Social Anxiety Disorder: A Common, Underrecognized Mental Disorder
Timothy J. Bruce
Social phobia is a highly prevalent yet often overlooked psychiatric disorder that can cause severe disability but fortunately has shown responsiveness to specific pharmacotherapy and psychotherapy. Recognition of its essential clinical features and the use of brief, targeted screening questions can improve detection within family practice settings. Cognitive behavioral therapy, with or without specific antidepressant therapy, is the evidence-based treatment of choice for most patients. Adjunctive use of benzodiazepines can facilitate the treatment response of patients who need initial symptom relief. The use of beta blockers as needed has been found to be helpful in the treatment of circumscribed social and performance phobias. Treatment planning should consider the patient’s preference, the severity of presenting symptoms, the degree of functional impairment, psychiatric and substance-related comorbidity, and long-term treatment goals. (Am Fam Physician 1999;60:2311-22.)
For years, social anxiety disorder, also known as social phobia, has been underrecognized and undertreated. That situation is beginning to change, however, because recent research has shown that the disorder is highly prevalent, chronic in its untreated course, often associated with comorbid mental and substance-related problems, and capable of disabling those who have it. We now know more about recognizing social phobia and the types of interventions to which it is responsive.
The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV),(1) describes social phobia as an intense, irrational and persistent fear of being scrutinized or negatively evaluated by others (Table 1). In patients with this disorder, feared social or performance situations typically provoke an immediate anxious reaction ranging from diffuse apprehension to situational panic. The types of fears and avoidance commonly associated with social phobia (Table 2) are, to some degree, experienced by most people. However, to meet the diagnostic criteria for this disorder, the symptoms must be severe enough to cause significant distress or disability. Social phobia can be generalized, meaning that the patient fears many or most social interactions, or it can be limited to one or a few situations, such as public speaking or performing.
In social phobia, fear and avoidance typically develop into a vicious cycle that can become severely distressing, debilitating and demoralizing over time. Although patients are usually aware that their fears are unreasonable, they still find themselves experiencing significant dread before facing a feared social encounter. The encounters themselves often evoke physical sensations of anxiety (e.g., blushing, sweating) and a preoccupation with possible embarrassment or humiliation. Encounters may be endured with distress or, more typically, avoided–either subtly (e.g., by modifying one’s interactions within encounters) or overtly (e.g., by nonattendance). These various forms of avoidance preclude any change in the patients’s core pathologic social fears and cause significant distress or functional impairment.
It should be noted that not everyone who suffers from social phobia appears shy, withdrawn or overtly nervous. Presentation of symptoms varies widely (Table 3). In some situations, the patient may not appear anxious, thus obscuring the underlying fear, avoidance, distress and disability.
Epidemiology, Course and Disability
Recent epidemiologic studies report that social phobia has a lifetime prevalence rate of 13.3 percent and a one-year prevalence rate of 7.9 percent in community samples, making it the third most prevalent psychiatric disorder, following substance abuse and depression.(2) In community samples, circumscribed fears of public speaking or performing are most prevalent. In clinical samples, generalized fears of many social interactions predominate, perhaps because of the greater likelihood of disability, and consequent help-seeking, in generalized social phobia.
Onset of social phobia typically occurs between 11 and 19 years of age. Onset after age 25 is rare,(3,4) although it is not uncommon for an existing social phobia to remain unprovoked for years until some new social or occupational demand (e.g., meeting new people, public speaking, promotion) forces these persons into social encounters that trigger the syndrome. Slightly more females than males have social phobia.(3) In one study,(5) about one half of the patients reported that their phobia began in response to a specific embarrassing experience; the others reported that it had been with them for as long as they could remember.
Untreated, social phobia is chronic and unremitting. Selective avoidance of social situations may temporarily reduce symptoms but usually leaves underlying fears intact. Disability from social phobia can be pervasive and severe. Approximately 85 percent of patients with the disorder experience academic and occupational difficulties caused by their inability to meet the social demands of securing and maintaining employment or relationships. In one epidemiologic sample,(3) nearly one half of those with social phobia were unable to complete high school; 70 percent were in the lowest two quartiles of socioeconomic status; and approximately 22 percent were on welfare.
