What can I take safely for social phobia
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What can I take safely for social phobia?

Q: I curently feel that my Bipolar I is controled for the most part, but I have had and continue to have severe social anxiety. My doctor will not give me paxil or any other SSRI for fear that they will induce mania. My question is are there any other medications that will relieve my social anxiety. I take clonazepam sometimes, but it kinda defeats the purpose because I feel too drugged out to participate in social situations anyway. I've also tried Effexor XR to no avail. Any suggestions?

Dear Timothy --
First, there's a great psychotherapy approach for social phobia, if you live in a big enough city to find it.  Some people have adapted the "cognitive behavioral therapy" for panic disorder into a treatment for social phobia.  I've done both types, and it's not only pretty easy therapy to do, it's kind of fun, because it can be so effective.  Hard work for the client sometimes, especially if you want it to go fast.  So, use the "find a therapist" tools and see if you can find somebody local to you who can so "cognitive behavioral therapy for social phobia", and how many folks have they treated doing that.  The answer should be "not very many", because this approach is pretty new; if it's hundreds, they are either a tremendous pro' or they aren't really doing CBT as it is now being tested for SP.

As far as med's go, you've probably heard that MAOI's are great for social phobia.  There's a great article about the foods you have to avoid that makes the process a lot easier (it comes down to some beers and wines, most cheeses, and a few other things that we don't use much of in the US anyway, except salami/pepperoni...).

You may also have heard that MAOI's seem to have pretty much the lowest "switch rate" of any of the antidepressants, probably better than Wellbutrin which is probably the best of the usual ones (most experts put Paxil next after that).  If you have good stability on some mood stabilizer(s), you can take a small risk to try one an MAOI (the risk is in the switch; and some very slight risk if you take the diet stuff seriously).

Finally, you can a little more confident with an antidepressant if you really prepare in advance with solid mood stabilizers, maybe several, and a concrete plan for how any emerging switch is going to be detected and treated (in Oregon, for example, we have something called an Advance Directive, authorizing hospitalization if you become psychotic and are refusing hospitalization at the time).  Remember, the published "switch rates" on antidepressants are still only 30-50%, leaving you a 50% chance, perhaps, of not switching.  True, not really confidence-building odds...

Dr. Phelps


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