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Social anxiety disorder.

Social phobia, or social anxiety disorder, is a chronic, disabling fear of public situations that can limit one's personal, academic, and professional potential.

Researchers think the disorder has both biochemical and societal under-pinnings. Serotonin dysfunction is assumed to be present in social anxiety disorder, because it has a high rate of comorbidity with other serotonin dysfunction disorders: Up to 90% of patients also have depression, another anxiety, or panic disorder. The early socialization of girls to be quiet and nonassertive may also play a role in the development of the disorder; about 70% of those affected are female.


Among affected women, about 70% develop the disorder before age 25, but it can occur much earlier, with 50% reporting symptoms by age 15. Social phobia is associated with being female, younger, single, and of lower socioeconomic standing.

Patients experience intense and persistent fear in at least one type of social situation. These may include public speaking and work-related situations, but also such seemingly simple interactions as eating and drinking in front of others, attending any gathering, or meeting new people. The fear can induce palpitations, sweating, blushing, and tremors.

Women can go to great lengths to avoid the situations that provoke these symptoms. A key diagnostic criterion is self-awareness. Patients understand that these fears are unreasonable but are powerless to control them.

Social phobia is a chronic disease. One study showed that only 38% of women experienced full remission after 8 years of treatment. Comorbidity with other mental disorders, poor physical health, and suicidal ideation are poor prognostic signs. Alcohol abuse is present in about 50% of affected patients, who use it to ease feelings of anxiety.


Treatment usually combines pharmacotherapy and some form of psychotherapy. Cognitive-behavioral therapy (CBT) encourages patients to directly face fear-inducing situations, and their associated excessively negative thoughts and overfocus on physical sensations.

A recent study compared CBT, exposure group therapy without explicit cognitive interventions, and no intervention (wait-list controls). Both treatments were superior to the wait-list group in reducing social anxiety, but only the CBT group showed continued improvement up to the 6-month follow-up. These results suggest that cognitive intervention leads to better maintenance of treatment gains (J. Consult. Clin. Psychol. 2004;72:393-9).

Pharmacotherapy usually begins with one of the drugs approved for use in social phobia: the selective serotonin reuptake inhibitors paroxetine, sertraline, or escitalopram, or the serotonin-norepinephrine reuptake inhibitor venlafaxine. Although some studies indicate these are not the most effective drugs, they are associated with fewer side effects and restrictions than any other class used for this disorder.

Because patients with social anxiety disorder are exquisitely sensitive to physical sensations associated with anxiety, many clinicians recommend starting SSRIs at a lower dose to lessen the possibility of side effects such as jitteriness or sleep problems. The dose can then be titrated upward until symptoms are relieved. It's important not to underdose, however, and some patients will need doses higher than those usually necessary to control depression.

Monoamine oxidase inhibitors are also prescribed for social anxiety disorder, and some studies show they are more effective than the SSRIs in treating this condition. There have been few head-to-head drug studies. However, three recent reviews indicate that phenelzine is more effective for social phobia than are the SSRIs.

A recent review of placebo-controlled medication trials concluded that 60%-70% of social phobia patients responded to phenelzine, ranking it above SSRI treatment. The study also concluded that buspirone, tricyclic antidepressants, and [beta]-blockers were either ineffective or had very limited use in the disorder (Acta. Psychiatr. Scand. Suppl. 2003;417:65-71).

Two additional metaanalyses concluded the phenelzine was more effective than SSRIs (Depress. Anxiety 2003;18:29-40; World J. Biol. Psychiatry 2000;1:27-33). However, its higher associated risks, drug interactions, and dietary prohibitions suggest that it is best prescribed by a specialist who can provide close patient follow-up. The MAO inhibitors are usually reserved for those who don't respond to SSRI therapy.

Benzodiazepines are probably not suitable for social phobia patients, especially those with a history of alcohol or substance abuse, because of their high risk of dependence.

Sources: Nada Stotland, M.D., Rush Medical College, Chicago; Carol C. Kleinman, M.D., George Washington University Medical School, Washington
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Author:Sullivan, Michele G.
Publication:OB GYN News
Date:Dec 1, 2004
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