D-Cycloserine

I can't link the full text article due to copyright issues, but if you google "cycloserine social anxiety disorder" you should find a full text study in .pdf format.

Cycloserine is an antibiotic originally developed as a treatment for tuberculosis. However, research in the late 90s and 2000's revealed that it works on a receptor in the brain known as the NMDA receptor which scientists believe is in charge of learning processes with regards to anxiety and the amygdala.

Research showed that rats who were administered the drug prior to exposure to a feared stimulus were able to undergo "extinction" faster than rats who had no cycloserine. Extinction is the process in which a person's brain learns to drop automatic fear responses to previously feared stimuli.

Further research showed that people with social anxiety disorder who were given this drug in conjunction with exposure sessions reported a far greater reduction in social anxiety symptoms and much sooner than patients who were given placebo.

On the account of this research, I've become very excited to try this medication in conjunction with my own exposure therapy. I have to be honest, the exposure therapy I've done just hasn't seemed to reduce my symptoms. This last Christmas I experienced a great amount of physical anxiety symptoms coupled with an inability or unwillingness to communicate with my family members. Further, in events like ordering food or going to the bathroom I experienced the same heart racing/severe anxiety symptoms that I've experienced in the past.


I understand that treatment isn't meant to be constant progress and that I should expect to sort of "oscillate" between being better and worse, and I would be lying if I said there haven't also been times where I usually would have had physical anxiety symptoms and I didn't. It's just that progress hasn't been what I'd expected it to be and I feel I need to have something to "augment" my treatment.

This medication is still in the experimental stage for use in treating anxiety disorders, however other studies have been able to replicate its use in treating anxiety disorders such as panic disorder and acrophobia. So I'm fairly optimistic in its ability to treat anxiety disorders.

But as I've said, since it is still in an experimental phase in regards to anxiety disorders, getting prescriptions for it means that it would have to be prescribed off-label. This has proven to be an exceedingly difficult barrier to overcome, I've been to many general practitioners with little to no success. Tomorrow my mother is going to another doctor who'll hopefully give me the prescription.. otherwise I'm going to have to start calling psychiatrists and hope to find one who's willing to experiment.

I do think this is a promising treatment option, and encourage people who're willing to do exposure exercises to try to get this medication as it might help facilitate your treatment progress.

Please comment if you're reading this, I'd like to have discussions.

hello

I haven't really been doing any work in regards to the CBT since school is out of session and I'm in New York. Symptoms have been quite strong lately, with family gatherings. I feel that if I don't play with the kids and be social that it'll be a reflection on me as someone who just can't be around other people. However, I know that despite not living up to the social expectations I have for myself, my grandparents talk to me the same (probably isn't such a big deal to her, if she even notices) and really if people form that opinion of me as someone is secluded and incompetent socially well - I HAVE SOCIAL ANXIETY DISORDER. So ya, of course I'm socially inhibited. Furthermore it really doesn't effect me, like at all. If someone thinks I'm socially awkward or incapable of talking then they form that opinion and it stays in their brain. It might change the way the behave around me, and they may gossip to other people if they have nothing better to do. But it's not like it really effects MY life. Even if people view me negatively, they're just people I see every once in a while and there are plenty of other people in this world to whom first impressions can still be made.


In any event the impression of anxiety or quietness leaves once you've overcome the SA and become like yourself again, as I've noticed people who've commented on how boring I've been and how little I talk seem to forget all about that in the times my SA is in remission. I do long for the days when I don't feel this great weight on me in social situations but I recognize that a lot of hard work is left ahead of me if I'm going to get better.

Progress

Alright, so I haven't updated in a while, no I haven't suddenly forgotten about CBT. Actually these past few weeks I've sort of quasi ended treatment due mostly to an OVERWHELMING amount of school work and job obligations. I don't very much enjoy complaining so I won't go into those aspects, but suffice to say I've more regressed than progressed these past 3 weeks.

Today however was quite successful. I had my first appointment in 1 and a half weeks. I did what's known as an "in vitro" exposure, which honestly I think are best for beginning SA treatments. Exposures are absolutely essential to the treatment process and so it makes it even moreso important to have successful exposures. Doing exposures with strangers or friends/acquaintances is inherently more difficult because you don't have the opportunity to carry out a long conversation, you have to be assertive and find creative things to justify talking with strangers (which can be quite difficult), and furthermore you don't get feedback from them.

