In two studies with social phobia patients, the comorbidity rate of Attention Deficit Hyperactivity Disorder (ADHD) was found to be high. In the first study, in 108 patients who were primarily diagnosed with social phobia, frequency of adult ADHD comorbidity was 60.5%; while in the second study, in 130 social phobia patients, frequency of childhood ADHD comorbidity was found to be 72.3% (1,2). Predominantly inattentive type ADHD is overlooked in social phobia patients. Inattentive type ADHD and social phobia seems to be closely related. Additionally, inattentive type ADHD might be contributing to the development of social phobia.

Therefore, social phobia patients are divided into two groups by Dr.Ahmet Koyuncu Akademi  Social Phobia Center as follows (3, 4):

1) Social Phobia without ADHD comorbidity

2) Social Phobia with ADHD comorbidity

In accordance with this classification, the following treatment approach is applied for social phobia patients (3, 4)

Social Phobia without ADHD comorbidity = Normal Social Phobia Algorithm (5)

Social Phobia + ADHD comorbidity =Simultaneous Social Phobia Treatment + ADHD treatment 

In social phobia patients with ADHD comorbidity, abovementioned approach with simultaneous social phobia + ADHD treatment (i.e. simultaneous antidepressant + Concerta or Atomoxetine treatment) establishes Dr.Ahmet Koyuncu’s “dual approach model” in social phobia treatment. I apply this approach model in my own clinic successfully and obtain significant results. Currently, about 200 patients are regularly treated by Antidepressant + Concerta.

When I prescribe Concerta in addition to antidepressant medication in social phobia patients, response to treatment is more rapid and more consistent. Concerta potentializes social phobia response of antidepressants in social phobics with ADHD comorbidity. Moreover, in our studies (1 ), we found that antidepressant induced hypomania is related with ADHD and it occurs only in social phobics with ADHD comorbidity. We also found that when antidepressant is taken together with Concerta, hypomania induced by antidepressant does not occur. Concerta prevents development of switch in social phobics with ADHD as well as regulating mood instability in these patients.

CONCERTA is a very valuable social phobia drug in ADHD/ SAD comorbidity patients. Psychiatrist knows more emphasis on hyperactive or combined type ADHD. Hyperactive/impulsive structure already improves during adolescence. However, you overlook inattentive type of ADHD that remits very rarely and requires Concerta almost up to 50 years of age (with cardiologic examination). In our clinic, the eldest patient under antidepressant + Concerta treatment with diagnoses of social phobia + ADHD inattentive type is 47 years old.

In the literature, there is one study supporting my observation. Adler et al. (2009) (6) compared Atomoxetine and placebo on 442 patients diagnosed with social phobia and adult ADHD and it was reported that both ADHD and social phobia symptoms recover with Atomoxetine treatment. İn additon, another study, the improvement in ADHD symptoms because of MPH treatment correlates with a parallel improvement in SP. MPH treatment appears to be safe and effective in ADHD/SP children. (Golubchik et al., 2014 ) (7).

Morever ın our current report, we presented two cases with SAD and ADHD comorbidity who responded well to extended-release methylphenidate monotherapy. In both cases, symptoms of SAD and ADHD improved simultaneously by extended-release methylphenidate treatment without using any approved medication for the treatment of SAD ( in publication acsess)

I ask your support for development of my dual approach model in treatment of social phobia and for proving its efficiency in double-blind, placebo-controlled studies.

Respectfully submitted,

Best Regards

Dr. Ahmet Koyuncu

REFERANCES:

1) Koyuncu A, Tutkunkardaş D, Binbay Z, Özyıldırım I, Ertekin E, Tükel R. P-119-The prevalence and clinical features of adult attention deficit-hyperactivity disorder in social anxiety disorder patients. European Psychiatry 27, 1.

2)Koyuncu, A., Ertekin, E., Yüksel, C., Ertekin, B., Çelebi, F., Tükel, R., 2014b. İnattention predominant type ADHD is associated with social anxiety disorder. J. Attention Disorder. Published online before print May 9, doi: 10.1177/1087054714533193 Journal of Attention Disorders May 9, 2014 1087054714533193  

3) Koyuncu, A. Shyness, Timidity and Social Phobia” ( ISBN: 6056285516 ). Liman yayınları. (2. baskı ) 2012.

4) Koyuncu, A. Attention Problems and Hyperactivity in Social Phobics( ISBN: 6056285509 )  Liman yayınları.2012.

5 ) Anksiyete Bozuklukları Tedavi Klavuzu, Editör: Prof. Dr. Raşit Tükel ( Türkiye Psikiyatri Derneği Yayınları)

6) Adler, L.A., Liebowitz, M., Kronenberger, W., Qiao, M., Rubin, R., Hollandbeck, M., Deldar, A., Schuh, K., Durell, T., 2009. Atomoxetıne Treatment In Adults Wıth Attentıon-Defıcıt/Hyperactıvıty Dısorder And Comorbıd Socıal Anxıety Dısorder. Depressıon And Anxıety. 26, 212–221.

7) Golubchik P, Sever J, Weizman A. Methylphenidate treatment in children with attention deficit hyperactivity disorder and comorbid social phobia. Int Clin Psychopharmacol. 2014 Jan 20. [Epub ahead of print]