Beyond shy: When to suspect social anxiety disorder

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Applied Evidence

Beyond shy: When to suspect social anxiety disorder

J Fam Pract. 2007 May;56(5):369-374

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References

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2. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12 month prevalence of DSm III–R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19.

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4. Eaton WW, Weissman M. Panic and phobias. In: Robins E, Da Regier, eds. Psychiatric Disorders in America: The Epidemiological Catchment Area Study. New york: Free Press; 1991:155-179.

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6. Kessler RC, Chiu WT, Demier O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:617-627.

7. Lepine JP, Pelissolo A. Why take social anxiety disorder seriously? Depress Anxiety 2000;11:87-92.

8. Wittchen HU, Fuetsch M, Sonntag H, Muller N, Liebowitz M. Disability and quality of life in pure and comorbid social phobia–findings from a controlled study. Eur Psychiatry 1999;14:118-131.

9. Stein MB, Chavira DA. Subtypes of social phobia and comorbidity with depression and other anxiety disorders. J Affect Disord 1998;50:S11-S16.

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Social anxiety can interrupt education or job success, cause financial dependence, and impair relationships.¹⁰ (See “Fear of embarrassment hinders relationships and careers”.) Sufferers tend to miss out on important social events and activities in their lives,¹² and they begin to accumulate comorbidities such as depression and substance abuse.¹³ In fact, while many cases of social anxiety are overlooked as shyness, others are misdiagnosed as depression.

Fear of embarrassment hinders relationships and careers

Patients suffering from social anxiety tend to have more difficulty in dating situations because of their constant fear of participating in social interactions.³¹ In fact, a large study in France found a connection between social anxiety and marriage rates. Forty-three percent of individuals who reported symptoms of social anxiety were married, compared with 65% of those who reported no symptoms.⁷

Careers also suffer because of the patient’s constant fear of embarrassment. Patients who have social anxiety record more sick days than those without the disorder.³² In addition, socially anxious patients have reduced work productivity compared with healthy controls.³³ As a result of their inability to perform adequately in their career, many patients may have to rely on social assistance. In fact, one study indicates that 22% of patients with social anxiety were on social assistance compared with 10% of a matched controlled group.³²

Complicating matters further is the issue of substance abuse. The Epidemiological Catchment Area Study found that alcohol abuse was reported in 17% of social anxiety cases and drug abuse was reported in 13%.⁵ In the study conducted by Kessler et al, results indicated that 8.8% of individuals suffering from a substance abuse problem also suffered from comorbid social anxiety.⁶

The substance abuse evolves slowly,¹⁴ and tends to arise as an inappropriate coping mechanism because so many cases of social anxiety go untreated.¹⁵

Symptoms to watch for, questions to ask

The primary indicator of social anxiety is intense fear of social situations. A patient suffering from social anxiety fears that he or she will act in a way that will be humiliating when confronted with unfamiliar situations or people or by the possibility of being scrutinized by others.¹⁶ While many people with social anxiety realize that their fears are excessive or unreasonable, they are unable to overcome them.¹⁷

There are also a number of physical, cognitive, and behavioral symptoms that are associated with social anxiety. The physical symptoms may include rapid heart rate, trembling, shortness of breath, sweating, and abdominal pain. The cognitive symptoms include maladaptive thoughts and beliefs about social situations (ie, irrational thought processes), that increase the anxiety when in the situation. Finally, behavioral symptoms include phobic avoidance of the feared situation.¹⁸

FAST TRACK

Substance abuse evolves as an inappropriate coping mechanism since so many cases of social anxiety go untreated

There are many screening devices that you can use to identify patients with social anxiety disorder or to assess the severity of symptoms. Some examples include the Liebowitz Social Phobia Scale,¹⁹ the Social Phobia Inventory (SPIN),²⁰ Fear of Negative Evaluation Scale,²¹ and the Social Avoidance and Distress Scale.²² These tools, however, can be a bit time consuming.

A more handy—though admittedly less comprehensive—screening device is the “mini SPIN” that was used by the physician in our opener. In a study of 7165 managed care patients, 89% of the cases meeting criteria for social anxiety disorder were detected (with a score of 6 or better) using this screening method.¹

To review, you’ll need to ask patients to rate the following statements on a scale of 0 “not at all” to 4 “extremely present”:

Fear of embarrassment causes me to avoid doing things or speaking to people.
I avoid activities in which I am the center of attention.
Being embarrassed or looking stupid are among my worst fears.

TABLE
Pharmacologic options for treating social anxiety disorder

	INITIAL DAILY DOSE (MG)	MAXIMUM DAILY DOSE (MG)
SSRIs
Citalopram (Celexa)	20	40–60
Escitalopram (Cipralex)	5–10	20
Fluoxetine (Prozac)	20	80
Fluvoxamine (Luvox)	50	300
Paroxetine (Paxil)	20	60
Paroxetine CR (Paxil CR)	25	62.5
Sertraline (Zoloft)	50	200
MAOIs/RIMAs
Moclobemide	300	600
Phenelzine (Nardil)	15	90
Tricyclics
Clomipramine	25	200
Imipramine	25	150
Other antidepressants
Bupropion SR (Wellbutrin SR)	100–150	300
Bupropion XL (Wellbutrin XL)	150	300
Mirtazapine (Remeron)	15	45
Mirtazapine RD (Remeron RD)	15	45
Venlafaxine XR (Effexor XR)	37.5–75	225
Benzodiazepines
Alprazolam	0.25	1.5–3.0
Bromazepam	6	30
Clonazepam	.25	4
Diazepam	2.5	10
Lorazepam	0.5	3–4
Anticonvulsants
Gabapentin (Neurontin)	900	3600
Lamotrigine (Lamictal)	25	200
Pregabalin (Lyrica)	150	600
Topiramate (Topamax)	25	800
Atypical antipsychotics
Olanzapine (Zyprexa)	2.5	20
Risperidone (Risperdal)	0.5	6
Quetiapine (Seroquel)	50	800
SSRI, selective serotonin reuptake inhibitor; MAOI, monoamine oxidase inhibitor; RIMA, reverse inhibitor of monoamine oxidase A.

A score of 6 or higher should prompt you to further evaluate the patient using one of the screening devices listed earlier.

Treatments of choice: CBT and drug therapy

Although social anxiety most commonly spans a lifetime, studies indicate that treatment—typically cognitive behavioral therapy (CBT) with drug therapy—can help sufferers deal with their fears and function more efficiently in their everyday lives. The best effects in treating social anxiety, therefore, are in combining the different treatment strategies.¹⁴