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Social Anxiety Disorder Psychiatria Danubina, 2009; Vol. 21, No. 4, pp 533–542 Conference paper © Medicinska naklada - Zagreb, Croatia SOCIAL ANXIETY DISORDER: EPIDEMIOLOGY, BIOLOGY AND TREATMENT SOZIALPHOBIE: EPIDEMIOLOGIE, BIOLOGIE UND THERAPIE Martin Fink, Elena Akimova, Christoph Spindelegger, Andreas Hahn, Rupert Lanzenberger & Siegfried Kasper Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria SUMMARY ZUSAMMENFASSUNG Social anxiety disorder (SAD) is considered to be one of Sozialphobien gehören zu den häufigsten psychiatrischen the most common anxiety disorders. Despite its high Erkrankungen. Ungeachtet der hohen Prävalenz wird diese prevalence, the disorder is still considerably underdiagnosed Erkrankung noch immer zu selten erkannt, diagnostiziert und and undertreated. SAD shows a typically early onset in und ausreichend behandelt. Das Krankheitsbild entwickelt sich childhood or early adolescence and generally becomes typischerweise in der Kindheit oder im frühen Adoleszenzalter chronic. The disease places a massive burden on patients und zeigt häufig einen chronischen Verlauf. Die Erkrankung lives, affecting not only their social interactions but also their stellt eine massive Belastung für die Patienten dar und wirkt educational and professional activities, thereby constituting a nicht nur in sozialen Aspekten, sondern auch im Beruf und der severe disability. Although substantial progress in the study of Ausbildung der Betroffenen behindernd. Obwohl in der Erfor- the etiology of SAD has been made, no commonly accepted schung der Ätiologie der Erkrankung bereits große Fortschritte model has emerged yet. Data from genetic and neuroimaging gemacht wurden, hat sich noch kein allgemein akzeptiertes studies point towards a contribution of several neuro- Modell entwickelt. Die Daten aus genetischen Studien und transmitter systems (i.e. norepinephrine, dopamine and Studien mit bildgebenden Verfahren deuten auf ein Mitwirken serotonin) to the pathophysiology of this disorder. Functional des noradrenergen, des dopaminergen und des serotonergen magnetic resonance imaging studies have repeatedly Systems in der Pathophysiologie hin. In funktionellen Magnet- emphasized the central role of the amygdalae and insula in the resonanztomographiestudien wurde wiederholt die zentrale neural circuitry of the disorder. Selective serotonin reuptake Rolle von Strukturen wie den Amydalae und der Insula in der inhibitors (SSRI) are commonly accepted as first line therapy, neuronalen Grundlage der Sozialphobien gezeigt. In der Thera- however other substance classes like serotonin norepineprine pie der Sozialphobien werden allgemein selekive Serotonin- reuptake inhibitors (SNRI), monoamine oxidase inhibitors Wiederaufnahmehemmer als Mittel der ersten Wahl betrachtet. (MAOI), benzodiazepines and several other agents have also Andere Substanzklassen wie Serotonin-Noradrenalin-Wieder- proved effective. There is still a substantial lack of data on aufnahmehemmer, Monoaminoxidasehemmer, Benzodiazepine therapeutic options in cases of non-responsive SAD as well as und einzelne andere Psychopharmaka haben ebenfalls Thera- on add-on therapy. A combined treatment-approach including pieeffizienz bewiesen. Zum gegenwärtigen Zeitpunkt gibt es psychotherapy (e.g. cognitive behavioural therapy) may prove noch immer kaum Daten über Therapieoptionen bei Therapie- useful. resistenz oder über add-on Strategien. Eine weitere Möglichkeit stellen kombinierte Therapiestrategien mit psychothera- Key words: anxiety disorders - social anxiety disorder – peutischen Ansätzen (z.B. kognitive Verhaltenstherapie) dar. pharmacotherapy - epidemiology Schlüsselwörter: Sozialphobie - Psychopharmaktherapie - Epidemiologie * * * * * INTRODUCTION population (Stein et al. 2000). A Canadian community survey showed that a considerable Awareness of social anxiety disorder (SAD, percentage of the interviewed persons report at previously termed social phobia) has developed least moderate difficulty in giving a speech (15%), over the years from perception that it is no mere participating in a meeting (14%) or talking to shyness or timidity but a clinical state, which may people they do not know (13%). This makes it become chronic and possesses neurobiological and difficult to distinguish a border between perso- organic correlates. SAD is among the most nality traits like shyness and SAD. The relatively frequent psychiatric disorders and shows a high late identification of SAD 40 years ago, as a lifetime prevalence of 12% and a 12 months diagnostic entity separate from the group of prevalence of 7.1% (Kessler et al. 2005). Social specific phobias might reflect this fact. Unlike fears are also common among the general commonly observed isolated social fears, this 533 Martin