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Social Anxiety Disorder: A Common, Underrecognized Mental Disorder

American Family Physician, Nov 15, 1999 by Timothy J. Bruce, Sy Atezaz Saeed

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Pharmacologic Treatments

It is important to distinguish between the circumscribed and generalized types of social phobia before initiating pharmacotherapy, because the circumscribed type has responded to an "as-needed" schedule (typically of beta blockers), whereas the generalized type has responded better to standing dosage schedules (typically of specific antidepressants) of at least three months' duration. Although the outcome literature supports the efficacy of several agents, it does not indicate a clearly superior one. Treatment selection therefore involves matching the individual patient's preferences, symptoms and treatment goals with the relative benefits and risks of the following treatment options.

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MONOAMINE OXIDASE INHIBITORS

The monoamine oxidase inhibitors (MAOIs) have performed well in clinical trials for treatment of generalized social phobia. Phenelzine (Nardil), in particular, has been tested extensively in placebo-controlled studies.(12-14) Open and controlled trials suggest that approximately two thirds of patients will show clinically significant improvement during acute treatment with these agents.

The MAOIs have restrictions and adverse-effect risks that should be considered during treatment planning. The required low-tyramine diet, which prohibits many popular foods (Table 5), will deter some patients from accepting therapy with MAOIs. Patients risk a potentially fatal hypertensive reaction if they do not comply with the diet. Common adverse effects at therapeutic dosages (usually 45 to 90 mg per day for phenelzine) include postural hypotension, sedation, sexual dysfunction and weight gain. Some common over-the-counter medications, such as cold and cough remedies, are contraindicated in patients using MAOIs. Reversible MAOIs such as moclobemide, which do not require dietary restrictions, showed promise in early trials(15) but mixed results in more recent ones,(16,17) and to date they are not available in the United States.

The advantages and disadvantages of MAOI therapy for social phobia are summarized in Table 6. Although their advantages have led many to consider MAOIs an appropriate first-line treatment, their disadvantages have prompted others to relegate them to a second-line position behind the newer antidepressants.(18)

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

Several studies support the efficacy of selective serotonin reuptake inhibitors (SSRIs), including large controlled trials of paroxetine (Paxil)(19,20) and fluvoxamine (Luvox)(21); smaller controlled trials of sertraline (Zoloft)(22) and fluvoxamine(23) and, most recently, an open, uncontrolled trial of citalopram (Celexa).(24) As a group, SSRIs have shown acute-treatment improvement rates ranging from 50 to 75 percent of patients. Relatively safe and well tolerated, SSRIs are currently considered an appropriate first-line consideration. The advantages and disadvantages of SSRI therapy for social phobia are shown in Table 6.

BENZODIAZEPINES

The benzodiazepines are fast-acting, well-tolerated anxiolytics that have shown efficacy in the acute treatment of social phobia, but they have also revealed some significant drawbacks related primarily to difficulties with discontinuation. Controlled studies of alprazolam (Xanax)(12) and clonazepam (Klonopin)(25) report acute-treatment improvement rates ranging from approximately 40 to 80 percent, with clonazepam showing more favorable results. However, standing dosages are sometimes difficult for patients to taper and discontinue without symptomatic worsening and a high risk of acute relapse.(12)

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Social Anxiety Disorder: A Common, Underrecognized Mental Disorder

American Family Physician, Nov 15, 1999 by Timothy J. Bruce, Sy Atezaz Saeed

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