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J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from CLINICAL REVIEW Social Disorder: Common, Disabling, and Treatable

Mark A. Zamorski, MD, MHSA, and Randy K. Ward, MD

Background: disorder (also known as social ) is characterized by extreme , avoidance, or both of one or more social or perfonnance situations, such as making a presentation, meeting new people, or eating in front of others. This condition is common, with a lifetime prevalence of up to 13%, and one third of affected persons have major dysfunction. Methods: The English-language literature on social indexed on MEDLINE was searched using the phrases "social phobia" or ";" this search was supplemented with other data sources, such as recent textbooks, to detennine common clinical symptoms, , and management in the setting. Results: Recognition and treatment of social anxiety disorder is poor; only a small minority of pa­ tients with this condition have it appropriately diagnosed or treated. Primary care physicians should suspect social anxiety disorder in patients who have specific symptoms and signs (such as hyperhidro­ sis, flushing, , and white-coat hypertension), in patients who have symptoms of anxiety (such as chest , , or dizziness), or in patients who have another known anxiety disorder, depres­ sion, or substance . treatment consists of -reuptake inhibitors, monoamine oxidase inhibitors, or high-potency . A specific type of called cognitive behav­ ioral therapy is another effective treatment, but it is not acceptable or accessible to most patients. Conclusions: Because social anxiety disorder is common, disabling, and treatable, primary care phy­ sicians should intensify their efforts to recognize it.O Am Board Fam Pract 2000;13:251-60.)

It is normal to be a little nervous when meeting new abled, unemployed, underemployed, and divorced, people, making a presentation, or confronting some­ and on the average they even make less money than one in a position of authority. Such anxiety reflects persons who do not suffer from the disorder.2 the simple fact that all social encounters, especially Surprisingly, social anxiety disorder is also one of http://www.jabfm.org/ those with unfamiliar or socially advantaged people, the most common mental illnesses, affecting between entiil some risk. We are, after all, social beings, and 2 % and 13 % of the general population at some point others in determine to a certain extent what in their lives.3 Despite its chronic nature and consid­ social benefits we might and might not enjoy. erable functional impact, only a few patients with the In social anxiety disorder (also known as social condition are recognized as having it. 2,4 And despite phobia), this normal social anxiety assumes phobic the growing availability of effective therapies, only a on 1 October 2021 by guest. Protected copyright. proportions, and sufferers might avoid even innocu­ few receive specific treatment.5,6 ous social situations or endure them with extreme The most important role for the primary care distress. Such fear and avoidance are more than an physician with respect to social anxiety disorder is annoyance or a simple personality quirk. Patients with to recognize the condition in his or her patients. social anxiety disorder suffer disproportionately from Once the disorder is recognized, patients can be , other anxiety disorders, , either referred to a mental specialist who has and even . 1 They are more likely to be dis- experience with the condition or treated medically by the primary care provider.

Submitted, revised, 5 April 2000. From the Department of Family , University of Methods Michigan Medical School, Ann Arbor. Address reprint re­ Using MEDLINE, we searched the English lan­ quests to Mark A Zamorski, MD, MHSA, Department of Family Medicine, University of Michigan Medical School guage literature on social anxiety disorder using the 4260 Plymouth Rd, Ann Arbor, MI 48109-2702. phrases "social phobia" or "social anxiety disorder."

