Question

I have suffered with Social Anxiety Disorder now for about 5 years, but have only recently started treatment for it. I was originally taking paroxetine (Paxil), which didn't seem to do much for me. Now the doctor has put me on Prozac (fluoxetine), which is making me even worse. I do not leave the house at all, and on the odd occasion get bad dizzy spells with pins and needles in my face and lips. What do you suggest?

Answer

Social Anxiety Disorder, previously called social phobia, is a very disruptive and frightening anxiety disorder. The person with this problem has difficulty functioning in any social situation that involves interaction with others as well as having difficulty analyzing themselves; they are usually overly critical of their performance, which results in lowered self esteem. This disorder involves both a "chemical"(physiological) problem and a behavioral (environmental) problem.

Medication is utilized to stabilize the chemical problem, which basically relates to the phobia or fear of being in social situations. You may know of the 'flight or fight' reaction of the body to a stressful situation. When challenged by a significant stress, the body responds by producing adrenalin (epinephrine), which is a substance that transmits signals between nerve cells in various part of the body (it's a neurotransmitter). The physiological response to release of adrenalin is to increase the heart rate, shunt blood to the muscles and away from the digestive tract, and to make the person in general 'hyper- alert'. This added energy from the response to adrenalin allows the person to fight, or run from, the stressor. If you think about this normal survival mechanism working in a non-life threatening situation, it makes sense that the symptoms like sweaty palms, fast heart rate, dizzy spells, etc can occur. The excess adrenalin generated in individuals with anxiety disorders is what basically causes these symptoms. It's very frustrating because the person doesn't have control over these symptoms - they are mediated by the autonomic (or automatic) nervous system. You no more have 'control' over these things than you do over your digestive tract. As these types of mechanisms are automatic, the more you try to control them, the more fear/anxiety results and the more adrenalin is generated, worsening the symptoms.

The medications that you were given are ones that are normally used for a minor mood disorder or clinical depression. In the USA, paroxetine (Paxil) is classified as an antidepressant medication, but it's also used in the treatment of obsessive-compulsive disorder and social anxiety disorder. It's a 'serotonin reuptake inhibitor'; by inhibiting its removal, more serotonin is available. (Serotonin is a neurotransmitter too, that's involved in the regulation of mood, emotions, appetite and sleep.) Fluoxetine (Prozac) is a more powerful serotonin reuptake inhibitor, which may explain why you actually felt worse with the Prozac; serotonin is probably not the only problem.

The symptoms mediated by the adrenalin can be well controlled with some anti-anxiety agents. Buspirone (Buspar) is considered by many experts to be a very good choice. This drug takes about a month to exert its full response. In general, benzodiazepines (such as Valium) are the type of medication that is used for acute attacks of anxiety. Alprazolam (Xanax) is used for panic attacks.

One must also remember the behavioral component of social anxiety. The best way to correct this aspect is by learning new coping skills to prevent the symptoms from occurring during stressful times. Insight-oriented psychotherapy with good goal-setting is the best fine place to start. Please discuss all these issues with your physician, and find out what resources are available to you for correction of the behavioral component of your disorder.

Links

• Social Phobia/Social Anxiety Association