Social Anxiety Disorder (Social Phobia)
Symptoms and Treatment
Symptoms of Social Anxiety Disorder:
Social Anxiety Disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. It exceeds normal “shyness” when it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include most any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, etc. Physical symptoms include “mind going blank”, fast heartbeat, blushing, stomach ache. Cognitive distortions are a hallmark, and learned about in CBT. Thoughts are often self-defeating and inaccurate.
Neurobiology of Social Anxiety Disorder:
Dysregulation of neurotransmitter function in the brain is thought to play a key role in Social Phobia (SP). Specifically, dopamine (DA), serotonin (SE), and / or GABA dysfunction are hypothosized in most cases of SP. in varying degrees depending on the individual. The MAOI antidepressant “phenelzine” (Nardil) uniquely boosts levels of all three – and is probably the single most effective (single drug) treatment for Social Phobia.
There is strong evidence for dopamine dysfunction in SP. Comorbidies with other DA hypofunction disorders such as atypical depression, dysthymia, attention deficit disorder (ADD), and alcoholism are common. It has been noted that those with generalized Liebowitz observed in comparison studies between the TCA “imipramine” (Tofranil) and the MAOI “phenelzine” (Nardil) that while phenelzine was extremely effective in treating Social Anxiety, imipramine showed no efficacy – with the primary difference in the two drugs being the marked pro-DA effect of Nardil.
Since the 1990’s, evidence has emerged that an area of the brain called the striatum is different in patients with generalized Social Anxiety Disorder. More recent studies have switched focus to the amygdala, where evidence of abnormality accumulates. The amygdala is a core “primitive” part of the brain where many “automatic” animal type functions are regulated or controlled, such as fear and startle response, anxiety, sex, and aggression.
Research Past and Present:
Current research trends lean towards earlier recognition and treatment of SP. As the “world’s most neglected anxiety disorder” becomes more understood by the public, Social Anxiety Disorder will begin to be diagnosed far more frequently in the pre-teen or teen years, resulting in earlier treatment, more “normal” social development, and less later life complications. In my case, during my 3rd grade year I had a 2 months bout of “school phobia”, which commonly predicts SP in adulthood. Although Nardil and Klonopin existed at that time, the psychiatric diagnosis of Social Phobia did not. It was not until the early 1990’s that key studies began for the medication treatment of SP. Liebowitz (Nardil), and Davidson (Klonopin) were the early pioneers towards highly effective SP medication treatment. Nardil and Klonopin remain the most reliably effective medications to treat Social Anxiety Disorder.
Treatments for Social Anxiety Disorder:
Among possible psychological treatments for Social Anxiety Disorder, the best studied are CBT (Cognitive Behavioral Therapy) and CGBT (Cognitive Group Behavioral Therapy). While CBT and CGBT can often be helpful, medication treatments have been shown to produce more robust and dramatic improvement of symptoms. Patients with mild symptoms (as well as children or adolescents with Social Anxiety), may wish to pursue CBT or CGBT treatment methods as their first approach, while those with more significant or stubborn symptoms may prefer to use CBT as an adjunct to medication treatment. Good CBT therapists for SP are located primarily in larger cities. The best places to look are probably at large University Clinics or Health Centers.
Research suggests that “general” or “supportive” psychotherapy is also helpful for many patients with Social Anxiety Disorder. This is probably especially true in more moderate and severe cases where issues such as low self esteem and other psychological and/or adjustment difficulties may be more pervasive. Currently there is no evidence that CBT is more, or less, effective than other psychotherapy techniques in the treatment of Social Anxiety. There are no clear guidelines, and one is probably best off trusting their own instincts of what is best for them.
Medication treatment is the “tried and true” method to effectively treat Social Anxiety Disorder. Research trials for the treatment of Social Anxiety are still limited primarily to “monotherapy” treatment (one drug by itself). In actual practice, it is often the case that 2 or more medications are used in combination (polypharmacy). There are likely to be many different treatments (single drug or combinations) which are helpful for a given individual. Experimentation affords one an opportunity to find out which treatments are most satisfactory for them. Patient self-education continues to play a key role for those wishing to ensure that they receive the appropriate medical intervention they deserve.