Social Anxiety Disorder 251 J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from We then supplemented the search with other data Table 1. DSM-IV Criteria for Social Phobia (Social sources, such as recent textbooks, to determine Anxiety Disorder). common clinical symptoms, differential diagnosis, A. Marked or persistent fear of one or more social and management in the primary care setting. performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual that he or she will act in a way (or show anxiety symptoms) that will be humiliating or Illustrative Cases embarrassing. Note: In children there must be evidence of Generalized Subtype the for age-appropriate social relationships with A 32-year-old man came in for a physical examina­ familiar people, and anxiety must occur in peer settings, not just with interactions with adults tion. His only complaint was long-standing, occa­ B. Exposure to the feared situation almost always provokes sional, mild depressive symptoms, and that he felt anxiety, which may take the form of a situationally bound "down" about 10% of the time. He related a 10- to or situationally predisposed attack. Note: In children, the anxiety may take the form of crying, tantrums, 15-year with about 10 freezing, or shrinking from social situations with different therapists for "self-esteem problems," but unfamiliar people he always felt that something was missing, and the C. The person realizes that the fear is excessive or unreasonable. Note: In children, this feature may be therapy never seemed to help much. Because he absent appeared to be unusually nervous during the inter­ D. The feared social or perforrnance situations are avoided or view and examination, he was asked about social else are endured with intense anxiety or distress anxiety. He readily endorsed substantial social pho­ E. The avoidance, anxious , or distress in the feared social or performance situation(s) interferes with the bic symptoms and consequences to early person's normal routine, occupational (academic) , including fear or avoidance of many functioning, or social activities or relationships, or there is marked distress about having the phobia social interactions, difficulty participating in F. If the individual is under 18 years, the duration of the school, and underachievement at work. symptoms is at least 6 months G. The fear or avoidance is not due to the direct physiologic effects of a substance (eg, a drug of abuse, a ) NongeneralizedSubtype or a general medical condition, and it is not better A 27-year-old Latin American man complained of accounted for by another (eg, with or without , separation anxiety difficulty making presentations at work. He was a very disorder, , a pervasive successful management consultant who had had no , or schizoid ) trouble making presentations or with other social H. If a general medical condition or another mental disorder is present, the fear in criterion A is unrelated to it (eg, encounters until about 9 months before his visit in the trembling in Parkinson , abnorrnal eating behavior primary care setting. He had had a single in or )

while giving a presentation, and since that time, he http://www.jabfm.org/ Source: Diagnostic and statistical manual of mental disorders, experienced substantial anxiety and making 4th ed [DSM-IV], pp 416-7,1994. Copyright 1994, the Amer­ presentations, even to a small, familiar group. He had ican Psychiatric Association. Reprinted by permission. no further panic attacks, and his problems with social anxiety were limited to making presentations at work. well as interactional situations such as speaking on He acknowledged increasing symptoms of depression the telephone, talking to strangers, going to social since the onset of his social phobia, and he began to gatherings, and dealing with authority figures, have on 1 October 2021 by guest. Protected copyright. believe that he would be better off returning to his been described.8 As a result of these fears, patients , where he would feel more secure. either avoid social or performance situations or endure them with extreme distress.' Adults with Description the condition (but not necessarily children) are Patients with social anxiety disorder are unusually aware that their fears are excessive.' Although Di­ fearful of social interactions with others. Specifi­ agnostic and Statistical Manual of Mental Disorders: cally they are afraid of doing something humiliat­ DSM-IV criteria sets are often not especially useful ing or embarrassing, or they are concerned about to primary care physicians, the set for social anxiety others noticing their anxiety symptoms, such as disorder is included as Table 1. trembling hands, sweating, or .' Com­ monly feared are performance situations, such as Subtypes public speaking or even using a public restroom. In the generalized subtype, DSM-IV specifies the Eating, drinking, and writing in front of others, as presence of serious social anxiety in "most social

