Question. I’ve suffered from general social phobias all my life. I’m unable to tolerate the MAOIs due to digestive difficulties and the RIMAs are not available in the U.S. I’ve also tried Klonopin and Valium which wore off and never helped with the internal thought processes. I’m currently taking Remeron, Lamictal, BuSpar, Cogard and Zyprexa. I’ve tried almost every SSRI, many TCAs and Effexor and Serzone. CBT also failed. My symptoms include rage, depression and insomnia as well. Is their anything left for this hopeless phobic?
Answer. You certainly do seem to have a very refractory case of social phobia (SP) – though I am a bit puzzled by the use of Zyprexa, which is an antipsychotic agent and is NOT used for the treatment of uncomplicated social phobia. If there is an additional psychotic symptom picture, that would certainly complicate both your course and treatment. I also wonder about your rage, which is being treated with an anticonvulsant that has some mood stabilizing properties. Rage is not a typical feature of uncomplicated social phobia, and lamictal is not a standard treatment for social phobia (it is being investigated for the treatment of bipolar disorder).
I suggest you clarify these diagnostic and treatment issues with your treating psychiatrist. If you are not satisfied with his/her explanation, you might ask for a “second opinion” with someone specializing in the treatment of social phobia. Assuming we are just discussing resistant SP, there are a number of options you can consider, though I certainly don’t want to give you false hopes of some kind of miracle out there.
On the other hand, I do not think your situation is hopeless. Let’s start with relatively straightforward possibilities. You could try CBT again with a different therapist; sometimes the problem isn’t with the treatment, but with the particular therapist. Also – have you been involved in any forms of group therapy for social phobia? Have you tried contacting the social phobia support group on the Internet? You might also be interested in The Anxiety & Phobia Workbook by Edmund J. Bourne, Ph. D.
In terms of medications for resistant social phobia, you could ask your doctor to make arrangements with a psychiatrist in Canada for a trial on the RIMA agent moclobemide; this would involve one appointment, and then the prescription could be provided to your own doctor for dispensing to you, or to you directly. This is cumbersome, but not impossible, and some data suggest that moclobemide may be useful in SP. Alternatively, you could consider a re-trial on Nardil with a “GI consult” (seeing a specialist in gastrointestinal disorders) to help manage the digestive difficulties. There are a few anecdotal reports finding that bupropion [Wellbutrin], clonidine, and ondansetron may be useful for SP, but the evidence is very preliminary. I would not rule out combining two SSRIs, or augmenting an SSRI with a tricyclic. The combination of Remeron and Effexor could also be considered, though all of these strategies have their associated risks, and none has been validated in the treatment of social phobia. Your doctor may be interested in seeing the nice review by J. W. Jefferson in the Journal of Clinical Psychiatry, which discusses these and other options for SP. I hope that some of these recommendations may prove useful for you.