So my train of thought is (in in vitro exposures) is that the people enlisted to listen to me talk are doing so with the knowledge that I have SA, that I'm working to getting better, and so they're understanding if I show anxiety. This allows me to focus on getting better, rather than worrying so much about showing my anxiety.

Case in point:

Today I was to give a series of presentations to a group of 4 people, and as I went through my chart, I felt like my peak anxiety would be around 90. I felt my heart racing in anticipation, I felt the sweaty palms, the nervous tension. etc etc.

Went through the CBT exercises, then went into the conference room.

First exposure duration: 10 minutes.
So when I first started talking, I was very visibly nervous. Shaking, incoherent talking, losing breath, heart pounding etc etc. Then I started to kind of level off, I still felt an intense radiation of anxiety come over me as I felt they were judging me negatively. I forgot a lot about what I was talking about and hence I received a lot of "he looked nervous, etc etc" feedback

Second exposure duration 12 minutes:
I started off anxious again, but not as much. I felt like I knew it wasn't going to escalate, and I was able to focus on what I was talking a little bit more than my anxiety. Overall, the peak anxiety I felt was the same as the first session but on the average I was getting to pockets of time where I felt comfortable.

Third exposure duration 12 minutes:
I really started to engage the audience, I felt a little more confident due to an absence of anxiety symptoms, I was able to bring out more of my confidence and as I brought my confidence I felt a further decrease in my anxiety. By the end of this exposure, I literally felt no anxiety. Like I could talk for as long as I needed and it would have been as if I was talking to air.

Fourth exposure duration 15 minutes:
Felt no anxiety, had an increased sense of confidence, really got an engaging conversation going, I felt in control and the people enjoyed my personality. Again, to reiterate, I couldn't feel anxiety symptoms and my mind was able to enter a creative world that's only accessible in non-anxious states.

So the point I want to drive home here, is that I started out in anxiety attack mode, but by repeated exposure, I was able to get to a point where my anxiety was the same as that as someone without SA. That's a huge confidence booster and the fourth exposure session really made me feel happy! Because I don't get a lot of attention and I felt like for the first time in a long while I was able to accrue positive feedback which was reflected in their notes on my presentations.

The exposure session totaled about 2 hours which is actually short for what most "successful" exposure sessions should be. I want to layout this experience for readers to understand how they themselves should be conducting their exposure sessions that is to say, with repetition with the mindset that eventually your body will lose the ability to sustain the anxiety response and your anxiety will come down and as it comes down your mind will undergo what's called "extinction" where it reprograms itself to not automatically initiate the anxiety response in future situations.

Week 4 progress

As the name suggests I'm in my fourth week of treatment.

Current progress is actually very easy for me to describe (sometimes progress is more subtle and difficult to notice)

Ok, so today I walked into the school cafeteria and I heard someone call my name. It was a friend of my old room mate's from a few years back. I had met her before a few weeks ago (before treatment) and then I was very nervous talking with her. (Heart racing, mind going blank, dizzy, headachey etc.)

But this time, I actually asked to eat with her and some of her friends ( of course she said yes) and I was actually the center of attention at the table, I was able to talk with mild to no anxiety. My mind didn't go blank like it usually does, and I wasn't at all noticing physical anxiety symptoms. I was able to make her and her friends laugh and we talked for over an hour about various things.

I felt really comfortable, like even if I made a mistake it was alright because I knew that people really don't latch onto people showing anxiety as much as I used to think they did. I'll want to write more on this but right now unfortunately I'm having a headache.

It's only been four weeks but I'm feeling around 20-35% better by just doing exposure therapy sessions (haven't really worked on cognitive sessions)

Getting into treatment.

The first hurdle to overcoming social anxiety disorder is finding the right therapist. This is by no means a trivial case. In my quest to find psychiatric help I have called my insurance company many times, over 20 psychologists, written dozens of emails, and had several "failed" first sessions. (Fail as in, you go in, and realize the therapist knows little about CBT or how to conduct it.)