252 JABFP July-August 2000 Vol. 13 No.4 .. J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from

Figure 1. Average striatal reuptake density measure by positron emission tomography (PET} can. Differences in dopamine reuptake sites in of (A) 11 controls and (8) 11 patients with social anxiety disorder; (C) subtraction image. Those with social anxiety disorder have substantially lower receptor densities, especially in the right striatum. Source: American Journal of , volume 154, pages 239-42,1997. Copyright 1997, the American Psychiatric Association. Reprinted by permission. situations.,,7 Others are classified as having the tribution to the disorder comes from its strong nongeneralized subtype. Avoidant personality dis­ ,13,14 the effectiveness of a variety of order, a DSM-IV axis IT disorder characterized by in treating the condition,15 and even a pervasive pattern of social inhibition, feelings of abnormalities in receptor density inadequacy, and hypersensitivity to negative evalu­ shown by positron emission tomography (PET) ation, is also diagnosed in most adults with the scans, as shown in Figure 1.16 generalized type of social anxiety disorder.9 These patients appear to have an earlier age of onset and more serious dysfunction. 10 Comorbidtty As with the other anxiety disorders, CUnical with other psychiatric disorders is the rule rather Once thought to be quite rare, social anxiety dis­ than the exception, 1 especially in more everely http://www.jabfm.org/ order is a surprisingly common condition. The affected patients.s Important comorbid di orders National Comorbidity Survey documented a I-year are shown in Figure 2. prevalence of DSM-ill-R social anxiety disorder of 7.9% and a lifetime prevalence of 13.3%.3 About one third of these patients was judged to be severely Siglls alld Symptoms impaired. II The condition is widespread in the pri­ Like many mental disorders, social anxiety disorder mary care setting.6,12 goes unrecognized in both clinical and mental on 1 October 2021 by guest. Protected copyright. The condition has its onset in childhood or health settings. I ,6,12 In one study of a large man­ young adulthood, with an average age of 22.6 years aged care population, only 1 of 200 patients with for the nongeneralized subtype, 16.0 years for the this condition was receiving treatment for it by a generalized subtype, and 10.9 years for the gener­ physician or therapi t.2 alized subtype with comorbid avoidant personality Typical complaints include hyperhidro is, disorder. 10 Untreated, the condition appears to tremor, blushing or flushing, dry mouth, persist for many years.4 In community samples the or cracking voice, or "butterflies in the tomach.,,1 7 disorder is more common in women than in men, These might also be apparent, with a ratio of 1.5 to 1. along with hyperten ion and , to the observant clinician, e pecially during the fir t vi it. Cause ccasi nal patients will complain of panic phe­ The cause of the condition i unknown, but a with nomenolog/ triggered by social or performance other mental disorders, eviden e for a biologic con- situations.

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Figure 2. Comorbid conditions of social anxiety disorder. OCD = obsessive compulsive disorder. Reprinted with permission from Schneier FR,JohnsonJ, Hornig CD, Liebowitz MR, Weissman MM. Social phobia. Comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 1992;49:282-8. Copyright 1992, American Medical Association.

Generalized or Anticipatory Anxiety 1. Is being embarrassed or looking stupid among Somatic manifestations of anxiety are common in your worst fears? the primary care setting; common ones include 2. Does fear of embarrassment cause you to avoid , palpitations, , dizzi­ doing things or speaking to people? ness, , , and gastrointestinal com­ 3. Do you avoid activities in which you are the

plaints. If a wide variety of social or performance center of ? http://www.jabfm.org/ situations are feared, and especially if unpredictable situations are feared, patients with social anxiety Differential Diagnosis disorder can feel restless, anxious, keyed-up, and on Medical Conditions edge, constantly fearing a chance social encounter. No medical condition causes tlle characteristic symptom complex of social anxiety disorder. If at­ Stlbstance Abtlse and Other Comorbid Psychiatric tention is paid to only a single physical complaint of on 1 October 2021 by guest. Protected copyright. Disorders anxious patients (eg, chest pain, palpitations, sweat­ Some patients struggling with substance abuse, es­ ing), the differential diagnosis will be extensive, but pecially , will have social anxiety disorder. most primary care physicians are familiar with the Exploring an early history of drinking to tolerate diagnosis of these complaints. social situations will often disclose the association. Patients with conditions diagnosed as depression, Normal Social AlIxiety panic disorder with or without agoraphobia, obses­ The distinction between normal social anxiety and sive compulsive disorder, and generalized anxiety social anxiety disorder is not always clear-cut, and disorder have comorbid social anxiety disorder of­ the DSM-IV criteria (Table 1/ leave some room ten enough to make it worthwhile asking some for uncertainty. Several key factors are helpful in questions for the condition.s One recent diagnosis: study showed that strong positive responses to the three following questions have a sensitivity of 89% 1. Does the patient experience serious dysfunc­ and a specificity of 90% for social anxiety disorder.2 tion or role impairment? One way of exploring

254 JABFP July-August 2000 Vol. 13 No.4 J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from Table 2. Patient Resources for Social Anxiety Disorder.