Comorbidity and Detection
Approximately one half of patients with social phobia have comorbid mental, drug or alcohol problems.(6,7) The disorder increases a patient’s lifetime risk of depression approximately fourfold.(3) Up to 16 percent of patients who present with social phobia have alcohol abuse problems(8); conversely, many patients presenting for treatment of substance abuse problems meet the criteria for social phobia.(9) Interestingly, longitudinal data show that social phobia precedes approximately 70 percent of these comorbid conditions,(3) suggesting that some comorbid conditions arise in response to the phobia. Importantly, the presence of comorbidity in social phobia has been associated with an increased lifetime incidence of suicidal ideation and suicide attempts.(3) Although these data underscore the need for early detection, social phobia often goes undetected.
In a recent epidemiologic study of 2,096 primary care patients in France,(10) it was found that approximately 5 percent of those detected through screening met the criteria for social phobia. Of those patients with early onset (before age 15), 70 percent had comorbid major depression. Interestingly, of patients presenting with social phobia alone, only 46 percent were initially recognized as having any psychiatric disorder. Of patients presenting with social phobia and depression, 76 percent were recognized as having psychiatric problems, although the social phobia was specifically identified in only 11 percent. These data reemphasize the importance of comprehensive psychiatric screening and highlight the need to screen for social phobia, particularly in patients who present with other common mental health disorders, such as depression or substance abuse.
As with all psychiatric conditions, detection can be facilitated by the use of a brief screening instrument that assesses for the primary features of disorders. This method is particularly relevant for social phobia, because patients often avoid volunteering their fears face-to-face. Some general screening devices for mental disorders (e.g., the Structured Clinical Interview for DSM-IV-Screen [SCID-Screen]) include questions related to social phobia but are quite lengthy, requiring up to 25 minutes to complete; others do not screen for social phobia (e.g., the Primary Care Evaluation of Mental Disorders [Prime-MD]). Instruments designed specifically to measure social phobia (e.g., the Fear of Negative Evaluation Scale, the Social Avoidance and Distress Scale)(11) are extensive and more applicable to monitoring outcome than to screening.
In the absence of a brief yet thorough instrument for detecting social phobia, family physicians can improve detection by adding selected questions to their existing screening instrument. In a recent study of 9,375 managed care patients, the following yes-or-no statements were sensitive to detecting 89 percent of social phobia cases: (1) being embarrassed or looking stupid are among my worst fears; (2) fear of embarrassment causes me to avoid doing things or speaking to people; (3) I avoid activities in which I am the center of attention. Positive responses can be followed up to determine whether the phobia is a problem for which the patient desires treatment. A number of obstacles to prompt recognition and effective treatment have been identified (Table 4). When these obstacles are overcome, social phobia is responsive to specific pharmacologic and psychologic interventions.
It is important to distinguish between the circumscribed and generalized types of social phobia before initiating pharmacotherapy, because the circumscribed type has responded to an “as-needed” schedule (typically of beta blockers), whereas the generalized type has responded better to standing dosage schedules (typically of specific antidepressants) of at least three months’ duration. Although the outcome literature supports the efficacy of several agents, it does not indicate a clearly superior one. Treatment selection therefore involves matching the individual patient’s preferences, symptoms and treatment goals with the relative benefits and risks of the following treatment options.
MONOAMINE OXIDASE INHIBITORS
The monoamine oxidase inhibitors (MAOIs) have performed well in clinical trials for treatment of generalized social phobia. Phenelzine (Nardil), in particular, has been tested extensively in placebo-controlled studies.(12-14) Open and controlled trials suggest that approximately two thirds of patients will show clinically significant improvement during acute treatment with these agents.
The MAOIs have restrictions and adverse-effect risks that should be considered during treatment planning. The required low-tyramine diet, which prohibits many popular foods (Table 5), will deter some patients from accepting therapy with MAOIs. Patients risk a potentially fatal hypertensive reaction if they do not comply with the diet. Common adverse effects at therapeutic dosages (usually 45 to 90 mg per day for phenelzine) include postural hypotension, sedation, sexual dysfunction and weight gain. Some common over-the-counter medications, such as cold and cough remedies, are contraindicated in patients using MAOIs. Reversible MAOIs such as moclobemide, which do not require dietary restrictions, showed promise in early trials(15) but mixed results in more recent ones,(16,17) and to date they are not available in the United States.
The advantages and disadvantages of MAOI therapy for social phobia are summarized in Table 6. Although their advantages have led many to consider MAOIs an appropriate first-line treatment, their disadvantages have prompted others to relegate them to a second-line position behind the newer antidepressants.(18)
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Several studies support the efficacy of selective serotonin reuptake inhibitors (SSRIs), including large controlled trials of paroxetine (Paxil)(19,20) and fluvoxamine (Luvox)(21); smaller controlled trials of sertraline (Zoloft)(22) and fluvoxamine(23) and, most recently, an open, uncontrolled trial of citalopram (Celexa).(24) As a group, SSRIs have shown acute-treatment improvement rates ranging from 50 to 75 percent of patients. Relatively safe and well tolerated, SSRIs are currently considered an appropriate first-line consideration. The advantages and disadvantages of SSRI therapy for social phobia are shown in Table 6.
