Archive for the ‘Social Anxiety Disorder’ Category


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.

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Social Anxiety Disorder Overview

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.

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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.

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Common Cognitive Styles of SAD

? 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

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Jerome Kagan Study of Shyness

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.

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Medications that Help Symptoms

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.

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Common Fears of SAD

• 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

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Common Physical Complaints of SAD

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

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Common Behavioral Treatment for Social Anxiety Disorder

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.

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Social Anxiety Disorder: Did You Know?

• 40-50% of people with SAD also have depression
• SAD is the most common anxiety disorder
• 13% of the population will have SAD in their lifetime
• 50% of those with SAD do not finish high school
• 22.3% of those with SAD are on welfare
• 50% of those with SAD are single, divorced, or separated
• Onset of SAD is usually age 14-16
• 50% of those with SAD also have another psychiatric disorder, especially
alcohol abuse
• 35% of SAD occurs before age 10
• Behavior treatment with medication is the most effective treatment for SAD
• 25% of patients with SAD decline when offered behavioral treatment
• Only 5% with SAD get treatment

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