Books Bourne EJ. The anxiety and phobia workbook: a step-by-step program for curing yourself of extreme anxiety, panic attacks, and . 2nd edition. New York: Fine , 1995 Rapee RM. Overcoming and social phobia: a step-by-step guide. Northvale, ~J: Jason Aronson, 1998 GreistJHj Jefferson JWj Katzelnick DJ. Social phobia: a guide. Madison, \Vis: Madison Institute of Medicine, 1997. Patient education materials Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD for office use 20852. (301) 231-9350. http://www.adaa.org National Institutes of , Room 7C-02, MSC 8030, 5600 Fishers Lane, Bethesda, MD 20892. 1-88-88-ANXIETY. http://www.nimh.nih.gov Support groups Toastmasters International, PO Box 9052, Mission Viejo, CA 92690. (949) 858-8255. http://www.toastmasters.org Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. (301) 231-9350. http://www.adaa.org

this question is to ask patients: "\\That sorts of Treatment Options things do you think you've missed out on as a Social anxiety disorder responds to a variety of result of your social anxiety (self-conscious­ different treatments. Nevertheless, it is important ness, shyness)? Do you think your work, family to set reasonable patient expectations. Patients with life, or personal life have been affected?" social anxiety disorder get better more slowly and 2. Does the patient avoid social situations? To often less completely than those with more familiar assess avoidance, ask: "Have you found yourself psychiatric disorders, such as depression or panic avoiding situations because of your anxiety disorder. (worry, shyness, self-consciousness)?" 3. Does the patient specifically fear doing some­ Patient Education thing humiliating or embarrassing, or fear that Patients with social anxiety disorder often feel a others will notice the sufferer's anxiety? Ask: great sense of relief when they learn that their "\\That are your specific fears about (a particu­ secret problem has a name, a biologic contribution, lar feared situation)? Are you concerned that and effective treatments. Occasional patients can you might do something embarrassing or hu­ successfully guide themselves through a cognitive http://www.jabfm.org/ miliating? Are you concerned that others will behavioral therapy program using a workbook notice your sweating hands, trembling, etc? (Table 2). 4. Has the patient resorted to unusual or destruc­ tive means to control their anxiety? Specifically Support Groups ask about using or alcohol to feel com­ Support groups have not been specifically evaluated fortable in social situations. for the treatment of social phobia, but some pa­ 5. Are the patient's feared social performance sit­ tients find them helpful. The international self­ on 1 October 2021 by guest. Protected copyright. uations unusual? Odd fears such as writing, help program called Toastmasters (Table 2) is very eating, or drinking in public are not common helpful for people with public-speaking phobia. IS in healthy individuals. Cognitll'e Behavioral Therapy A variety of mental disorders, including panic Cognitive theory suggests that patients with social disorder, agoraphobia, depressive disorders, obses­ anxiety disorder possess learned, irrational fears of sive-compulsive disorder, generalized anxiety dis­ negative evaluation that pervade their experience of order, psychotic disorders, and body dysmorphic social situations. These fears lead to their symp­ disorder, need to be distinguished from social anx­ toms of anxiety. trains patients iety disorder; DSM-IV7 highlights some useful dis­ to recognize, analyze, and dispute these irrational tinguishing features. Because some of these disor­ fears. Behavioral therapy involves exposing patients ders are commonly comorbid with social anxiety to graded exposures and simulations of anxiety­ disorder, several can be diagnosed in a given patient. provoking situations, which leads to desensitization

