Recently, the FDA approved Paroxetine (Paxil), manufactured by the pharmaceutical giant, Smith-Kline-Beecham, as a treatment for panic disorder and social anxiety disorder, the two largest anxiety disorders.

The fact that this research was entirely supported by the pharmaceutical company itself, has not gone unnoticed by the press and some members of the general public.

The pharmaceutical company is now involved in a massive media marketing campaign to sell its product to the population, but especially to prescription-writing doctors.  This campaign is increasing knowledge concerning social anxiety disorder, but it is occurring at the cost of a resounding backlash and the breakdown of the premise that "scientific research" necessarily means anything at all. 

Stuck in the middle between the SKB drug studies and the cynicism of the general public are the people that want and need help.   

As a result of this multi-million dollar campaign, most GPs and psychiatrists now associate "social anxiety disorder" with "Paxil".  And, although the pharmaceutical company and the SKB researchers are careful to point out that they are NOT saying this medication will "cure" social anxiety, this is the message that is already being received by the general public and medical practitioners.

As a result of this cozy alliance between the pharmaceutical companies and researchers, a spate of recent articles have appeared.  One, a cynical, but insightful, article in The New Republic (August 2, 1999)  questions the basic premise that social anxiety disorder is prevalent at all.  This is very sad for people with social anxiety disorder, but journalistic investigation is a natural result of this type of drug company supported "research".   No one is too surprised that the "results" of the study happen to suggest that the medication that the pharmaceutical company sells is effective. 

For another recent article on the subject read the Salt Lake City Tribune article from October 1999. 

Unfortunately, research can be made to say whatever you want it to say.   Death cures suicide and research will prove that, but is this research worth anything? 

As the pharmaceutical companies rake in the money as a result of their studies. where does this leave people with an anxiety disorder?    As is already happening, only this medication is now being considered by the majority of physicians.  To the despair of many people with anxiety, a medication they have already tried, and has not worked, is the only medication now being considered by the majority of physicians. 

I would kindly ask them to set up an internet site and let people with anxiety disorders write in to them like they do to me.  Then, perhaps they would get a partial sense of the pain and frustration that people with anxiety disorders have.  There is very little help from any "professional" source for these disorders. 

What is now in jeopardy?  For a moment in time (a very short moment) panic and social anxiety disorder were being taken seriously -- and physicians were beginning to recognize these disorders at some level.  With the publication of the SKB studies, however, the light is now off these anxiety disorders because the cure has already been found. 

Take this drug and you will be well.  That is the message that physicians are already telling their patients.  My e-mail exploded after the SKB drug studies were published.  As most of us in this area know, the SSRIs are not highly effective for panic and social anxiety disorder.  They do not work well for the majority of people with anxiety.  To make them the only medication for anxiety disorders, which is what has happened as a result of the drug company studies, is another real slap in the face to people with panic and social anxiety disorder. 

If your doctor will only prescribe an SSRI for panic disorder or social anxiety disorder, and you have tried these medications, switch doctors.   Complain to your HMO or insurance company.  You must raise a "big stink" to get the appropriate kind of help that other people would get routinely for other maladies.  You are entitled to proper and appropriate medical care.  In this day and age, you likely know much more about anxiety disorders than your doctor, who generally has no knowledge or training in this area.  

It really makes no difference whether 2% or 4% or 7% of the population suffers from social anxiety disorder.  No one with this disorder wants to live with it, and everyone who has this disorder wants to think, feel, and be different.  It is their lives that are being taken away from them by this disorder   -- it is these people -- regardless of their exact number in the population -- who should be helped. 

The people we work with are not suffering from shyness.

They have suffered -- horribly in most cases -- from social anxiety disorder.

It is very unfortunate that the word "shyness" has been used in conjunction with "social anxiety disorder" because these are not the same constructs (concepts).  A shy person can usually get along fine in the world.  Being shy is not a psychiatric or psychological diagnosis.  Shy people do not need medical or psychological treatment. 

Social anxiety disorder, while sometimes partially developing from a shy personality, does not always develop from a shy personality.   Thus, it is not correct to assume that "shyness" is a precursor to "social anxiety disorder". 

I see people daily who were not shy as children and/or adolescents.  Shyness may predispose some people to social anxiety (and there will have to be countless other environmental variables in this mixture, too), but shyness is not a necessary component of social anxiety disorder.

What does this mean?  Shyness is not the same thing as "social anxiety disorder" and shyness does not necessarily lead to "social anxiety disorder".  The idea that shyness leads to "social anxiety disorder" is a flawed hypothesis, and is currently causing many  problems.

Thus, back to the article in the New Republic, which asks many important, yet disturbing, questions.  

Unfortunately to those of us who work with socially-anxious people, the SKB studies and the multi-million dollar marketing of the drug Paxil, will continue to arouse legitimate suspicion.  This will be a major hindrance to people suffering from anxiety disorders.

Michelle Cottle, the author of this article, is correct in many of her assumptions.  You can read the New Republic article and form your own judgement.

Social anxiety disorder, as the New Republic suggests, should not be seen as "shyness".  Shyness is a personality trait that is genetically influenced and does need to be changed.  "Social anxiety disorder", always seen as a negative thing by the people who have it, is something else entirely.  This distinction must be made more directly and clearly. 

Maybe the most negative thing to come out of all of this is that people with social anxiety disorder are going to be gobbling down Paxil and other SSRIs, trusting and believing they will get better (because their doctor told them so).  When these medications don't work, people with social anxiety disorder will become more mistrusting and doubtful, and feel even more hopeless than they already do.  Another drug, another failure.

What makes this situation particularly sad is that we know that cognitive-behavioral therapy (CBT), done appropriately, over the right time frame, results in permanent improvement.

We also know the MAOIs work well for more severe forms of generalized social anxiety disorder, and we know that Klonopin, an anti-anxiety agent, works well for (generalized) social anxiety disorder.  Since we already know this, we should use these medications first. If safety is an issue, then Klonopin is the clear choice among all medications.  Klonopin has repeatedly been shown to be non-addictive to people with clinical anxiety disorders.  It is one of the safest (i.e., less toxic) medications on the market (it is safer than aspirin and Vitamin C, for example).  

None of these medications produce permanent results by themselves anyway.   They must be used in conjunction with cognitive-behavioral therapy to change the persons' thoughts, beliefs, perceptions, and feelings. Any medication that is not used in conjunction with the appropriate kind of comprehensive CBT will always leave the person in danger of almost-certain relapse. 

Yes, if you read the fine print, these studies do have all of these qualifications.  But, regular physicians and psychiatrists do not read these studies.  They listen to their SKB pharmaceutical rep who tells them Paxil works best for anxiety disorders -- and here are the studies to prove it.  Plus, some free samples.....

No drug can cure social anxiety.  Only comprehensive CBT, done by people who specialize in the treatment of anxiety disorders, can help people overcome social anxiety.   Medication may help while a person is in CBT, but it must be an appropriate medication.  Multi-million dollar campaigns should not be a factor in making these decisions when we are dealing with peoples' lives.

The biggest question is: who is looking out for the people with social anxiety?   What happens when the SSRIs fail and another "dream" is flushed down the toilet?  How resilient can we expect people to be as we treat them like lab rats and push them through the maze of one drug failure after another, while ignoring the only therapy shown to be of permanent efficacy in the elimination of social anxiety disorder?  

The loud flocking to the multi-million dollar money lenders is not a help to people with social anxiety disorder.  It is typical, however, of what is being passed off as "medical" and "psychological" care as we enter the new millenium.  It is a very scary prospect. 

-- Thomas A. Richards, Ph.D.

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