Eric Hollander - Coping with Social Anxiety: The Definitive Guide to Effective Treatment Options

Table of Contents

I first would like to acknowledge the wonderful collaborative relationship I have had with Nick Bakalar, a skilled writer of good humor and great insight. I also acknowledge my very productive, long-standing collaborations with Dan Stein, M.D., who edited the American Psychiatric Publishing Textbook of Anxiety Disorders with me, Daphne Simeon, M.D., who edited The Concise Guide to Anxiety Disorders with me, and Marc Summers, who wrote Everything in Its Place: My Trials and Triumphs with Obsessive-Compulsive Disorder with me. I am indebted to Francine Cournos, M.D., who read the manuscript and made many useful suggestions for improvements.

I also thank the following colleagues: Stefano Pallanti, M.D., Joseph Zohar, M.D., Naomi Fineberg, M.D., Lorrin Koran, M.D., Katherine Phillips, M.D., Kenneth L. Davis, M.D., Jack Gorman, M.D., Larry Siever, M.D., Donald F. Klein, M.D., Michael Liebowitz, M.D., Daphne Simeon, M.D., Andrea Allen, Ph.D., Sallie Jo Hadley, M.D., Stacey Wasserman, M.D., Evdokia Anagnostou,M.D., Latha Soorya, Ph.D., Ann Phillips, Ph.D., Bill Chaplin, Ph.D., Hirschell and DeAnna Levine and Jack Cohen of the Seaver Foundation, and Paula and Bill Oppenheim of the PBO Foundation.

Acknowledgment is also due for research grants from the National Institute of Mental Health, the National Institute of Neurological Disorders and Stroke, the National Institute of Drug Abuse, the Orphan Products Division of the Food and Drug Administration, as well as Solvay Pharmaceuticals, Wyeth Laboratories, Pfizer, Abbott, UCB Pharma, GlaxoSmithKline, and Lilly Research Laboratories. I acknowledge as well the important work that the Anxiety Disorders Association of America and its founder, Jerilyn Ross, M.A., L.I.C.S.W., does on behalf of anxiety disorder sufferers.

Finally both Nick Bakalar and I are thankful for the splendid editorial work of Lisa Considine, whose well-sharpened blue pencil has made the book much better than it would otherwise have been. We are also grateful for, and mightily impressed by, the sharp-eyed copy-editing of Erin Clermont.

ERIC HOLLANDER, M.D., is a professor of psychiatry at Mount Sinai Medical School in New York City. He is the coauthor of the American Psychiatric Associations Textbook of Anxiety Disorders and has appeared on Dateline and The Today Show.

NICHOLAS BAKALAR is the author or coauthor of eleven books, including Understanding Teenage Depression.

S ocial anxiety disorder, like other psychiatric disorders, has its origins in a malfunction of the brain, and it is in the brain itself that researchers are now looking to find answers about how these diseases affect us. Using new toolsmagnetic resonance imaging, computerized axial tomography, positron emission tomography, magnetic resonance spectroscopyand new drugs, researchers have discovered important information about the disorder. Neurobiological research of the causes of social anxiety is in its infancy, and practical clinical applications of current research are still far from clear, but much has already been learned.

If social anxiety originates in the brain, where in the brain is it? The question would have been impossible to answer, and may not even have been asked, just a few years ago. But now there are techniques, of which probably the most useful is functional magnetic resonance imaging (fMRI), that can actually locate thoughts and emotions in different parts of the brain. Why is this important for people with SAD?

MRI is probably at least vaguely familiar to most people as a kind of super X ray that can discern and produce detailed computerized pictures of human tissue. It works by detecting the small magnetic fields of hydrogen atoms. Since the human body is about 70 percent water, and since water molecules have two hydrogen atoms in each of them, that gives the machine quite a few tiny magnets to detect. But the magnetic field of a hydrogen atom is quite weak, and it requires a tremendously powerful magnet to detect it. An MRI machine is equipped with a magnet that is more than 50,000 times the strength of the earths magnetic field and it has to be cooled to a temperature of 270 degrees below zero in order to work. (Dont try this at home.) When the tiny magnetic field of a hydrogen atom is exposed to such a powerful magnetic field, it aligns with it (the same way a compass needle aligns with the magnetic field of the earth). Then a pulse of radio-frequency energy is used to disturb the tiny magnets from their alignment. As the alignments return to normal, they give off tiny pulses of energy that can be detected by an antenna that surrounds the subjects body. This signal indicates the relative amounts of water molecules in different areas of tissue, and it can then be converted into a computerized picture of the tissue under examination. The brain, like the rest of the body, is mostly water, and different parts of the brain contain different amounts of water. Nerve cells, for example, have lots of water; fatty tissue has less. So detecting how water is distributed in the brain draws a detailed picture of differing kinds of brain tissue.

Functional MRI is an advanced MRI scanner that uses the same magnetic properties of the hydrogen atom to detect blood flow. Tissue near blood depleted of oxygen has different magnetic characteristics from those near freshly oxygenated blood, and fMRI can detect this difference to draw a picture of the brain in action. In using it on the human brain, researchers can trace the blood flow to various parts of the brain while various stimuli are shown to thesubject. Although it takes a while sitting or lying down in a noisy machine in a position that can get uncomfortable, the procedure is, for all practical purposes, painless and harmless. The subject lies down with his head surrounded by a ring formed by the receiving coil. A high-resolution scan of the brain is made to provide the background against which the blood flow will be shown. Then a series of low-resolution scans are taken over a period of timeusually about 150 scans at 5-second intervals, which means this part of the procedure takes about 12 to 15 minutes. While these scans are going on, the patient is presented with various stimuli, often moving pictures, to trace the flow of blood to different parts of the brain as the patient watches the images. When the scan is finished, the set of images is analyzed. This involves applying various mathematical techniques and image-correcting tools to turn the images into three-dimensional pictures of the brain, with the blood flow highlighted as a different color overlaying the picture of the organ. Where the blood flows, activity is occurring, so you can, almost literally, watch a person thinking.

This technology opens many possibilities for investigators to watch the brain in action under various conditions, and there seems no limit to the phenomena that can be examined. Researchers have looked at a huge number of normal cognitive processesmemorization, the experience of pain, the recognition of faces, the taste of foods, and hundreds of othersand this has led to many insights about the ways the brain reacts to stimuli.

Shy children, as we know, often grow into shy adults. Infants demonstrate this very early in life by their varying behavior: some love to approach novel or unfamiliar people or objects; others run and hide when faced with anything or anyone they havent seen before. One study performed fMRI examinations on two groups ofadults whose average age was about twenty-two: one group had, as two-year-olds, been characterized as very inhibited, the other as uninhibited. They presented both groups with pictures of novel and familiar faces. The adults who had been characterized as inhibited showed a greater response to novel faces than the uninhibited group in a particular part of the brain called the amygdala, demonstrating that this structure is in some way involved in this aspect of temperament. The research authors are careful to point out, however, that such amygdala activity is not necessarily diagnostic of social anxiety, and only two of the twenty-two subjects in this study suffered from the disorder. But the study did show how persistent temperament is from infancy through early adulthood, how much of it is wired in to our brains even before any environmental influences can have an impact. And it provided further evidence for the physical location of shyness in the brain.