Social Anxiety Disorder 255 J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from and severing the link between the social situations with obsessive-, higher doses and anxiety. 19,20 (eg, an average of 37 mg/d of ) are re­ Cognitive behavioral therapy combines these quired, and the rate of improvement is slow. As therapies in a specialized form of psychotherapy, shown in Figure 3, symptom control and improve­ with specific goals and structure and a time-limited ment in functioning occurs within at least 12 weeks. course. Cognitive behavioral therapy for social anx­ Social anxiety disorder is an intrinsically refractory iety disorder is usually done in a group setting, allow­ disorder, and only about one half of patients taking ing patients to try out their new social behaviors in a SSRIs will realize a substantial improvement in safer environment. There are data to support the their symptoms. Given that high doses for extended efficacy of cognitive behavioral therapy as a primary periods are required for the condition, medication treatment of social anxiety disorder. Cognitive behav­ side effects are a major obstacle to treatment. ioral therapy appears to be as effective as pharmaco­ Benzodiazepines, especially the newer, high-po­ therapy and is associated with a relatively durable tency agents such as (Xanax) , clonaz­ response. In clinical practice cognitive behavioral epam (Klonopin), and (Ativan), have therapy can be used as a primary treatment or in also been shown to be effective in both the gener­ conjunction with pharmacotherapy.21 ,22 alized and non generalized forms of social anxiety disorder.24 Of these medications, of­ Pharmacotherapy fers the advantage of requiring only twice-a-day Selective serotonin reuptake inhibitors (SSRIs) dosing,25 and it might be less likely to be misused.26 have become the most widely recommended med­ Average doses in clinical trials have been about 2.5 ications for social anxiety disorder. 15 ,18 Most SSRIs mg/d of clonazepam or its equivalentP have been studied at least in an uncontrolled fash­ Monoamine oxidase inhibitors (MAOIs) were ion, and all appear to be effective.23 Paroxetine the first agents to be shown to have important (Paxil) has become the best-studied agent in this activity in social anxiety disorder.24 Because of their class, and it is the only one to have received FDA side-effect profile and their potentially fatal drug­ approval for this indication at the present time. As drug and drug-food interactions, they are seldom

60 50 -+- Paroxeline

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Figure 3. Efficacy of paroxetine in social anxiety disorder. Percentage of patients taking paroxetine or placebo (from a randomized, double-blind study) considered therapeutic responders, using Clinical Global Impression Global Improvement Item (standardized method of assessing improvement in mental disorders) (paroxetine vs placebo, P = .001). Note that up to 12 weeks of therapy were required for optimal effect. Mean paroxetine dosage in this study was 36.6 mg/d (SO 12.1 mg). Reproduced with permission from: Stein MR, Uebowitz MR, Lydiard RD, Pitts CD, Bushnell W, Gergel I. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA 1998;280:708-13. Copyrighted 1998, American Medical Association.

256 JABFP July-August 2000 Vol. 13 No. 4 Table 3. Treatment Implications of Common Comorbid Conditions Associated With Social Anxiety Disorder. J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from

Comorbid Conditions Treannent Implications

Depression, SSRI (or for refractory cases, MAOI) is preferred. Avoid benzodiazepines Avoid unless administered with stabilizer, such as or (Depakote) Panic disorder SSRI (or MAOI for refractory cases) preferred; benzodiazepines will also treat both disorders, as will cognitive behavioral therapy Obsessive-compulsive disorder SSRI preferred; higher doses might be required. Specific forms of behavior therapy (OCD) effective in OCD. Given refractory, complex nature of both OCD and social anxiety disorder, referral of patients with this pattern of comorbid conditions to anxiety disorders specialist is strongly encouraged Generalized anxiety disorder SSRI is preferred; cognitive behavioral therapy will treat both disorders. Benzodiazepines (either alone or with an SSRI) will also treat both disorders Agoraphobia, specific phobias Cognitive behavioral therapy preferred; most patients with agoraphobia will also benefit from an SSRI Substance abuse Benzodiazepines contraindicated. Patients need independent treannent of substance abuse in addition to social anxiety disorder Avoidant personality disorder Patients with this pattern of comorbidity tend to be most severely affected, have more comorbid conditions, and tend to have incomplete responses to SSRI therapy. Referral to anxiety disorders specialist is strongly encouraged

SSRI = selective serotonin reuptake inhibitor, MAOI = monoamine oxidase inhibitor.

24 used, but they are a viable treatment option for able to a placebo response. As-needed benwdi­ patients refractory to treatment.18 azepines are usually not indicated, unless the cir­ Tricyclic antidepressants have been shown to be cumstances are truly extraordinary, and time does surprisingly ineffective in the treatment of social not allow other approaches.24 anxiety disorder. 18.23 Even though ~-adrenergic For patients who suffer from more extensive fear blockers have been used to treat social phobia, not or avoidance, an SSRI or cognitive behavioral ther­ much has been published that supports their use apy (or both) are reasonable choices, depending on except for occasional patients with simple perfor­ patient preferences and availability of a therapist. 15,18 mance anxiety.24 (BuSpar) has shown Because of its well-established efficacy and known similarly disappointing results,28 although there is dose- and time-response curve,32 paroxetine (Paxil) is limited experience with using it in conjunction with a good choice among the SSRIs. Preliminary evi­ http://www.jabfm.org/ 29 3 an SSRI for refractory cases. (\Vell­ dence supports the use of other SSRIs 3-37 as well, so butrin) has not been well studied in social anxiety if one SSRI is not effective (or not tolerated), switch­ disorder,30 but its performance in other anxiety ing to another SSRI might be effective, just as in disorders has been disappointing.31 depression. For clinicians who are comfortable using them, the higher doses of the high-potency benzodi­

