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.

Tenex (generic Guanfacine) is a medication that has been used for years as a mild antihypertensive.  In the body and in the lower brain centers it reduces the release of norepinephrine (sometimes called noradrenalin).  In the prefrontal cortex in the front of the brain it decreases sensitivity to distracting stimuli and therefore helps with focus (on target stimulus).  A slow release form of Tenex will likely be FDA approved for ADHD within the next year or two. There are good controlled studies showing that Tenex benefits many ADHD symptoms although it doesn’t help with boredom or enhance ability to focus on things the ADHD individual has low interest in.  Only stimulants help the full range of ADHD symptoms and that’s why stimulants are considered the first line treatment.

 
Stimulants increase norepinephrine throughout the brain and sometimes in the body.  In the prefrontal cortex this helps decrease distractibility but in other areas of the brain it sometimes causes nervousness, insomnia, decreased appetite, or irritability and in the body can cause muscle twitches, stomach ache, or increased blood pressure.  In the lower brain centers in children it has sometimes been found to delay growth.

 
All of these negative effects can be reduced or eliminated by Tenex (Guanfacine) plus distractibility is further improved.  If taken in too high a dose it can cause sluggishness or dizziness and occasionally can cause swelling.  It is one of my top 10 most frequently prescribed medications – usually with stimulants or sometimes antidepressants.  It can be taken once or twice daily (See how to take) because it has a half life of 16 hours – it can be effective if taken just once a day.

 
Tenex is related to Clonidine.  But Tenex is 10 times stronger in the prefrontal cortex than in lower brain centers where Clonidine has the same potency in all brain areas and is therefore much more sedating – sometimes causing morning drowsiness when taken at night.  But some people need the higher sedation at night and it has a stronger enhancement of growth hormone – in fact Clonidine is sometimes abused by body builders to increase muscle building.

 
Many of my patients have found Tenex to be helpful for social anxiety.  It reduces symptoms like sweating, and dry mouth but it also decreases distractibility.  People with social anxiety are distracted by negative or “what if” thoughts.  They are also distracted by physical symptoms and they are distracted by any negative cues in their environment, e.g., if giving a presentation and one person yawns the immediate thought is, “I must be boring”.  It’s very hard to do a good presentation when your mind is jumping all over the place.  Stimulants also help social anxiety by increasing control of what you focus on.  The combination of stimulants (such as Adderall XR, Daytrana) and Tenex is especially helpful in lowering public speaking anxiety symptoms so that with adequate opportunities to practice, public anxiety response will gradually desensitize.

Social anxiety disorder is characterized by excessive fear and or avoidance of situations in which an individual believes he or she may be the subject of evaluation or scrutiny while interacting with other people or performing a specific task. The central theme of the disorder is the fear of negative evaluation by others. As a result, social situations are avoided or endured with great discomfort, leading to significant functional impairment.
Social anxiety disorder is the most common anxiety disorder, affecting 8% of the general population. The main cause is genetic. It usually starts in early life-average age 14. Social anxiety may be limited to specific situations, such as public speaking, or it may effect multiple situations and be generalized social anxiety.
There are several reasons that recognition and treatment are important: SAD has a significant impact on quality of life, both personal and occupational. Not only is there painful self-consciousness and
embarrassment, but anticipatory anxiety that sometimes lasts for weeks while awaiting a presentation or event. Social situations or events are often endured with great discomfort or avoided altogether.
Estimates are as high as 60% of alcohol problems are associated with self treatment of social anxiety.
Persons with SAD are more likely to be single and more likely to have lower levels of income and education.
Treatment involves medication, support, and desensitization. To get over social anxiety you have to confront the various situations and have them be OK. Forcing yourself to do it and suffering major embarrassment just reinforces a negative experience.
Medication can be used situationally for specific anxiety like public speaking, or on a regular basis for generalized social anxiety.

DSM IV CRITERIA FOR SAD
A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of situationally bound or situationally predisposed panic attack.
C. The person recognizes that the fear is excessive or unreasonable.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the persons normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

? Overestimates scrutiny by others
• Embarrassment, humiliation, and rejection over sensitivity
• Preoccupation with other’s perceptions and/or responses
• Certainty of negative evaluations
• Discounts personal achievements and over-emphasizes failures

When a stranger walks into a nursery full of toddlers, most of them stop playing, look at the stranger for a few seconds, and then resume playing. About 10% of the toddlers are overly shy or inhibited and will not resume play until the stranger leaves. Another 10-15% are outgoing. These “bold” children will walk up to the stranger and start asking questions.
Jerome Kagan, a psychologist at Harvard University has studied social behavior for over 20 years. He has found that shy toddlers frequently grow up to be adults with significant social anxiety. Shy children are different even in utero in that they will have a much greater increase in fetal heart rate in response to a loud noise. Bold toddlers grow up to be extroverts and in some cases may even grow up to be criminals. The bold toddler’s fetal heart rate doesn’t change in response to loud noises. These as well as other studies strongly support genetics as the primary underlying cause of social anxiety disorder.

Paxil was the first SSRI approved for generalized social anxiety. It may be more effective than the other SSRI’s, (Prozac, Celexa, Lexapro, Zoloft). The CR formula of Paxil is better tolerated than regular Paxil. Effexor XR and Zoloft were recently approved by the FDA for SAD also. The SSRI’s and Effexor XR probably work mostly by down regulating the brain transmitter Serotonin.
Clonazepam is the most beneficial of the benzodiazepines, probably because it has some effect on Serotonin.
Neurontin has shown beneficial effects for SAD also.
Inderal (Propranolol) is effective for heart racing and tremor in situational SAD.
Cardura has shown to be effective for excessive sweating.
The most potent medications for SAD are the MAO inhibitors (Nardil, Parnate). Unfortunately, they require diet restrictions and have significant side effects.

• Small group participation
• Eating, drinking, writing in public
• Talking to authority figures
• Public speaking, performing
• Attending formal family events
• Being observed working
• Meeting strangers
• Using public restrooms
• Being center of attention

• Stuttering
• Butterflies
• Sweating
• Palpitations
• Trembling/shaking

Cognitive behavioral therapy has proven to be very effective in treating social anxiety disorder.
Behavioral therapy focuses on specific steps to lessen anxiety and reduce the likelihood of recurrence. The patient is asked to face the thing they fear (exposure), and not avoid to cope with the situation.

Patients must be willing to endure temporary increases in anxiety and other symptoms in order to attain long term reduction of symptoms. The therapy is time consuming. Hard work is required by the patient to insure symptomatic relief.
The cognitive part of therapy involves replacing negative thoughts (self-talk) with positive. e.g., Instead of, “they will think I’m stupid”, replace it with “I know I’m smart.” Optimists see things better than they are. Pessimists see things worse than they are. Realists see things as they are.
Optimists have the highest quality of life and live longer.
Exposure therapy:
Real life (in vivo)-involves having the patient place themselves in actual anxiety provoking situations until they experience at least a 50% reduction of anxiety.
Every treatment outcome study utilizing exposure has produced significant reductions in social anxiety symptoms. The therapy requires repetitive patient exposure to all anxiety triggers for best results. This will include reduction of anticipatory anxiety and increased comfort levels in social situations.
Social Skills Training-some people benefit from learning techniques to become more assertive, make small talk more effectively, improve eye contact, etc.