The benzodiazepines are fast-acting, well-tolerated anxiolytics that have shown efficacy in the acute treatment of social phobia, but they have also revealed some significant drawbacks related primarily to difficulties with discontinuation. Controlled studies of alprazolam (Xanax)(12) and clonazepam (Klonopin)(25) report acute-treatment improvement rates ranging from approximately 40 to 80 percent, with clonazepam showing more favorable results. However, standing dosages are sometimes difficult for patients to taper and discontinue without symptomatic worsening and a high risk of acute relapse.(12)
Because of their ability to produce physical dependence, benzodiazepines must be used with caution in patients with a history of substance abuse, a condition often associated with social phobia. When these drugs are used as needed in performance-related situations, sedation and psychologic reliance can develop. Given those risks, benzodiazepines are considered for use in patients with a low risk for substance abuse who are unresponsive to alternative treatments. The most common use of these agents, however, is in low-dose therapy (e.g., 0.25 to 0.5 mg of clonazepam twice a day) for initial symptom relief in conjunction with an antidepressant, psychotherapy, or both. The advantages and disadvantages of benzodiazepine therapy for social phobia are shown in Table 6.
Treatment studies of beta blockers for social phobia show mixed results. Controlled trials using standing dosages for generalized social phobia have been discouraging.(13,26) Beta blockers such as propranolol (Inderal) appear to be clinically effective when used in low doses (10 to 40 mg for propranolol) on an as-needed basis for mild to moderate circumscribed performance anxiety. Risk of chronic overuse suggests that these drugs should be used only intermittently until the patient’s confidence in performance situations is restored. Except for use in circumscribed social phobia, beta blockers lack consistent empiric support to recommend them as a first-line treatment for generalized social phobia. The advantages and disadvantages of beta blockers for social phobia, including important contraindications, are shown in Table 6.
A recent initial controlled trial of gabapentin (Neurontin) reported that it produced a significant reduction in social phobia symptoms compared to placebo.(27) An open trial of nefazodone (Serzone) reported that 70 percent of 23 participants showed improvement.(28) Although initial open trials of buspirone (Buspar)(29,30) looked promising, a recent controlled study found no significant differences between this drug and placebo.(31) Results of a recent open trial suggest that buspirone may be useful in augmenting partial response to an SSRI.(32)Although the tricyclic antidepressant imipramine (Tofranil) has performed well in some case reports, larger trials have not supported its efficacy in treating social phobia.(33) Agents such as bupropion (Wellbutrin) and clonidine (Catapres) have yet to be investigated outside of case reports and clinical anecdotes. Common therapeutic dosage ranges and cost estimates for the evidenced-based options discussed in this section are given in Table 7.
General supportive psychotherapy has not been found to be as useful in treating social phobia as more directive therapies focused on reducing anxiety by reducing avoidance. Social phobia has been particularly responsive to behavioral and cognitive behavioral therapy involving the use of exposure (gradual reentry into feared situations). Cognitive behavioral therapy is a multicomponent treatment that typically is tailored to patients based on their presenting features (Table 3). It is conducted in individual or (preferably) group formats and usually lasts for 16 to 24 sessions. Components of cognitive behavioral therapy for social phobia often include symptom management skills, social skills training, cognitive restructuring aimed at changing patients’ anxious thought processes, and exposure (Table 8).
Approximately 20 controlled studies have examined various components of behavioral and cognitive behavioral interventions for social phobia. Results indicate that cognitive behavioral therapy involving exposure and focusing on changing phobic thinking can benefit as many as 75 percent of patients.(34) Evidence suggests that treatment gains made during cognitive behavioral therapy generally endure after treatment is discontinued.(35) Initial comparative data show that relapse rates after discontinuation of cognitive behavioral therapy are significantly less (range: zero to 17 percent) than those following discontinuation of effective pharmacotherapy (~50 percent).(36) Taken together, the study data support the use of cognitive behavioral therapy as a first-line consideration in the treatment of social phobia. Whether the common clinical practice of combining pharmacotherapy and cognitive behavioral therapy provides any benefit over either modality alone or for specific subgroups (e.g., the severely symptomatic) awaits direct study.