Fink, Elena Akimova, Christoph Spindelegger, Andreas Hahn, Rupert Lanzenberger & Siegfried Kasper: SOCIAL ANXIETY DISORDER: EPIDEMIOLOGY, BIOLOGY AND TREATMENT Psychiatria Danubina, 2009; Vol. 21, No. 4, pp 533–542 disorder greatly affects the patient’s social and EPIDEMIOLOGY, COURSE AND professional life and relationships (Katzelnick et BURDEN OF THE DISEASE al. 2001) and the high disability level resulting from SAD is comparable with that observed in SAD shows a typically early onset in cases of major depression (Sheehan et al. 1996). adolescence and even childhood in the case of the SAD is classified with other phobic disorders generalized type (Chavira and Stein 2005). A in the Diagnostic and Statistical Manual of Mental french study in primary care patients determined Disorders IV (DSM-IV) and in the International the mean age of onset as 15.1 years with a 90% Classification of Diseases 10 (ICD-10). According probability of this disease developing in sufferers to the criteria in the DSM-IV a patient diagnosed before the age of 25. Therefore SAD is the second with SAD has to have a marked and persistent fear most frequent anxiety disorder occurring by early of one or varying social situations involving adulthood (Chavira et al. 2004). Maltreatment in exposure to strangers or possible scrutiny by childhood or other traumatizing psychosocial others. The sufferer is extremely afraid of doing or events are apparently not associated with a saying something embarrassing or humiliating, or childhood onset of SAD (Chavira and Stein 2005). showing symptoms of anxiety. Exposure to such Moreover behavioural inhibition, a heritable situations provokes anxiety, which may even temperamental trait, seems to be a precursor of the present as a panic attack and they are therefore disease (Hirshfeld-Becker et al. 2007). Twin often avoided or endured with distress although the studies confirm anxiety traits to be heritable (Stein patient realises that this fear is excessive or et al. 2002) and moderate heritability of SAD is unreasonable. The anxious state is due neither to suggested by further family studies. substance effects, nor to a general medical The disease generally becomes chronic and condition or other mental disorder. At a appears to be more frequent in women than men. pathological level, SAD affects functioning in all Prevalence rates appear to be stabile in youth and aspects of daily life, including professional adulthood and symptoms persist even in old age functioning, social activities and relationships. (Cairney et al. 2007, Kessler et al. 2005). As There are two subtypes characterized in the mentioned previously, the lifetime prevalence is DSM-IV which are distributed equally among approximately 12% (Kessler et al. 2005) and patients, namely the generalized and the non- studies in the USA, Canada and Australia show generalized (performance-type) social anxiety similar rates (Iancu et al. 2006). disorder. Persons with generalized SAD typically The harmful effects of SAD on the patient’s experience fear and show avoidant behaviour in development often begin in childhood in the form most social situations. This subtype is reported to of school refusal. The association between SAD be more common in patients in primary healthcare and leaving school early has been frequently (Stein et al. 1999) and is associated with more psychiatric comorbidities and functional shown (Stein and Kean 2000). Academic impairment than non-generalized SAD. Individuals underachievement, underperformance at work or with performance-type SAD experience fewer even the inability to work, reflected by higher social fears, with the fear of speaking in public unemployment rates in patients with SAD are occurring most frequently - 80% (Kessler et al. among the consequences (Wittchen and Beloch 1998). 1996) resulting in a reduced quality of life (Stein et Reported physical symptoms in patients with al. 2005). SAD are sweating, trembling, blushing, palpi- SAD frequently shows psychiatric tations, nausea and diarrhoea. Patients complain of comorbidities that aggravate its detrimental effect concentration difficulties, nervousness, restless- on patient’s lives. Major depression frequently ness, and show hypervigilant behaviour. Social accompanies the disorder (Rush et al. 2005), withdrawal is often a consequence of this extreme moreover SAD, like other anxiety disorders is a situation-related discomfort, but unlike persons significant risk factor for developing major that isolate themselves willingly due to psychiatric depression (Beesdo et al. 2007). The co-occurence conditions (e.g. schizoid personality disorder), of major depression and SAD has been also persons with social anxiety disorder crave the reported as increasing the risk of suicide
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