It's very difficult to find qualified CBT therapists for social anxiety disorder. Even harder still is to find one on your insurance plan. In fact, I found no one - I had to eventually resort back to graduate students at my university.

However, my recommendation to you is to not get discouraged, after all with each failed attempt you're showing yourself your commitment. "Hey I might not have gotten what I wanted now, but because I've trying despite not getting anywhere tells me that I'm committed."


Clinical psychologists, those with PhD's and specifically talk about CBT for SA are the very first and really only people you should seek out. Masters psychologists/generalists/or psychologists in general offer you not only nothing, but they offer you nothing and take your time and money.

If you have any questions about getting involved in a program, please by all means ask. I feel I've become an expert in my several week quest.

Now, also what's important is that you understand the basics of CBT so that in your first appointment you can screen if your psychologist is someone you want to be around. Ask specific questions about new and old points of CBT in the literature and see how they respond. For instance, ask "Is exposure therapy only as effective as CBT (exposure + cognitive)." The answer should be relatively "yes" since two studies have been published on the issue and found statistically similar results between the two treatments.

Ask about their general expertise in conducting CBT, if they researched any components of it, the experience they have with other patients, what their view is on the therapy.

Ask what their philosophy is towards completing homework assignments and if they'd be able to do exposures in the appointments. It's actually very important that they have access to other people for you to talk with so that you can do exposures in session and receive live feedback.

Symptoms

Ok, so the exposure I've done this week has been to write out my cognitive distortions in class and leave the paper out so there's a possibility that neighbors can read it. Honestly the difficulty stems from the idea of showing anxiety and showing potentially embarrassing thoughts. But if you think about it, you wouldn't judge someone going through physical therapy if their aim is to get better, and likewise I don't view other people seeing me try to conquer my anxiety as a bad thing.

It was difficult at first and it still is, but I've done it everytime and nothing disasterous has happened to me. No one's laughed or commented or made fun of me or anything really. This all ties in with the previous post I made that showing anxiety is not nearly as severe as we think it is.

CBT: current progress and future direction

I want to use this blog to chart potential progress, and provide a realistic perspective of what a person going through treatment actually experiences. We read the literature on social anxiety disorder and we see the numbers of responders CBT offers as a treatment, but there is no detailed account of what reduction in symptoms we can quantitatively and qualitatively expect from treatment. There is very little knowledge at least in accessible form of what we can expect going through treatment, how progress is made, what's being done etc. etc. So I hope this blog serves to elaborate on these issues and provide a motivational support for readers which I assume are also SA sufferers.


So, I guess to be relevant I should write about what has happened so far, what my future directions are, and I want to conclude with a discussion on medication (I say discussion because I'm hoping readers will comment on their opinions on the matter.)

I was diagnosed with moderate to severe social phobia, that is to say that on many ratings I am near maximum anxiety provocation - such as socializing with crushes, giving presentations to large audiences, or opinions in a group meeting. However, I retained the "moderate" status because I'm still functional, that is to say I attend classes, I can go on a bus, I can walk/eat in public, and to some extent have acquaintances that I communicate with.

The "testing" phase actually consisted of about 4 sessions in which I took several personality and anxiety questionnaires and interviews, that really highlighted where my focus is, my own individual beliefs that are contributing to my social anxiety etc.

In fact I want to comment on this briefly as I feel it is very important. I want to start with an example using OCD. OCD is of course a disorder in which people have obsessions that can last weeks to months in duration where they're constantly worrying over a potential harmful event occurring in some form or another. However, there are various forms of OCD. Some sufferers worry about germs, such to an extent that they'll wash and scrub their hands until they're raw and bleeding - other OCD sufferers couldn't careless about germs but rather are deadly afraid of having terminal illnesses such as cancer or HIV. Still other OCD sufferers think people who worry about diseases are mental cases but are deathly afraid of having things out of order and may spend hours making sure everything is aligned and categorically placed.

Now, transition to social anxiety disorder, which exhibits (in a more subtle form) the very same versatility in focused fear. Some SA sufferers are deadly afraid of blushing, that's the symptom they focus on in public - others are afraid of trembling - and myself, I'm afraid of losing my voice (by running out of breath) and not being able to communicate.

Of course, on the more severe side of SA, people worry about all of these symptoms or any physical symptom that could be interpreted as showing anxiety.