A Medication Treatment Algorithm for Social Anxiety:
One reasonable algorithm of trial is as follows:
(Goal is typically effectiveness and tolerability over the long term):
a) SSRI or SNRI … else try …
b) MAOI (Nardil)
a) Klonopin (alone)
b) Klonopin + Antidepressant (any above)
3) May wish to augment (add) any of following:
a) Provigil (modafinil): Mild stimulant. Very low doses 20-100mg/day, divided
b) Neurontin (gabapentin): Anticonvulsant
c) Keppra (levetiracetam): Anticonvulsant
CERTAIN COMBINATIONS OR SINGLE DRUGS DANGEROUS: CHECK WITH DOCTOR FOR ALL TREATMENT RECOMMENDATION
Several SSRI’s have in recent years gained FDA approval in the treatment of Social Anxiety Disorder. During this time the SRI’s have also come to be labeled the first line treatment for Social Anxiety Disorder in the general medical community.
Two SSRI’s (Paxil and Zoloft) and one SNRI (Effexor XR) – are the only FDA approved drugs for SP at this time. Because of these recent FDA approvals and a relatively low risk of serious adverse events related to overdose and drug interactions, the SRI’s are quite easy and legally safe for general physicians and psychiatrists to prescribe. Most Dr’s will now initially prescribe an SRI when a previously untreated patient presents with symptoms of Social Anxiety Disorder.
SRI’s are quite helpful in the treatment of SP symptoms. Their usefulness in SP is increased by the fact that they are effective not only in some of the direct symptoms of SP itself, but are also very helpful for a number of other common co-occurring disorders which may be present. These include dysthymia, depression, panic, general anxiety, and obsessive compulsive disorder (OCD).
Paxil CR (paroxetine)
These include Effexor XR, Cymbalta, Wellbutrin SR, and Remeron. They each have fairly different characteristics from each other and from the SSRI’s. Used alone, any of them might be helpful for primary SP. Augmentation may modify the effects of any of these to create a more effective SP treatment.
Effexor XR (venlafaxine)
Wellbutrin XR (bupropion)
The MAOI “Nardil” is definitely the most powerful and effective antidepressant for Social Phobia.
Nardil (phenelzine): It was once considered the “Gold Standard” antidepressant for SP. Nardil is excellent for many other anxiety and depressive disorders also. Nardil has more potential side effects than SSRI’s and also requires a special diet, as is the case with other irreversible MAOI’s. Nardil is considered a 3rd line medication for the treatment of social phobia. Many experts consider the MAOI’s to be underutilized.
Parnate (tranylcypromine): Parnate is not as effective as Nardil for SP, but occasionally may work well. It is more activating than Nardil.
Emsam / Eldepryl (selegiline): On February 28, 2006, the FDA approved selegiline (in a special patch form which carries the brand name Emsam for the treatment of major depression. Prior to 2006, selegiline was used primarily for use in the treatment of Parkinson’s Disease. At very low doses selegiline selectively boosts dopamine in the brain and at higher doses increases all monoamines like other MAOI’s.
Long term use of benzodiazepines remains controversial. About 10 are available but Klonopin is by far the most effective for SP. Xanax is sometimes helpful also.
Klonopin (clonazepam): Klonopin is very effective for SP and usually works great. Klonopin can be taken either “as needed” or everday. “As needed” (prn) use can be done up to twice per week, and will usually provide excellent effect within 30 minutes, lasting several hours to 1/2 day. Long term use is more controversial.
Xanax XR (alprazolam): May be helpful. Alprazolam has a short half life which may limit its utility in long term use.
Myths About Benzodiazepines:
* “Benzodiazepine dose keeps escalating”: False. Dose usually stabilizes after a few months
Possible Drawbacks of Long Term Benzodiazepine Use:
* Depression may be aggrevated.
* Reduced mental sharpness may occur.
* Reduced motivation may occur.
Research and Medication:
Site Author: Chad Miller, 2000-2009