Hi and welcome to Healthcare Magic. Thanks for your question...

From your brief description, I infer that you are suffering from a social anxiety problem, which has not responded well so far to medication or CBT. I understand that you must be going through a difficult time trying to cope up with these symptoms and I will try my best to help you with my suggestions.

Now, persons with social anxiety can have varied presentations and different degrees of severity. Social anxiety disorder is also a relatively common form of anxiety disorder (in fact, it is the most common anxiety disorder in the U.S), and due to the nature of the problem, people often hesitate to seek help. So, I would appreciate you for taking the initiative to seek help and I'm sure that, with a little more help and effort, you would be able to overcome it soon.

Now, in order to understand your problem and help you better, I would like to know a few more details about your problem...

- Since when have you been suffering from these symptoms?

- Was the onset of your symptoms preceeded by any personally or socially traumatic experience?

- What exactly are the psychological symptoms that you experience during these periods of anxiety?

- What are the kind of thoughts that go through your mind at such times of anxiety?

- What are the social situations where you experience anxiety (school / public places / group of friends / crowds with strangers)?

- Are there social situations which you have been avoiding repeatedly in order to avoid anxiety or embarassment?

- Have you suffered from panic attacks at any time?

- Are you going through any significant stress or personal difficulties?

- What medication were you prescribed before and for how long were you on it? How many sessions of CBT did you have?

Please do get back to me with these answers, so that I would be able to advise you accordingly.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hi again and thanks for writing in...

I am able to get a fairly good understanding of your problem. Your social anxiety seems to be long-standing problem, probably with its roots in your childhood. Social anxiety occurs as a normal part of development of social functioning in early childhood (Developmental social anxiety) and most children grow out of it, as they aquire sufficient social skills. However, there may be some who fail to do so and thereby continue to have persistent social anxiety. Gradually, this behaviour of social avoidance gets reinforced and the person starts developing a negative or distorted pattern of thinking that they as "social misfits" , "unwanted" , "ugly" , etc. So, they start avoiding social situations even more and thereafter, everything becomes a totally negative cycle.

I think, this is what has been happening to you and right now you are in a state where you have lost your self-esteem, these negative thinking patterns have become fixated and have probably become part of your personality.

Since you have mentioned that you do not suffer from any physical symptoms of anxiety, medication may have only a minor role. What you need is predominantly psychological therapy. Now, it is important to understand that since yours is a long-standing problem, it may require more intense and longer duration of therapy. This is because we are not addressing your social behaviour alone but we are aiming at changing your way of thinking and maybe, your personality traits. Unfortunately, there may not be a one-time or quick solution to your problem, but there is definitely a solution if you are persistent in your efforts.

Now, there are various forms of psychological therapy available. CBT is just one of them. There are several specific behavioural therapies, relaxation therapies, hypnotherapy, psychodynamic psychotherapy, etc.

"Systematic desensitization" is a popular form of behavioural therapy for social anxiety. Here, you are first thought to master certain relaxation techniques which you can readily employ at times of anxiety. Then with the help of your therapist you will be making a hierarchy of social situations which cause you anxiety, starting from the least severe to the most severe. Then you will be guided to face these situations, starting from the least severe, and by using the relaxation techniques which you have mastered, you will be able to overcome each situation step by step. There are also other forms of behavioural therapy like "graded exposure", etc.

The principle in all these behavioural therapies is simple. The socially maladaptive behaviour is something which you have acquired and has become reinforced over time. Similarly, socially adaptive behaviour can also be acquired and reinforced with time through therapy.

There are other psychological therapies, mostly aimed at countering your anxiety with relaxation - like relaxation therapies, hypnotherapy, etc. Since you have developed your social anxiety from childhood, you may also benefit from psychodynamic psychotherapy (which basically involves exploring unconscious inner conflicts which may have its roots in your childhood).

You also need help to work on your low self-esteem and the negative / self-reproachful thinking pattern which contributes a lot your social avoidance. Learning new social skills and practicing them whenever possible is also important for success.

I would advise that you don't lose heart, but be patient and keep trying hard. It is definitely not an impossible task. It just requires persistent effort and the help of a skilled and understanding therapist. It will also help if you involve your parents or siblings or just 1 or 2 close friends during therapy, so that they will be able to motivate you whenever you feel down and support you through the various stages of therapy.

Regarding your query about supplements, there are certain natural supplements available like 5-HTP, St. John's Wort, etc. which may help in depression and anxiety, but their effects may not be predictable.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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