Combination Therapy azepines are an appropriate alternative (either alone on 1 October 2021 by guest. Protected copyright. Anxiety specialists often use combinations of med­ or in combination with an SSRI).24 Comorbid con­ ications to treat social anxiety disorder, but there is ditions are important when selecting therapies of so­ little more than anecdotal experience with them. 18 cial anxiety disorder; treatment implications are Anxiety disorder commonly care for patients shown in Table 3. with social anxiety disorder using a combination of both medications and cognitive behavioral therapy. Indications for Referral Selection ofTherapy If available and accessible, immediate referral to an For patients with isolated public-speaking phobia, anxiety specialist or program experienced in treat­ self-help groups (eg, Toastmasters) or cognitive ing social phobia with cognitive behavioral therapy behavioral therapy are usually preferred.ls An oc­ and medications ensures confirmation of the diag­ casional patient will find ~-adrenergic blockers nosis, assessment of important comorbid condi­ helpful, but much of the relief is probably attribut- tions, extensive patient education, and more expe-

Social Anxiety Disorder 257 J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from rienced selection and implementation of therapies. Follow-Up of Patients If such services are not available locally, clinicians Patients with anxiety disorders are unusually sensi­ should consider referral for patients who fail to tive to medication side effects, especially the agita­ benefit from (or fail to tolerate) adequate doses of tion or jitteriness that can occur early in the course several SSRIs with or without a high-potency ben­ of treatment with SSRIs. Accordingly, it is usually zodiazepine. Such patients can benefit from a safest to initiate the medication at one half of the MAOr, cognitive behavioral therapy, or more com­ usual starting dose for depression, eg, 10 mg/d of plex or experimental regimens. Patients with mul­ paroxetine. The dosage is increased every few days tiple comorbid conditions (fable 3) can also benefit to a week until the target dose has been reached from evaluation by a qualified specialist. (usually near the maximum of the recommended The lack of recognition and appropriate treat­ dosage). Once the target dosage has ment of the disorder in the community, even been reached, the medication should be continued among the majority of patients who have sought for at least 12 weeks before concluding the medi­ out mental health services, shows that currently cation trial to be a success or failure. Visits every 1 most mental health professionals are not capable of to 2 weeks are appropriate as the medication dosage diagnosing and treating this condition. Accord­ is being increased; brief monthly visits are appro­ ingly, referral to a regional center with special ex­ priate as the patient is waiting to see benefits and pertise in anxiety disorders is strongly encouraged. side effects. Such centers can be found in larger urban areas and Social phobia is a , and many in association with larger teaching hospitals. patients will require life-long drug therapy to achieve symptom control. Firm guidelines do not Social Anxiety Disorder During Childhood exist for when a trial off medication is indicated, but and Adolescence most experts will consider a trial off medication if Social anxiety disorder exists in childhood, and the the patient's symptoms have been well controlled somatic symptoms and types of situations feared are for 6 to 12 months or more. 15,18,23 similar to those of the adult form of the disorder. Onset in childhood appears to lead to a more severe and refractory course. A major difficulty in the Conclusions diagnosis is the child's immature cognitive and ver­ Once aware of the diagnosis and its implications, bal abilities, which limit self-report and the useful­ clinicians will be able to recognize social anxiety ness of the subjective symptoms of the disorderP disorder among their patients with anxiety, depres­ Social anxiety disorder in children can elude sion, or substance abuse. Effective treatment with http://www.jabfm.org/ diagnosis because it is not primarily an "acting out" an SSRI, cognitive behavioral therapy, or other type of disorder. In school, these children can be interventions can help patients with this disorder seen as quiet and well behaved, or "just shy." They lead more happy and productive lives. might come to attention because of , social , or oppositional behavior when References placed in situations where they are forced to inter­ on 1 October 2021 by guest. Protected copyright. 1. Schneier FR,JohnsonJ, Hornig CD, Liebowitz MR, act with others. I' Undiagnosed and untreated so­ Weissman MM. Social phobia. Comorbidity and cial anxiety disorder can lead to the development of morbidity in an epidemiologic sample. Arch Gen other comorbid psychiatric disorders, such as drug Psychiatry 1992;49:282-8. abuse or depression. 17 2. Kobak KA, Schaettle SC, Greist JH, Jefferson JW, Referral to a child or is Katzelnick DJ, Dottl SL. Computer-administered recommended so that children with clinically se­ rating scales for social anxiety in a clinical drug trial. Depress Anxiety 1998;7:97-104. vere symptoms can be evaluated appropriately. Al­ though there is a lack of controlled studies on the 3. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric various treatment methods used to treat this disor­ disorders in the . Results from the der in children, individual and family psychother­ National Comorbidity Survey. Arch Gen Psychiatry apy and pharmacotherapy with antidepressants and 1994;51:8-19. benzodiazepines have been used as components of 4. Davidson JR, Hughes DL, George LK, Blazer DG. comprehensive treatment plans.38 The epidemiology of social phobia: findings from

