranquilizer that is most commonly effective for social anxiety is Klonopin, or clonazepam.  It is actually the most potent for panic.  Klonopin is also the only medication in that class that has an effect on serotonin which is the worry system and obsessing. It also reduces racing thoughts.  Plus it lasts longer so it does not have to be taken as often as Xanax.

In terms of your son, I have had a teenager do home schooling for a semester or so but the goal is always to get them back into the normal situation.  They just have to start desensitizing possibly in another environment.  One girl I treated wouldn’t go to school, but got a job during the summer as a hostess in a restaurant and because she was on medication it allowed her to tolerate that situation and it desensitized her to the point that she was able to go back to school.

The most important thing is you can’t get over social anxiety first and then start getting into social situations.  The only way to get over it is to be in the situations
but not having severe symptoms.  Forcing oneself or being forced into situations and having a horrible time, being embarrassed, feeling humiliated, and can’t wait until it’s over doesn’t help, it actually worsens the condition because it more strongly conditions the brain that the situation is bad news. 

The way to get over it is by being in social situations with minimal anxiety or at least less than before and having various techniques, including cognitive techniques to use.  But if you are overwhelmed with anxiety then it is pretty hard to use cognitive techniques. 

If the physical symptoms are severe then managing them is important and things like Propranolol are good, but you have to take the right dose.  So too much can cause additional physical symptoms and too little doesn’t control the symptoms.  For things like sweating, medications like Cardura or anticholinergics are more effective and for blushing sometimes Klonopin helps and sometimes Pindolol helps because it has the serotonin and beta blocking effect. 

It is best to only change one medication at a time.  Lamictal is good for the depression associated with bipolar disorder.  200mg is the most typical dose.  Prozac is effective in terms of OCD or obsessing.  You wouldn’t want to take Prozac and Effexor together.  Effexor does have good studies for social anxiety disorder and covers a wider range of symptoms but you would have to transition it gradually, reducing the Prozac by 20mg each week so you would need to wait a week before starting the Effexor.  Then you would gradually taper off one while adding the other.

So the most important thing is your son can get over Social Anxiety Disorder. It’s common, it’s disabling and there are a lot of medications that can help by taking the right one or combination of medications at the right doses and then getting into the dreaded situations and desensitizing.  He will have to get to where he doesn’t avoid at all because any avoidance reinforces the symptoms.

Don’t give up! Persevere until you find the right medications at the right dose to help your son. Good luck in your efforts to help your son find a normal, healthy life.
Answer:

Dr. Jones
My son is 14 yrs. old and has been diagnosed with bipolar more depression
than mania. ADHD and Anxiety. He is on 150 mg of Lamitical, and he is
starting 36mg of Concerta, and is currently on 80mg. of Prozac. My son has
severe social anxiety and performance anxiety. He is a select basketball
player and baseball player. He has dropped all sports due to anxiety. The
only thing he does now is ride bikes with his dad and works out at the gym.
We are looking at also having to home school him due to his condition. He
is very smart, talented in music and sports, but locked up with anxiety. Can
you please help. We have also tried Xanax, Propanolol (for Physical
symptoms) Nothing we have tried has helped the anxiety. Anxiety and panic
attacks run in my family. Most of my family are taking Effexor XR. What do
you think my 14 year old son trying this medication. Please help!!
This anxiety is so crippling.

From Dr. Jones:
Social Anxiety Disorder is the most common anxiety disorder,
affecting 16% of people to some degree. Most patients are somewhat
comforted by knowing there is a strong genetic factor. Studies of pregnant
women monitoring the pulse of the fetus with a loud noise or acute
stimulation show that those that will have a shy temperament have a much
stronger reaction in terms of increased heart rate and their heart rate
stays up much longer. I have found that many people with social anxiety are
also ADHD so that is common. Also, being diagnosed with bipolar is not
unusual because all three of these conditions involve the dopamine system of
the brain. See social anxiety newsletter

Stimulants are often helpful, although my experience has been that the
Adderall Vyvanse, Dexedrine type of medications are often the best. One of
the reasons they are helpful and one of the paradoxical things we find is
that stimulants decrease anxiety because they help us to think of one thing
at a time and can help with more easily ignoring distractions. Especially
with Social Anxiety distractions come from all directions, mind, body, and
other people – what if this?, what if they don’t like me?, what if I say
the wrong thing?, and what if I draw a blank?. They may feel their heart
racing, or their throat gets tight, or they feel hot or flushed. Any
negative stimulation in the environment affects them. There can be a
thousand people in the room and if somebody yawns when they are talking,
they think, “oh no, they think I’m boring”. Or somebody laughs and they
think they are laughing at them, which makes it very hard to stay on track
and the anxiety keeps escalating.

Propranolol is helpful for some types of symptoms as long as asthma is not a
problem. But it has to be the right dose for the individual. It is
especially good for racing heart, shaking muscles, quivering voice and
tremor. It is not particularly good for sweating and blushing but a lot of
patients take it along with one of the tranquilizers at least for
situational things like giving a talk or being in class if that’s what the
problem is. Xanax is good for anxiety but the tranquilizer that is most
commonly effective for social anxiety is Klonopin, or clonazepam. It is
actually the most potent for panic. Klonopin is also the only medication in
that class that has an effect on serotonin which is the worry system and
obsessing. It also reduces racing thoughts. Plus it lasts longer so it does
not have to be taken as often as Xanax.

In terms of your son, I have had a teenager do home schooling for a semester
or so but the goal is always to get them back into the normal situation.
They just have to start desensitizing possibly in another environment. One
girl I treated wouldn’t go to school, but got a job during the summer as a
hostess in a restaurant and because she was on medication it allowed her to
tolerate that situation and it desensitized her to the point that she was
able to go back to school.

The most important thing is you can’t get over social anxiety first and then
start getting into social situations. The only way to get over it is to be
in the situations
but not having severe symptoms. Forcing oneself or being forced into
situations and having a horrible time, being embarrassed, feeling
humiliated, and can’t wait until it’s over doesn’t help, it actually worsens
the condition because it more strongly conditions the brain that the
situation is bad news.

The way to get over it is by being in social situations with minimal anxiety
or at least less than before and having various techniques, including
cognitive techniques to use. But if you are overwhelmed with anxiety then
it is pretty hard to use cognitive techniques.

If the physical symptoms are severe then managing them is important and
things like Propranolol are good, but you have to take the right dose. So
too much can cause additional physical symptoms and too little doesn’t
control the symptoms. For things like sweating, medications like Cardura or
anticholinergics are more effective and for blushing sometimes Klonopin
helps and sometimes Pindolol helps because it has the serotonin and beta
blocking effect.

It is best to only change one medication at a time. Lamictal is good for
the depression associated with bipolar disorder. 200mg is the most typical
dose. Prozac is effective in terms of OCD or obsessing. You wouldn’t want
to take Prozac and Effexor together. Effexor does have good studies for
social anxiety disorder and covers a wider range of symptoms but you would
have to transition it gradually, reducing the Prozac by 20mg each week so
you would need to wait a week before starting the Effexor. Then you would
gradually taper off one while adding the other.

So the most important thing is your son can get over Social Anxiety
Disorder. It’s common, it’s disabling and there are a lot of medications
that can help by taking the right one or combination of medications at the
right doses and then getting into the dreaded situations and desensitizing.
He will have to get to where he doesn’t avoid at all because any avoidance
reinforces the symptoms.

Don’t give up! Persevere until you find the right medications at the right
dose to help your son. Good luck in your efforts to help your son find a
normal, healthy life.