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CITALOPRAM IN SOCIAL PHOBIA
LETTERS TO THE EDITOR
tion (Mathew et al., 1996). The symptoms remitted completely 72 hours after sertraline was stopped. One month after discharge the patient was taking 5 mg of fluoxetine twice a day and was reportedly doing well. Pedro A. Munera, M.D. Department of Child and Adolescent Psychiatry Western Psychiatric Institute and Clinic Pittsburgh Amy Goldstein, M.D. Department of Neurology Children’s Hospital of Pittsburgh Delva NJ, Horgan SA, Hawken ER (2000), Valproate prophylaxis for migraine induced by selective serotonin reuptake inhibitors. Headache 40:248–251 Larson EW (1993), Migraine with typical aura associated with fluoxetine therapy: case report. J Clin Psychiatry 54:235–236 Mathew NT, Tietjen GE, Lucker C (1996), Serotonin syndrome complicating migraine pharmacotherapy. Cephalalgia 16:323–327
CITALOPRAM IN SOCIAL PHOBIA To the Editor: Social phobia, or social anxiety disorder, is a prevalent condition that is associated with significant impairment. The disorder typically manifests during adolescence; however, it frequently goes untreated until common comorbid disorders such as agoraphobia, depression, substance abuse, and obsessivecompulsive disorder surface later in life (Schneier et al., 1992). Therefore, early diagnosis and treatment of social phobia may prevent the development of chronic, debilitating adult disorders. Effective treatment for social anxiety disorder in adults includes cognitive-behavioral therapy, social skills and assertiveness training, and pharmacological treatments such as selective serotonin reuptake inhibitors (SSRIs) (Davidson, 1998; Mancini et al., 1999). In fact, paroxetine recently was indicated for the treatment of adult social phobia. However, despite the early onset of the condition, data supporting the use of these compounds in the treatment of child and adolescent social phobia are scarce (Birmaher et al., 1994; Black and Uhde, 1992; Mancini et al., 1999). The following case report describes the successful management of adolescent social phobia (generalized subtype) with the SSRI citalopram. Patient A is a 16-year-old Hispanic male who, in social situations over the past 2 years, had been experiencing intermittent anxiety, depression, tremors, shaking, and gastrointestinal (GI) distress (i.e., upset stomach, nausea, and diarrhea), which severely affected his ability to function. Patient A’s GI symp-
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toms had become so debilitating that they interfered with his ability to attend classes, and his academic performance deteriorated so much that he dropped out of school. Prior to psychiatric evaluation, patient A underwent multiple medical workups including endoscopy, but all results were negative. He was started on antacids, but the GI complaints persisted. The patient was referred to a psychologist, but after four visits, patient A’s symptoms did not resolve and he was referred for psychiatric assessment. Patient A had no family history of psychiatric problems. Presenting symptoms were primarily GI, although he also reported feeling anxious. Citalopram 20 mg/day was initiated. One month later, the GI symptoms were less severe but the patient still was frequently absent from school. The citalopram dosage was increased to 30 mg/day. A follow-up evaluation 2 months later revealed that patient A continued to miss school because of anxiety and was experiencing a reemergence of mild GI distress. Citalopram dosage was increased to 40 mg/day. One month later, patient A’s anxiety had improved markedly, and he no longer was experiencing the initial GI problems. However, because the patient complained of constipation (which the family was advised was not likely to be caused by citalopram), the family requested a switch in medication. The citalopram dosage was tapered to 20 mg/day, and sertraline 50 mg/day was added during week 2 of citalopram 20 mg/day. The following week, citalopram was discontinued and the sertraline dose was increased to 100 mg/day. Within 1 week at this dose, all previous symptoms returned and GI complaints, particularly diarrhea and upset stomach, were markedly worse. Sertraline then was tapered (50 mg/day for 1 week, and then 25 mg/day the following week), and patient A was restarted on citalopram. After an upward titration from 10 to 40 mg/day over 1 month, the patient no longer complained of constipation and had no other somatic complaints. Furthermore, citalopram reduced patient A’s anxiety so that he is now able to function at school and in other social settings. His grades have markedly improved, he engages with his classmates and teachers, and he has enjoyed sports for the past year. To my knowledge, this is the first published case documenting the effectiveness of citalopram in the treatment of adolescent social phobia. This report, combined with other reports of the successful use of SSRIs in the treatment of child and adolescent social phobia (Birmaher et al., 1994; Black and Uhde, 1992; Mancini et al., 1999), indicates that further controlled studies are warranted. Paul H. Kosieradzki, M.D. Pacifica Therapists Huntington Beach, CA
