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

1. Connor KM, Kobak KA, Churchill LE, Katzelnick D, Davidson JR. Mini-Spin: A brief screening assessment for generalized social anxiety disorder. Depress Anxiety 2001;14:137-140.

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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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Cognitive begavioral therapy

FAST TRACK

Benzodiazepines and anticonvulsants may work when other options fail

Heimberg and colleagues found that 75% of social anxiety patients who participated in a cognitive behavioral therapy group experienced improved function and saw a reduction in symptoms of social anxiety.²³ Successful CBT seems to not only alleviate symptomatic distress, but improve the patients’ perceptions of their general quality of life.²⁴ Including behavioral components such as reinforcement or conditioning in CBT appears to be effective in helping sufferers minimize their symptoms. In addition, cognitive restructuring (ie, changing a patient’s thought process) has also been shown to be a helpful treatment.²³

Some of the basic elements of CBT include anxiety management skills (ie, breathing and relaxation techniques), social skills training (ie, maintaining conversation with the patient while monitoring the patient’s eye contact), and gradual exposure to the feared situation (ie, exposure to social situations).

Drug therapy

Studies have also demonstrated the effectiveness of a variety of medications (including Venlafaxine XR [Effexor XR], Paroxetine [Paxil], Paroxetine CR [Paxil CR], Sertraline [Zoloft], and Fluvoxamine [Luvox]) in managing social anxiety disorder.^25-28 If you are caring for a patient with social anxiety disorder, you’ll want to start him on a selective serotonin reuptake inhibitor (SSRI) or serotoninnorepinephrine reuptake inhibitor (SNRI).

If this doesn’t achieve the desired results, the next step is a monoamine oxidase inhibitor, such as phenelzine (Nardil), or a reverse inhibitor of monoamine oxidase A, such as moclobemide. Additionally, some benzodiazepines and anticonvulsants (clonazepam and pregabalin [Lyrica]) may also be effective if the other options do not achieve the desired results. The TABLE outlines common medications used to treat social anxiety, as well as recommended dosages.²⁹

FAST TRACK

Patients may want to check out the Social Anxiety Network, at www.social-anxiety-network.com

When putting your patient on any of these medications, patient teaching will be important. You’ll need to advise the patient that common antidepressant side effects include, but are not limited to, nausea, diarrhea, sexual dysfunction (ie, delayed orgasm), and headaches. These effects, however, typically disappear by the second week of intake.¹⁵ If the patient is taking a benzodiazepine, you’ll need to warn him about the risk of psychomotor or cognitive impairment.

If the patient has a comorbid substance abuse problem, you and the patient will also need to adjust your expectations somewhat. That’s because patients with a substance abuse problem are likely to have a poorer response to some of these medications than patients without a substance abuse problem.³⁰

Patient resources

ON THE WEB…

The anxiety Disorders association of Canada/association Canadienne des Troubles des anxieux www.anxietycanada.ca
The Social anxiety Network www.social-anxiety-network.com
The Social Phobia and Social anxiety association www.socialphobia.org

IN PRINT…

Dying of Embarrassment: Help for Social Anxiety & Phobia (Barbara Markway, C. Alec Pollard, and Teresa Flynn), 1992
Painfully Shy: How to Overcome Social Anxiety and Reclaim your Life (Barbara markway and Gregory markway), 2003
The Shyness and Social Anxiety Workbook: Proven Techniques for Overcoming your Fears (Martin M. Anthony and Richard P. Swinson), 2000

Though the time it takes to manage the condition is variable, patients with social anxiety disorder can improve their situation and go on to live more fulfilling and happy lives. The trick, really, is spotting the disorder early, rather than assuming your patient is simply the “quiet type.”

Correspondence
Martin A. Katzman, MD, FRCPC, START Clinic for Mood and Anxiety Disorders, 790 Bay St, Toronto, Ontario, Canada M5G 1N8 mkatzman@startclinic.ca