It's Nobody's Fault (22 page)

Another important distinction is in the patient’s desire to get well. People with social phobia aren’t comfortable with their disorder; they want to go to school, speak out in class, and play with their friends. They’d like to go to a birthday party without being terrified of looking silly. They know they’re in pain, and they want to feel better.

Psychiatrists look for—and frequently find—signs of depression (see
Chapter 14
) associated with social phobia. In the course of a recent study of adolescent depression it was discovered that 47 percent of the children with depression also had an anxiety disorder, most often either separation anxiety disorder or social phobia. Of those adolescents 84 percent had the anxiety disorder
before
the depression. What the study did not say was whether the connection between anxiety disorders and depression is biological—that is, dictated by brain chemistry—or causal. Perhaps social phobia, and the social isolation it usually brings, contribute to depression.

Social phobia is underdiagnosed and undertreated. Parents often wait a long time—too long—before seeking professional help for their kids with social phobia. “He’s just shy. He’ll outgrow it,” is their perfectly reasonable response. They resist going to a child psychologist or psychiatrist
because they’re afraid, quite naturally, to find out that their child’s behavior is not quite normal. “We’ve waited six months. Let’s wait a year.” “We’ve waited a year. Let’s wait another six months.” So goes the typical reaction of parents who are faced with a child who is not getting better.

I encountered some parents who said exactly that for nearly three years while their daughter got progressively sicker. Rita was seven when I first saw her. For two years and nine months the only people Rita had spoken to were her mother, her grandmother, and two of her four siblings. She had barely said a word to her teacher or to any of her classmates since the first day of nursery school, but she’d recently started mouthing words to her teacher. In fact, this concerned teacher was the reason Rita finally made it to my office. At a recent parent-teacher conference she sat the mother and father down and told them to take Rita to see a professional or else. “We’re very worried. You have to deal with this. You are neglecting your daughter,” she said sternly. Mom brought Rita to see me, of course, but she didn’t accept the teacher’s assessment of the situation. “Rita’s really
much
better,” said the mother. “She’s mouthing words to her teacher now. And last week I think she whispered something to her cousin.” Parents, feeling protective of their child, become defensive and may have a hard time accepting negative reports from the school.

Certain children are born with a genetic predisposition for social phobia. In plain English: excessive shyness runs in families. Supporting this theory is the fact that if one twin has social phobia, the other is more likely also to have it if he or she is an identical twin (with the same genetic makeup) rather than fraternal (with similar but not identical genes)—even if the twins are raised apart. Children adopted at an early age show a great similarity to their biological mothers on ratings of shyness. Parents of behaviorally inhibited children, kids who are fearful or withdrawn in new or unfamiliar situations are much more likely to have social phobia or to have had the disorder as children than are parents of normal or uninhibited youngsters.

What specific brain chemistry do children with social phobia have? As
always, we can’t be sure, but we can make an educated guess. Most probably the brain has too much norepinephrine and not enough serotonin. Certainly the effective medication for this disorder supports that theory. The medications that are most useful in the treatment of social phobia are the MAOIs (monamine oxidase inhibitors) and the SSRIs (selective serotonin reuptake inhibitors), both of which have an impact on norepinephrine and serotonin. TCAs (tricyclic antidepressants) have no effect on this disorder.

The animal model adds support to the argument. Studies done with rhesus monkeys have been able to identify two different behavioral styles—laid-back or uptight—and to determine that the uptight monkeys have a different brain chemistry from those who are laid-back. When given an SSRI, the uptight monkeys become more sociable and more comfortable, more like their laid-back fellow monkeys.

