Social Anxiety Disorder: An Update on Evidence-Based Treatment Options

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Educational Objectives

After reading this article, you will be familiar with:

• Strategies used in cognitive behavioral therapy (CBT) for the treatment of severe mental illness
• Treatment approaches
• The benefits and challenges of using CBT

Who will benefit from reading this article?
Psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.

Social anxiety disorder (SAD), also referred to as social phobia, is a chronic and potentially disabling anxiety disorder characterized by the intense and persistent fear of being scrutinized or negatively evaluated by others. At its core, people with this disorder fear and/or avoid the scrutiny of others. Symptoms may occur only in circumscribed situations, such as a fear of speaking in formal or informal situations, or eating or drinking in front of others. More commonly, in the most severe form of SAD, symptoms arise in a variety of social situations.¹

A large-scale US epidemiological study, the National Comorbidity Survey, reported a lifetime prevalence for SAD of 13.3%, with a 1-year rate of 7.9% in community samples. These rates make SAD the third most common psychiatric disorder, following substance abuse and depression.² The more recent National Comorbidity Survey Replication estimated 12-month and lifetime prevalences to be 7.1% and 12.1%, respectively, with higher prevalence in females.^3,4

In both clinical and community samples, SAD is commonly associated with other psychiatric disorders. Merikangas and Angst5 reported that an average of 80% of persons with SAD who were identified in community samples also met the diagnostic criteria for another lifetime psychiatric disorder. The lifetime risk of depression is reported to be about 2 to 4 times higher in persons who have SAD.^6,7 An earlier study reported that up to 16% of patients with SAD may also have alcohol abuse problems.⁸

More recently, there has been an increasing realization that alcohol use disorders are commonly comorbid with SAD.^9-12 The National Epidemiologic Survey on Alcohol and Related Conditions showed that 48% of those with a lifetime diagnosis of SAD also met diagnostic criteria for an alcohol use disorder.¹¹

Furthermore, the 12-month prevalence of alcohol use disorder among those with SAD was 13.1% compared with 8.5% in the general population.^11,12 Kessler and colleagues9 reported that women with SAD appeared to show higher rates of alcohol use disorder than men.

An average of 50% of people with SAD in the community samples also report another anxiety disorder, such as panic disorder, generalized anxiety disorder, or another phobic disorder.⁵ Which came first is always a question with comorbidity. Schneier and colleagues⁶ reported that SAD preceded approximately 75% of comorbid mental disorders and 85% of comorbid substance abuse problems, which suggests that most comorbidity was a consequence of SAD.

Clearly, comorbidity has implications for treatment selection. The presence of comorbidity in SAD has also been reported to be associated with an increased lifetime prevalence of suicide ideation and attempts.⁶

Evidence-based treatment options
There is a robust body of evidence, based on large randomized controlled trials, to support the efficacy of both medications and cognitive-behavioral therapy (CBT) for the treatment of SAD.^13,14

Both pharmacotherapy and CBT are empirically supported choices for first-line management of SAD. Studies that have compared CBT and pharmacotherapy for SAD suggest that while effects of CBT may be more enduring than those of medication, it takes longer to produce those results with CBT.^15,16 Anecdotally, combined treatment has been recommended often, but there is no established evidence to suggest that combined treatment (CBT plus medications) is more effective than either treatment alone.

Two landmark studies examined the question of whether combining CBT with pharmacotherapy enhances the overall outcome.^17,18 In the first study, 387 patients with generalized SAD were randomly selected to receive sertraline, sertraline plus exposure therapy, exposure therapy plus placebo, or placebo alone for 24 weeks. Response rates for both sertraline groups were significantly greater than for placebo; there was a trend toward enhanced efficacy in the sertraline plus placebo group.¹⁷