The recently developed Social Phobia Inventory (SPIN) is a self-rated instrument that assesses the spectrum of cognitive, behavioral and physiological symptoms associated with SAD. Three of the 17 SPIN items have recently been found to reliably identify the majority of individuals with generalized SAD and may provide clinicians with a quick screening tool (Connor et al., 2001). Those three items are:
- Being embarrassed or looking stupid are among my worst fears.
- Fear of embarrassment causes me to avoid doing things or speaking to people.
- I avoid activities in which I am the center of attention.
Treatment of SAD should focus on: 1) acute reduction and control of pathological social anxiety and related phobic avoidance; 2) adequate treatment of depression/comorbid conditions; and 3) long-term management to permit and sustain optimal improvement. Cognitive-behavioral therapies, medication treatments and their combination have all been shown to be effective interventions (Lydiard, 2001).Pharmacotherapy
Performance fears are nearly always predictable and thus amenable to prn use of a ß-blocker or benzodiazepine (Table 2). Beta-blockers help control tremor, autonomic arousal/palpitations and other symptoms. Some patients benefit more from judicious use of a benzodiazepine taken 30 minutes to 60 minutes prior to the event. In contrast, generalized SAD is less predictable, and continual treatment is recommended.
Antidepressants. Because of the significant risk for depression in individuals with SAD, first-line antidepressant treatment is preferred whenever possible (Lydiard, 2001). The selective serotonin reuptake inhibitors are now considered the first-line pharmacological treatment for social phobia. The SSRIs also appear to be effective against the other psychiatric disorders with which SAD commonly co-occurs, such as panic disorder, major depression, generalized anxiety disorder and posttraumatic stress disorder. The limited empirical database suggests that SSRI treatment may require higher doses (up to twice as much as required for depression) for a significant percentage of patients. About 50% to 75% of patients with generalized SAD respond to any given SSRI (Bruce and Saeed, 1999). Failure to respond to one SSRI does not preclude response to another, so sequential trials of two or more SSRIs are suggested before changing classes of medication.
Irreversible MAOIs. The first antidepressant shown to be useful for SAD was the irreversible monoamine oxidase inhibitor phenelzine(Drug information on phenelzine) (Nardil). Tranylcypromine (Parnate) also appears to be effective for the treatment of SAD. However, because of the significant side-effect burden (i.e., weight gain, orthostatic hypotension, insomnia) and the inconvenience of dietary tyramine restriction, the MAOIs are used primarily when other treatments have failed (Bruce and Saeed, 1999).
Tricyclics. With the exception of clomipramine(Drug information on clomipramine) (Anafranil), which inhibits serotonin reuptake like the SSRIs, the tricyclic antidepressants are probably not effective for SAD (Ballenger et al., 1998; Bruce and Saeed, 1999; Davidson, 2000). While clomipramine is an effective anxiolytic and antidepressant, it causes intolerable side effects (sexual dysfunction, weight gain) in most patients.
Other antidepressants. The newer antidepressants venlafaxine (Effexor) and nefazodone(Drug information on nefazodone) (Serzone) have been less studied, but they show promise as treatments for SAD (Bruce and Saeed, 1999). The novel antidepressant bupropion (Wellbutrin) and the azapirone anxiolytic buspirone(Drug information on buspirone) do not appear to have efficacy in SAD.
Benzodiazepines. Benzodiazepines (BZs) are effective for SAD but are preferably used as adjunctive treatment with antidepressants (Bruce and Saeed, 1999). Since they are not especially effective for treating/preventing depression or anxiety disorders, which commonly accompany SAD, monotherapy with BZs should be limited to individuals intolerant of or unresponsive to other treatments. High-potency BZs (clonazepam [Klonopin], alprazolam(Drug information on alprazolam) [Xanax] and probably others) are effective for SAD.
Other agents. The anticonvulsant gabapentin(Drug information on gabapentin) (Neurontin), which potentiates -aminobutyric acid (GABA) function, has been found more effective than placebo in generalized SAD (Pande et al., 1999). Other anticonvulsants with GABA-potentiating properties may prove to be useful for patients with mood instability, current or prior alcohol(Drug information on alcohol)-related disorders, or head trauma. The empirical database is currently quite limited.Psychosocial Treatments
Several types of behavioral and cognitive-behavioral therapy (CBT) treatments appear to be effective in SAD (Heimberg, 1993). These treatments all target the core SAD features of cognitive distortions and avoidance behavior. Combined pharmacotherapy and CBT treatment are thought to be superior to either treatment alone for treating SAD (Bruce and Saeed, 1999). The available empirical information suggests that acute treatment differences between medications alone and medications with CBT are modest. However, there appears to be a lower rate of relapse following CBT than after medication discontinuation.Conclusion
Social anxiety disorder is still under-recognized and undertreated, despite recent advances in treatment. Support for public health education programs aimed at disseminating information and promoting increased awareness of SAD via the media and the Internet is clearly needed. In addition, education of teachers, school nurses, pediatricians and other pediatric health care providers will help increase rates of detection in children.
We routinely screen children and adults for tuberculosis, which is a serious but relatively rare disease. Given the estimated $42 billion annual cost of anxiety disorders in the United States (Greenberg et al., 1999), research targeted at early detection and treatment of SAD would appear to be a good investment.