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Industry: Email Alert RSS FeedSocial Anxiety Disorder: A Common, Underrecognized Mental Disorder
American Family Physician, Nov 15, 1999 by Timothy J. Bruce, Sy Atezaz Saeed
Because of their ability to produce physical dependence, benzodiazepines must be used with caution in patients with a history of substance abuse, a condition often associated with social phobia. When these drugs are used as needed in performance-related situations, sedation and psychologic reliance can develop. Given those risks, benzodiazepines are considered for use in patients with a low risk for substance abuse who are unresponsive to alternative treatments. The most common use of these agents, however, is in low-dose therapy (e.g., 0.25 to 0.5 mg of clonazepam twice a day) for initial symptom relief in conjunction with an antidepressant, psychotherapy, or both. The advantages and disadvantages of benzodiazepine therapy for social phobia are shown in Table 6.
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BETA-ADRENERGIC BLOCKERS
Treatment studies of beta blockers for social phobia show mixed results. Controlled trials using standing dosages for generalized social phobia have been discouraging.(13,26) Beta blockers such as propranolol (Inderal) appear to be clinically effective when used in low doses (10 to 40 mg for propranolol) on an as-needed basis for mild to moderate circumscribed performance anxiety. Risk of chronic overuse suggests that these drugs should be used only intermittently until the patient's confidence in performance situations is restored. Except for use in circumscribed social phobia, beta blockers lack consistent empiric support to recommend them as a first-line treatment for generalized social phobia. The advantages and disadvantages of beta blockers for social phobia, including important contraindications, are shown in Table 6.
OTHER AGENTS
A recent initial controlled trial of gabapentin (Neurontin) reported that it produced a significant reduction in social phobia symptoms compared to placebo.(27) An open trial of nefazodone (Serzone) reported that 70 percent of 23 participants showed improvement.(28) Although initial open trials of buspirone (Buspar)(29,30) looked promising, a recent controlled study found no significant differences between this drug and placebo.(31) Results of a recent open trial suggest that buspirone may be useful in augmenting partial response to an SSRI.(32)Although the tricyclic antidepressant imipramine (Tofranil) has performed well in some case reports, larger trials have not supported its efficacy in treating social phobia.(33) Agents such as bupropion (Wellbutrin) and clonidine (Catapres) have yet to be investigated outside of case reports and clinical anecdotes. Common therapeutic dosage ranges and cost estimates for the evidenced-based options discussed in this section are given in Table 7.
Psychotherapeutic Interventions
General supportive psychotherapy has not been found to be as useful in treating social phobia as more directive therapies focused on reducing anxiety by reducing avoidance. Social phobia has been particularly responsive to behavioral and cognitive behavioral therapy involving the use of exposure (gradual reentry into feared situations). Cognitive behavioral therapy is a multicomponent treatment that typically is tailored to patients based on their presenting features (Table 3). It is conducted in individual or (preferably) group formats and usually lasts for 16 to 24 sessions. Components of cognitive behavioral therapy for social phobia often include symptom management skills, social skills training, cognitive restructuring aimed at changing patients' anxious thought processes, and exposure (Table 8).
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