J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1
LETTERS TO THE EDITOR
Birmaher B, Waterman GS, Ryan N et al. (1994), Fluoxetine for childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 33:993–999 Black B, Uhde TW (1992), Elective mutism as a variant of social phobia. J Am Acad Child Adolesc Psychiatry 31:1090–1094 Davidson JRT (1998), Pharmacotherapy of social anxiety disorder. J Clin Psychiatry 59(suppl 17):47–51 Mancini C, Van Ameringen M, Oakman JM, Farvolden P (1999), Serotonergic agents in the treatment of social phobia in children and adolescents: a case series. Depress Anxiety 10:33–39 Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM (1992), Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 49:282–288
J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1
The Letters column is a corner of the Journal that encourages opinion, controversy, and preliminary ideas. We especially invite reader comments on the articles we publish as well as issues or interests of concern to child and adolescent psychiatry. The Editor reserves the right to solicit responses and publish replies. All statements expressed in this column are those of the authors and do not reflect opinions of the Journal. Letters should not exceed 750 words, including a maximum of 5 references. They must be signed, typed double-spaced, and submitted in duplicate, accompanied by an electronic copy on diskette. All letters are subject to editing and shortening. They will be considered for publication but may not necessarily be published nor will their receipt be acknowledged. Please direct your letters to Mina K. Dulcan, M.D., Editor, Journal of the AACAP Editorial Office, Children’s Memorial Hospital, 2300 Children’s Plaza #156, Chicago, IL 60614-3394.
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tion (Mathew et al., 1996). The symptoms remitted completely 72 hours after sertraline was stopped. One month after discharge the patient was taking 5 mg of fluoxetine twice a day and was reportedly doing well. Pedro A. Munera, M.D. Department of Child and Adolescent Psychiatry Western Psychiatric Institute and Clinic Pittsburgh Amy Goldstein, M.D. Department of Neurology Children’s Hospital of Pittsburgh Delva NJ, Horgan SA, Hawken ER (2000), Valproate prophylaxis for migraine induced by selective serotonin reuptake inhibitors. Headache 40:248–251 Larson EW (1993), Migraine with typical aura associated with fluoxetine therapy: case report. J Clin Psychiatry 54:235–236 Mathew NT, Tietjen GE, Lucker C (1996), Serotonin syndrome complicating migraine pharmacotherapy. Cephalalgia 16:323–327
CITALOPRAM IN SOCIAL PHOBIA To the Editor: Social phobia, or social anxiety disorder, is a prevalent condition that is associated with significant impairment. The disorder typically manifests during adolescence; however, it frequently goes untreated until common comorbid disorders such as agoraphobia, depression, substance abuse, and obsessivecompulsive disorder surface later in life (Schneier et al., 1992). Therefore, early diagnosis and treatment of social phobia may prevent the development of chronic, debilitating adult disorders. Effective treatment for social anxiety disorder in adults includes cognitive-behavioral therapy, social skills and assertiveness training, and pharmacological treatments such as selective serotonin reuptake inhibitors (SSRIs) (Davidson, 1998; Mancini et al., 1999). In fact, paroxetine recently was indicated for the treatment of adult social phobia. However, despite the early onset of the condition, data supporting the use of these compounds in the treatment of child and adolescent social phobia are scarce (Birmaher et al., 1994; Black and Uhde, 1992; Mancini et al., 1999). The following case report describes the successful management of adolescent social phobia (generalized subtype) with the SSRI citalopram. Patient A is a 16-year-old Hispanic male who, in social situations over the past 2 years, had been experiencing intermittent anxiety, depression, tremors, shaking, and gastrointestinal (GI) distress (i.e., upset stomach, nausea, and diarrhea), which severely affected his ability to function. Patient A’s GI symp-