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the Duke Epidemiological Catchment Area Study. 21. Stravynski A, Greenberg D. The treatment of social Psychol Med 1993;23:709-18. phobia: a critical assessment.. Acta Psychiatr Scand 5. Pollard CA, Henderson JG, Frank M, et a1. Help­ 1998;98:171-81. seeking patterns of anxiety-disordered individuals in 22. Juster HR, Heimberg RG. Social phobia. Longitu­ the general population. J Anxiety Disord 1989;3: dinal course and long-term outcome of cognitive­ 131-8. behavioral treatment. Psychiatr Clin North Am 6. Weiller E, Bisserbe JC, Boyer P, Lepine JP, Lecru­ 1995;18:821-42. bier Y. Social phobia in general : an un­ 23. Schneier FR. Monoamine oxidase inhibitors, selective recognised undertreated disabling disorder. Br J Psy­ serotonin reuptake inhibitors, and other antidepres­ chiatry 1996;168:169-74. sants in pharmacotherapy. In: Stein MB, editor. Social 7. American Psychiatric Association. Diagnostic and phobia: clinical and research perspectives. \Vashington, statistical manual of mental disorders: DSM-IV. DC: American Psychiatric Press, 1995:347-74. Washington, DC: American Psychiatric Press, 1994. 24. Sutherland SM, Davidson ]RT. Beta-blockers and 8. Hazen AL, Stein ME. Clinical phenomenology and benzodiazepines in pharmacotherapy. In: Stein MB, comorbidity. In: Stein MB, editor. Social phobia: editor. Social phobia: clinical and research perspec­ clinical and research perspectives. Washington, DC: tives. Washington, DC: American Psychiatric Press, American Psychiatric Press, 1995: 3-41. 1995:323-46. 9. Heimberg RG, Holt CS, Schneier FR, et a1. The 25. Racagni G, Masotto C, Steardo L. of issue of subtypes in the diagnosis of social phobia. J drugs. In: Costa E, Silva J, Prilipko LL, Anxiety Disord 1993;7:249-69. editors. WHO expert series on . Seat­ 10. Holt CS, Heimberg RG, Hope DA. Avoidant per­ tle: Hogrefe & Huber, 1998:118. sonality disorder and the generalized subtype of so­ 26. American Psychiatric Association Task Force on cial phobia. J Abnorm Psychol 1992;101:318-25. Dependence Toxicity, and Abuse. 11. Walker JR, Stein ME. Epidemiology. In: Stein MB, Benzodiazepine dependence, toxicity, and abuse. editor. Social phobia: clinical and research perspec­ Washington, DC: American Psychiatric Press, 1990. tives. Washington, DC: American Psychiatric Press, 27. Davidson]R, Ford SM, Smith RD, Potts NL. Long­ 1995:43-75. term treatment of social phobia with c1onazepam. 12. Stein MB, McQuaid JR, Laffaye C, McCahill ME. ] Clin Psychiatry 1991;52(Suppl):16-20. Social phobia in the primary care medical setting. J 28. van Vliet IM, den Boer JA, Westenberg HG, Pian Fam Pract 1999;48:514-9. KL. Clinical effects of buspirone in social phobia: a 13. Stein MB, Chartier M], Hazen AL, et a1. A direct­ double-blind placebo-controlled study. J Clin Psy­ interview family study of generalized social phobia. chiatry 1997;58:164-8. Am] Psychiatry 1998;155:90-7. 29. Van Ameringen M, Mancini C, Wilson C. Buspirone 14. Knowles]A, Mannuzza S, Fyer AJ. Heritability of augmentation of selective serotonin reuptake inhib­ social phobia. In: Stein MB, editor. Social phobia: itors (SSRIs) in social phobia. J Affect Disord 1996; http://www.jabfm.org/ clinical and research perspectives. Washington, DC: 39:115-21. American Psychiatric Press, 1995:147-62. 30. Emmanuel NP, Lydiard RB, Ballenger ]C. Treat­ 15. den Boer ]A. Social phobia: epidemiology, recogni­ ment of social phobia with bupropion. ] Clin Psy­ tion, and treatment. BMJ 1997;315:796-800. chopharmacoI1991;11:276-7. 16. Tiihonen J, Kuikka], Bergstrom K, Lepola U, Ko­ . 31. Sheehan DV, Davidson], Manschreck T, Van Wyck ponen H, Leinonen E. Dopamine reuptake site den­ Fleet J. Lack of efficacy of a new antidepressant

