Social anxiety, hypomania and the bipolar spectrum: data, theory and clinical issues

Reports in the literature indicate a subtle but consistent relationship between panic and bipolar II disorder. The possible connection between social phobia and bipolarity is less investigated. When we studied the treatment outcome of 32 social phobic patients administered either the reversible monoamine oxidase inhibitor (RIMA) meclobomide or the irreversible inhibitor MAOI phenelzine, we found that eighteen had remission > 50% of their socially anxious symptoms. Moreover, 14/18 of those improved became hypomanic, according to the Raskin Mania Scale (RMS) and the Young Mania Scale (YMS) coupled with expert clinical diagnosis. These findings possibly allude to a relationship of social phobia to bipolarity. Treatment with RIMA or MAOI exposed these subjects as having an atypical bipolar syndrome which is part of the bipolar spectrum. We then compared this special subset of subjects to the 18 socially phobic patients who failed to respond to RIMA's or MAOI's and to 26 patients with generalized anxiety disorder (GAD). Eleven of the 14 hypomanic responders gave histories of serious developmental deprivation (anaclisis); only 5/18 social phobics and 3/26 GADs without hypomanic responses had anaclitic histories. The author raises the possibility that anaclisis may have interacted with the impediment of volition of uncomplicated bipolar depression to produce social inhibition and anxiety. Finally, the author upholds the central role of depressive inhibition in bipolar disorder, which during antidepressant therapy often overshoots in a hypomanic direction; even in the absence of prior spontaneous hypomania, such disinhibition should classify this special subset of social phobic patients within the bipolar spectrum.