1126
toms had become so debilitating that they interfered with his ability to attend classes, and his academic performance deteriorated so much that he dropped out of school. Prior to psychiatric evaluation, patient A underwent multiple medical workups including endoscopy, but all results were negative. He was started on antacids, but the GI complaints persisted. The patient was referred to a psychologist, but after four visits, patient A’s symptoms did not resolve and he was referred for psychiatric assessment. Patient A had no family history of psychiatric problems. Presenting symptoms were primarily GI, although he also reported feeling anxious. Citalopram 20 mg/day was initiated. One month later, the GI symptoms were less severe but the patient still was frequently absent from school. The citalopram dosage was increased to 30 mg/day. A follow-up evaluation 2 months later revealed that patient A continued to miss school because of anxiety and was experiencing a reemergence of mild GI distress. Citalopram dosage was increased to 40 mg/day. One month later, patient A’s anxiety had improved markedly, and he no longer was experiencing the initial GI problems. However, because the patient complained of constipation (which the family was advised was not likely to be caused by citalopram), the family requested a switch in medication. The citalopram dosage was tapered to 20 mg/day, and sertraline 50 mg/day was added during week 2 of citalopram 20 mg/day. The following week, citalopram was discontinued and the sertraline dose was increased to 100 mg/day. Within 1 week at this dose, all previous symptoms returned and GI complaints, particularly diarrhea and upset stomach, were markedly worse. Sertraline then was tapered (50 mg/day for 1 week, and then 25 mg/day the following week), and patient A was restarted on citalopram. After an upward titration from 10 to 40 mg/day over 1 month, the patient no longer complained of constipation and had no other somatic complaints. Furthermore, citalopram reduced patient A’s anxiety so that he is now able to function at school and in other social settings. His grades have markedly improved, he engages with his classmates and teachers, and he has enjoyed sports for the past year. To my knowledge, this is the first published case documenting the effectiveness of citalopram in the treatment of adolescent social phobia. This report, combined with other reports of the successful use of SSRIs in the treatment of child and adolescent social phobia (Birmaher et al., 1994; Black and Uhde, 1992; Mancini et al., 1999), indicates that further controlled studies are warranted. Paul H. Kosieradzki, M.D. Pacifica Therapists Huntington Beach, CA
J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1
LETTERS TO THE EDITOR
Birmaher B, Waterman GS, Ryan N et al. (1994), Fluoxetine for childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 33:993–999 Black B, Uhde TW (1992), Elective mutism as a variant of social phobia. J Am Acad Child Adolesc Psychiatry 31:1090–1094 Davidson JRT (1998), Pharmacotherapy of social anxiety disorder. J Clin Psychiatry 59(suppl 17):47–51 Mancini C, Van Ameringen M, Oakman JM, Farvolden P (1999), Serotonergic agents in the treatment of social phobia in children and adolescents: a case series. Depress Anxiety 10:33–39 Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM (1992), Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 49:282–288
J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1
The Letters column is a corner of the Journal that encourages opinion, controversy, and preliminary ideas. We especially invite reader comments on the articles we publish as well as issues or interests of concern to child and adolescent psychiatry. The Editor reserves the right to solicit responses and publish replies. All statements expressed in this column are those of the authors and do not reflect opinions of the Journal. Letters should not exceed 750 words, including a maximum of 5 references. They must be signed, typed double-spaced, and submitted in duplicate, accompanied by an electronic copy on diskette. All letters are subject to editing and shortening. They will be considered for publication but may not necessarily be published nor will their receipt be acknowledged. Please direct your letters to Mina K. Dulcan, M.D., Editor, Journal of the AACAP Editorial Office, Children’s Memorial Hospital, 2300 Children’s Plaza #156, Chicago, IL 60614-3394.
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