To me, I couldn't careless if people see me blushing, ya they might interpret that as showing anxiety, but the symptom itself isn't severe enough to warrant any concern from me. I don't feel like it's something a person really cares about at all. Same thing for trembling, if my hands are shaking or my legs are shaking it's not severe enough to warrant concern from me. But gosh forbid if my voice!! trembles or I lose breath I feel like an escalating sense of impending doom and utter patheticness at not being able to communicate (and the wealth of negative thoughts that come from that)

So my "form" of SA is mainly centered around voice concern.

So I began the "treatment" phase roughly 3 weeks ago. I don't really want to comment on all of the things I've done so far as that would make this blog extraordinarily long. So I want to summarize.

Basically I did "exposures" in and out of the lab. In lab exposures consisted of me making small talk with a stranger several times (each time we graded my performance on several measures such as "how anxious did I appear" "how weak was my voice" "how likable was I?" etc. etc.) there was also me reading in front of a small group of other undergraduates doing the same grades of performance..

and then recently there was an out of lab exposure where I went outside and made small talk with strangers at a bus stop (communicating for a little bit then asking them a question). With obviously no grading of my performance.

So, I want to comment on the progress I've made so far in the three weeks of treatment. The first thing that I'm still beginning to realize, is that showing anxiety is in absolutely positively no way as severe as we think it is. There is a HUGE misconception of what people actually think about someone who shows anxiety in our brains. I did an exposure where I talked until I ran out of breath and couldn't talk anymore, and instead of the other people looking at me with disdain and ridicule they looked concerned and wanted to help me. In fact that's what they commented on.

Then I talked with them normally, and it was as if they totally forgot I showed anxiety! We communicated normally, I got them to laugh GENUINELY not out of pity. By no means is anxiety this permanent brand that once you show it - you're branded forever in the eyes of the people you're communicating with to be looked down upon, to have your opinions slighted, and to not want to be around.

Now, obviously this is a pretty pathetic summary of what I've done so far - maybe I'll come back in another blog and write more intensively on the subject but again for the sake of brevity I don't want to write a book.


I guess I want to comment on symptoms I've noticed have improved and what has happened so far. So for one thing, communicating with acquaintances have become easier. I feel lighter, like I'm less inhibited, I don't feel as anxious, and I'm able to focus on what they're doing and not be as concerned about what I'm doing.

That's been the most noticeable symptom improvement thusfar.

Now also, recently I was giving a rather extended talk >1 minute (i.e. potential to lose my voice if anxiety increases) to a group of acquaintances where the focus was explicitly on me. I felt the anxiety, the sort of adrenaline escalating feeling and that they were noticing my voice etc. etc. and that I was losing control.. BUT unlike previous circumstances where this would happen - from my exposure, I knew that the anxiety had a stopping point, that I've been there before and that people actually AREN'T noticing the symptoms like I think they are and that that feeling though unpleasant was actually in my control.

So the anxiety didn't dissipate, but I was able to tolerate it enough to finish my talk, which is something I could not say in the past. I then went on to give another talk in an even larger setting and I didn't feel the physical symptoms of anxiety but I did get the mind going blank thing a little bit.

But the point was, was that mid anxiety-feeling - my mind was able to kick in alternative thinking skills very much different than what it was used to.. So I can begin to see how this treatment is supposed to work and how it is GOING to work.


Ok, so as I said in the beginning I want to talk about medications.

There is a study that a certain antibiotic - D-cycloserine can improve exposure therapy by assisting the mind in learning new behaviors. Unfortunately it is virtually impossible to obtain a prescription for this medication as it is off-label (it's traditionally used as an antibiotic).

There is however another study, about Phenelzine Sulfate it's an MAOI that in studies have shown to dramtically improve the chances of SA remission... however whenever you hear the word MAOI you best panic like shit because that shit will fuck you up. Like no joke, this stuff can actually kill you as there are a plethora of potential dietary interactions such as if you eat cheese while on this stuff you could potentially die.

As much as I want to get better, I'm not sure if I want to seriously risk my life..

It's just very ironic that the meds I want with no serious side effects I can't get, but the ones that could kill me I could get??

What are your opinions?