Treating Social Anxiety/GAD

[maverick323]

Student here with a couple questions.

1) When treating Social Anxiety/GAD what do you take into consideration when prescribing medications? (This is after trying CBT)

From what I read online first line of treatment is always an SSRI, Remeron, TCA's etc. All of which are usually for depression, OCD, and other issues that seem to be a little more severe IMO. They all can have bad side effects and in the case of Mirtazapine needs a higher dose because too low of a dose causes extreme hunger and fatigue.

Are there no primarily anxiolytic medications?


2) In the case of medications that can be addictive or cause dependance like Pregabalin or a GABAergic "nootropic" like Phenibut. What is the big concern, if the individual is responsible? Like the drugs mentioned above they would require a weaning off process. It is not like you can just stop an SSRI cold turkey. From what I read the withdrawals seem softer than the potential issues with stopping an SSRI CT.

Thank you

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[ObsequiousAplomb]

Why do you have the impression that as a whole MDD and OCD are more severe than GAD/social anxiety/agoraphobia? All of them can be quite mild, all of them can be debilitating.

Many of the medications you mentioned are approved for GAD. There are also other medications you didn't list that are approved for GAD.

 

[clozareal]

Student here with a couple questions.

1) When treating Social Anxiety/GAD what do you take into consideration when prescribing medications? (This is after trying CBT)

From what I read online first line of treatment is always an SSRI, Remeron, TCA's etc. All of which are usually for depression, OCD, and other issues that seem to be a little more severe IMO. They all can have bad side effects and in the case of Mirtazapine needs a higher dose because too low of a dose causes extreme hunger and fatigue.

Are there no primarily anxiolytic medications?


2) In the case of medications that can be addictive or cause dependance like Pregabalin or a GABAergic "nootropic" like Phenibut. What is the big concern, if the individual is responsible? Like the drugs mentioned above they would require a weaning off process. It is not like you can just stop an SSRI cold turkey. From what I read the withdrawals seem softer than the potential issues with stopping an SSRI CT.

Thank you

1) the SSRIs have a higher effect size for anxiety disorders compared with depressive disorders and from my clinical experience, faster response if they are able to tolerate a faster uptitration (most of the time not). You can also consider buspirone. Anxiolytic medications off label include gabapentin/pregabalin, hydroxyzine, beta blockers, or even antipsychotics. Supplemental options include Silexan (lavender oil) or kava.

2) Benzos are extremely effective as an anxiolytic, but have their own set of problems although still should be in the treatment algorithm for treatment-resistant anxiety in my opinion. See the other thread by the pain physician for more of a discussion on this. Pregabalin/gabapentin do not affect GABA directly and are considered more addictive by the regulatory bodies in Europe than the US. I would not recommend phenibut, kratom, cannabis, etc for anxiety at this time, but if they were on it then I would refer to an addiction specialist to help them wean off these slowly. Often times, you'll need to replace it with something else before you can wean down. You should not stop any SSRI cold turkey except for fluoxetine and even then, people have issues with symptoms when titrating down.

 

[hamstergang]

Mirtazapine needs a higher dose because too low of a dose causes extreme hunger and fatigue.

This seems not true despite being widely said. That is, higher doses are not less fatiguing and appetite-inducing than lower doses.

 

[calvnandhobbs68]

This sounds suspiciously like a patient trying to gather some info about why they "shouldn't" be prescribed an SSRI and "should" get pregabalin or use phenibut or something.

You're a student of what exactly?

 

[maverick323]

This sounds suspiciously like a patient trying to gather some info about why they "shouldn't" be prescribed an SSRI and "should" get pregabalin or use phenibut or something.

You're a student of what exactly?

Freshman Biology at UC Irvine.

No, that is not what I am doing. I was looking at new treatments for Rosacea and saw that Mirtazapine was being prescribed to some people for facial flushing at about 40mg. I looked it up and saw that it was an anti-depressant and the reason it was prescribed is that along with it working as an anti-histamine many people who have Rosacea suffer from anxiety which exacerbates the flushing.

I then went down the rabbit hole of anxiolytics and from what I read most are not for anxiety but, for other illnesses like the ones I mentioned. Anxiety seemed to be used off label or as a side treatment i.e "It has/can also be used for anxiety".

The comparison I made was just to show that you are kind of dependent/ tied to both types of treatments. You cannot just stop either cold turkey yet SSRI's seem to be pushed. Admittedly, I have never been addicted/dependent on something so, I do not know how fair of a comparison it is.

 

[maverick323]

Why do you have the impression that as a whole MDD and OCD are more severe than GAD/social anxiety/agoraphobia? All of them can be quite mild, all of them can be debilitating.

Many of the medications you mentioned are approved for GAD. There are also other medications you didn't list that are approved for GAD.

Mostly because, there are many OTC supplements that claim to help with GAD/social anxiety. Many with studies to back them up. Some people use alcohol as a social lubricant. Can the same be said for something like OCD?

I guess severity would play a major role. L-Theanine is not going to help someone who cannot leave their home.

 

[hamstergang]

I then went down the rabbit hole of anxiolytics and from what I read most are not for anxiety but, for other illnesses like the ones I mentioned. Anxiety seemed to be used off label or as a side treatment i.e "It has/can also be used for anxiety".

A medication's FDA approved indications (ie what the drug company is allowed to say the medication is for) is not so much about what the science supports as it is about business decisions and politics.

 

[ObsequiousAplomb]

Mostly because, there are many OTC supplements that claim to help with GAD/social anxiety. Many with studies to back them up. Some people use alcohol as a social lubricant. Can the same be said for something like OCD?

I guess severity would play a major role. L-Theanine is not going to help someone who cannot leave their home.

I do not believe there is any quality evidence that an OTC substance works for MDD or GAD or SAD. Interestingly, one can get NAC OTC, which has marginal evidence for OCD. I still wouldn't recommend any of those.

More importantly, that's incredibly specious reasoning you are using. Did you stop to consider that those products are merely marketing themselves in an unethical way without any evidence, and OCD is a smaller market?