Social Phobia: Treatment

Arguably the most important clinical point to emerge from studies of social disorder is the benefit of early diagnosis and treatment. Social disorder remains under-recognized in primary care practice, with patients often presenting for treatment only after the onset of complications such as clinical depression or substance abuse disorders. The patients who achieve full resolution are usually far fewer; there are still many who, after receiving treatment, are unable to function in the long-term without symptoms.

Research has provided evidence for the efficacy of two forms of treatment available for : certain medications and a specific form of short-term psychotherapy called Cognitive-behavioral therapy (CBT), the central component being gradual .

Pharmacological treatments

SSRIs

(SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised . These drugs elevate the level of the , among other effects. The first drug formally approved by the Food and Drug Administration was , sold as Paxil in the US or Seroxat in the UK, Compared to older forms of medication, there is less risk of tolerability and drug dependency. However, their efficacy and increased suicide risk has been subject to controversy.

In a 1995 double-blind, placebo-controlled trial, the SSRI was shown to result in clinically meaningful improvement in 55 percent of patients with generalized social disorder, compared with 23.9 percent of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, and a placebo. The first four sets saw improvement in 50.8 to 54.2 percent of the patients. Of those assigned to receive only a placebo, 31.7 percent achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.

General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and juvenile suicide. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. Recent studies have shown no increase in rates of suicide.These tests, however, represent those diagnosed with depression, not necessarily with social disorder. However, it should be noted that due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression.

Other drugs

Although SSRIs are often the first choice for treatment, other prescription drugs are also commonly issued, sometimes only if SSRIs fail to produce any clinically significant improvement.

In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitors (MAOIs) were frequently used in the treatment of social . Their efficacy appears to be comparable or sometimes superior to SSRIs or Benzodiazepines. However, because of the dietary restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to. A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A (RIMAs) inhibit the MAO enzyme only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.

Benzodiazepines are a short-acting and more potent alternative to SSRIs. The drug is often used for short-term relief of severe, disabling . Alprazolam and clonazepam are usual benzodiazepines for social fear. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is much concern over the development of drug tolerance, dependency and recreational abuse. Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.

Some people with a form of called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of and can be taken before a public performance.

A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with facilitates the effects of of (Hofmann, Meuret, Smits, et al., 2006). DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory (Hofmann, Pollack, & Otto, 2006). It has been shown that administering a small dose acutely 1 hour before can facilitate extinction learning that occurs during therapy.

Psychotherapy

Research has shown that a form of psychotherapy that is effective for several disorders, particularly panic disorder and [61] is cognitive-behavioral therapy (CBT). It has two main components. The cognitive component helps people become aware of and to change thinking patterns that keep them from overcoming their fears. A person with might be helped to question how they can be so sure that others are continually watching and harshly judging him or her. The behavioral component of CBT seeks to change people’s reactions to -provoking situations. It also serves as a logical extension of cognitive therapy where people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which people confront the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique. It involves four components, duration, frequency, graded and focused. Ideally the person should be exposed to a feared social situation that is provoking but bearable (graded) for as long as possible (duration), two to three times a day (frequency), and the person must endure the until it declines (focused). A hierarchy of feared steps is constructed and the patient is exposed to each step. The aim is also to learn from acting differently and observing reactions (behavioral ‘experiments’). This is intended to be done with support and guidance when the therapist and patient feel they are ready. Cognitive-behavior therapy for also includes management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced ‘in-situ’. CBT may also be conducted partly in group sessions (Cognitive behavioral group therapy), facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg).

Some studies have suggested social skills training can help with social [62]. Whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations, does not seem to be clear[63].

Interpersonal Therapy has been shown to have efficacy for depression and a small study of the therapy in the treatment of suggests it may also work with

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May 10, 2008 | Filed Under Mental Disorders 

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