sities in patients with social phobia. Am] Psychiatry (bupropion) in the treatment of panic disorder with on 1 October 2021 by guest. Protected copyright. 1997;154:239-42. phobias.] Clin PsychopharmacoI1983;3:28-31. 17. Beidel DC. Social anxiety disorder: etiology and 32. Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, early clinical presentation. ] Clin Psychiatry 1998; Bushnell W, Gergel 1. Paroxetine treatment of gen­ 59(Suppl 17):27-32. eralized social phobia (social anxiety disorder): a ran­ 18. Ballenger JC, DavidsonJR, Lecrubier Y, et a1. Con­ domized controlled trial. JAMA 1998;280:708-13. sensus statement on social anxiety disorder from the 33. Katzelnick DJ, Kobak KA, GreistJH, Jefferson JW, International Consensus Group on Depression and Mantle JM, Serlin RC. for social phobia: a Anxiety. J Clin Psychiatry 1998;59 (Suppl 17):54- double-blind, placebo-controlled crossover study. 60. Am] Psychiatry 1995;152:1368-71. 19. Antony MM. Assessment and treatment of social 34. Van Ameringen M, Mancini C, Streiner DL. Fluox­ phobia. Can] Psychiatry 1997;42:826-34. etine efficacy in social phobia. ] Clin Psychiatry 20. Mattick RP, Page A, Lampe L. Cognitive and be­ 1993;54-:27-32. havioral aspects. In: Stein MB, editor. Social phobia: 35. den Boer JA, Westenberg HG, De Leeuw AS, van clinical and research perspectives. Washington, DC: Vliet L\1:. Biological dissection of anxiety disorders: American Psychiatric Press, 1995:189-227. the clinical role of selective serotonin reuptake in-

Social Anxiety Disorder 259 J Am Board Fam Pract: first published as 10.3122/15572625-13-4-251 on 1 July 2000. Downloaded from

hibitors with particular reference to . Int 37. Worthington JJ 3rd, Zucker BG, Fones CS, Otto Clin Psychopharmacol 1995;9(Suppl 4):47-52. MW, Pollack MH. for social phobia: a 36. Bouwer C, Stein DJ. Use of the selective serotonin clinical case series. Depress Anxiety 1998;8:131-3. reuptake inhibitor in the treatment of 38. Albano AM, Chorpita BF. Treatment of anxiety dis­ generalized social phobia. J Affect Disord 1998;49: orders of childhood. Psychiatr Clin North Am 1995; 79-82. 18:767-84. http://www.jabfm.org/ on 1 October 2021 by guest. Protected copyright.

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