There’s some evidence that with social phobia “nurture” plays a part as well as “nature.” The basic assumption is that infants come into the world with a predisposition for anxiety. After that, any of several scenarios are possible. For example, a temperamentally inhibited infant is very reactive and hard to comfort, and a parent may find this distressing and be less attentive. The lack of attention affects the parent-child relationship, of course, and it may make the child insecure and less inclined later on to participate in other social contacts. To take another example, a shy mother or father with a shy infant is less likely to expose that child to social situations, so the child never learns to be comfortable socially. His parent, not wanting to cause the child discomfort, continues to “protect” him from the outside world. In both of these examples the children, with limited social experience, become even more anxious.

A five-year-old boy being treated for selective mutism is making progress, but it’s slow, very slow. So far the treatment has consisted only of behavioral therapy, mostly directed toward modifying the boy’s behavior in school. His teacher is working with us on a program by which the child is rewarded with stars and stickers for communicating. The first step was a yes or no answer to a direct question. Step two required more than one word as an answer. Now, three months after the treatment
began, there are lots of stars and plenty of stickers but no qualitative gains. The child is still uncomfortable and largely dysfunctional; his teacher said he looks pained all the time.

We give the boy a small dose of Prozac, much smaller than the customary dose—about a quarter of a teaspoon, or 5 milligrams, in liquid form from a dropper each day—and continue the therapy. Within a month the boy is communicating easily with everyone. “He became a different person almost immediately,” his mother said. “He’s talkative, he’s friendly, and he feels at ease.” Six months later we discontinued the Prozac, and the boy continued to be fine.

There’s no such thing as a “good” brain disorder, but if there were, social phobia would be it. With active treatment social phobia can be cured. Behavioral therapy is an effective and necessary part of the treatment of social phobia, but because of the nature of the disorder—the patient is afraid to interact with and be judged by other people, including psychiatrists and psychologists—it is almost always a good idea for the child to be medicated as well. (Sometimes medication is all that a child with this disorder needs. I’ve seen it happen many times.) Medicine alleviates a child’s anxiety so that he can benefit from the behavioral therapy. Most of the children we treat for selective mutism and social phobia simply couldn’t do the work without the medication.

The first line of medication treatment used for children with social phobia and selective mutism is the SSRIs, specifically Prozac, Luvox, and Zoloft. With their minimal and infrequent side effects (occasional nausea, weight loss, restlessness, drowsiness, moodiness, and insomnia), these medicines are the drugs of choice. Also effective are the antianxiety agents, such as Klonopin, Xanax, and BuSpar. Klonopin and Xanax work fast and are quite effective in reducing the anxiety children experience before certain events. The most common side effect is drowsiness.

The MAOIs, especially Nardil, have been proven effective in treating adults with social phobia, but there are serious dietary restrictions attached to the MAOIs. When people taking MAOIs eat foods containing tyramine, a chemical found in aged cheese, red wine, beer, smoked fish, and aged meats, they may develop high blood pressure. Because of the difficulty in monitoring the diets of children and adolescents, this category of medication is rarely prescribed for them.

The category of medication most commonly prescribed for type two social phobia (pathological performance anxiety and anxiety in specific
situations) is the beta blockers, especially Inderal and Tenormin. Beta blockers, which were originally developed for the treatment of high blood pressure, block the peripheral physical symptoms of anxiety, such as palpitations, tremors, and sweating. Teenagers with severe test anxiety have been treated very successfully with Inderal. One child I treated, David, age 12, hated tests. He had headaches for a few days before an exam and would awake with a terrible stomachache on the morning of the test. During the test his hands would sweat and his heart would race, but his thoughts were sluggish. He said his mind would just go blank sometimes. David’s IQ was above average, and he knew the material, but he was nonetheless convinced that his teacher thought he was stupid. He just couldn’t control his thoughts when he sat down in front of a test. On a low dose of Inderal he was able to take tests comfortably.

Beta blockers are usually taken an hour before any “performance,” including tests, and only on an as-needed basis. Few side effects are experienced by youngsters taking these medicines, but a child’s heart rate and blood pressure should be measured and an electrocardiogram done before he takes any beta blocker for the first time.

Certain medicines work well for particular kinds of anxiety but not for others. For instance, Xanax tends to relieve anticipatory anxiety—it keeps a patient from worrying in advance—but it’s not recommended for performance anxiety, because it does tend to take away the edge that many performers say they need to do their best work. (“I
want
that sharpness,” a musician told me. “I want to be very clear-headed. I don’t want any cloudiness when I’m onstage.”) On the other hand, a small dose of Inderal can work wonders for performance anxiety. I treated a nine-year-old boy, a talented musician who could not perform. He’d get backstage and just freeze with panic. He’d sweat and feel light-headed. Eventually he developed a tremor. On a very low dose of Inderal taken an hour before a performance he became anxiety-free and was able to get up on stage and play, completely clear-headed. Not only does he feel less anxious, his teacher says he’s also playing better than ever.

If a child begins a careful program of behavioral therapy at the same time he takes medication, there is a good chance that he won’t have to take the medicine for very long. A 12-year-old boy I treated took 20 milligrams of Prozac a day for only six weeks, during which time he worked hard with a psychologist on improving his social skills. We started the treatment in late May. By July 1 he was ready to go away to
camp, without his medication. He needed a lot of encouragement arid a fair amount of coaching, but he did it. What’s more, his mother told me proudly, he made two friends the first day of camp.

While we’re on the subject of medication, I should say that one of the major pitfalls associated with social phobia in adolescents is
self-medication;
these adolescents drink and take drugs to make themselves feel better. Many of them say that the only time they don’t feel horrible is when they drink or smoke marijuana. However, when they sober up, they feel even worse than before. What’s more, this self-medication inevitably escalates; as time passes, it takes more alcohol and more marijuana to get that loose, relaxed feeling.

Behavior modification—learning how to act even after the medicine has been taken away—is the ultimate goal here. The social and coping skills that come naturally to most people must be consciously learned by children with social phobia, a process that requires time and a lot of effort. Most therapists begin by teaching the child some basic relaxation techniques to combat anxiety, especially deep breathing and progressive muscle relaxation. Visual imagery, the process by which a child pictures himself in a situation that scares him and then creates an image of himself working through it, is another basic treatment technique.

Children being treated for social phobia are given assignments for behavioral changes, starting very small and working up to the big challenges. Parents are indispensable co-therapists in these efforts. “Okay. Talk to one person today. Just say hello,” a mother might say to her daughter on Monday morning. On Tuesday it would be, “That was great. Now today I want you to talk to two people. And smile when you say hello.” The assignments escalate, and the child is gradually exposed to more social situations and made to feel more confident. Small rewards for completed assignments will increase motivation. Stars, stickers, check marks on a calendar—all of these signs of success can be traded in for comic books, video rentals, half hours of television, or any other token or activity the child holds dear.

Assignments are great, but it’s not enough to pat a child with social phobia on the head and send him out to have random conversations with the kids at school or the relatives at a family get-together. After all, children don’t have a lot of experience with idle chit-chat. Kids need to be coached, and they need to rehearse.
“But what will I say? What should I talk about?” a
child will want to know. Those are good questions. All
of us, not just kids with social phobia, feel more relaxed if we know what’s coming next and what we’re supposed to do.

I remember helping Henry, a six-year-old who had been in treatment for social phobia for a couple of months, get ready for a day he was truly dreading: Thanksgiving dinner with his large extended family. He had no idea what he was going to say to these people, and he was scared to death. I asked the parents to find out who would be sitting on either side of Henry. Then we came up with three questions he could ask each of his dinner partners. His assignment for the day was to ask those six questions and to answer any questions that were put to him. We even worked on answers to some of the more obvious questions: How is school? How old are you now? What do you want to be when you grow up? And finally, we rehearsed Henry’s good-bye and thanks to his grandmother. The little boy came through it beautifully. In fact, to hear his parents tell it, Henry’s social skills were a lot better than those of his aunts and uncles.