The average cost of 16 to 24 weekly sessions of cognitive behavioral therapy ($750 to $2,000, depending on the type of provider) can be prohibitive for some patients, although most third-party payers cover 50 to 80 percent of costs when the therapy is delivered by a licensed professional. Specialized training is required for cognitive behavioral therapy, limiting its availability. The Anxiety Disorders Association of America (ADAA; www.adaa. com; 301-231-9350) can help patients or physicians to identify qualified cognitive behavioral therapy providers in their area. Advantages and disadvantages of cognitive behavioral therapy are summarized in Table 6.
Treatment planning should be done after the benefits and risks of treatment options have been discussed with the patient. Considerations in treatment planning should include the patient’s preference, the severity of presenting symptoms, the degree of functional impairment, psychiatric and substance-related comorbidity, and long-term treatment goals. To date, there is no empirically derived algorithm for the treatment of social phobia, although evidence-based options include cognitive behavioral therapy, pharmacotherapy, or both. Expert consensus guidelines(18) are consistent with consideration of cognitive behavioral therapy alone for mild to moderate cases and combined cognitive behavioral therapy and pharmacotherapy (e.g., paroxetine) for moderate to severe cases of generalized social phobia. Time-limited use of low-dose benzodiazepine therapy (e.g., clonazepam) may help with initial symptom relief until slower-acting pharmacotherapy or cognitive behavioral therapy takes effect. For circumscribed social phobia, cognitive behavioral therapy with or without initial as-needed use of beta blockers is supported.
Some form of gradual reentry into feared situations should be a part of every treatment plan for social phobia, particularly because evidence is emerging that it may facilitate longer-term gains. Clinical experience also suggests that although many patients respond to acute treatment and maintain those gains over the long term, those who do not may need some form of continuing therapy involving pharmacotherapy and/or cognitive behavioral therapy to optimally restore or maintain gains. Whatever options are selected, patients should be educated about the phobia, reassured of their normalcy and instilled with a realistic hope of recovery. The role of the family physician in the management of social phobia is summarized in Table 9.
TIMOTHY J. BRUCE, PH.D., is an associate professor and director of medical student education in the Department of Psychiatry and Behavioral Medicine at the University of Illinois College of Medicine at Peoria. He is codirector of the department’s Anxiety and Mood Disorders Clinic.
SY ATEZAZ SAEED, M.D., is chairman of the Department of Psychiatry and Behavioral Medicine at the University of Illinois College of Medicine at Peoria. With Dr. Bruce, he codirects the department’s Anxiety and Mood Disorders Clinic.
Address correspondence to Timothy J. Bruce, Ph.D., Anxiety and Mood Disorders Clinic, Department of Psychiatry and Behavioral Medicine, University of Illinois College of Medicine, 5407 N. University St., Suite C, Peoria, IL 61614; e-mail address: firstname.lastname@example.org. Reprints are not available from the authors.
(1.) American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:411-7.
(2.) Kessler RC, McGonagle DK, Zhao S, Nelson CB, Hughes M, Eshleman 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.
(3.) Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM. Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 1992;49:282-8.
(4.) Scholing AE, Emmelkamp PM. Social phobia: nature and treatment. In: Leitenberg H, ed. Handbook of social and evaluation anxiety. New York: Plenum, 1990:269-324.
(5.) Ost LG, Hugdahl K. Acquisition of phobias and anxiety response patterns in clinical patients. Behav Res Ther 1981;19:439-47.
(6.) Katzelmick D, Kobak K, Helstad C, Greist J, Davidson J, De Laire T, et al. The direct and indirect costs of social phobia in managed care patients. Presented at the annual meeting of the American College of Neuropsychopharmacology. San Juan, Puerto Rico, December,1998.
(7.) Sanderson WC, DiNardo PA, Rapee RM, Barlow DH. Syndrome comorbidity in patients diagnosed with a DSM-III-R anxiety disorder. J Abnorm Psychol 1990;99:308-12.
(8.) Schneier FR, Martin LY, Liebowitz MR, Gorman JM, Fyer AJ. Alcohol abuse in social phobia. J Anx Disord 1989;3:15-23.
(9.) Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. Am J Psychiatry 1990;147:685-95.
(10.) Weiller E, Bisserbe JC, Boyer P, Lepine JP, Lecrubier Y. Social phobia in general health care: an unrecognized, undertreated, disabling disorder. Br J Psychiatry 1996;168:169-74.
(11.) Watson D, Friend R. Measurement of social-evaluative anxiety. J Consult Clin Psychol 1969;33:448-57.
(12.) Gelernter CS, Uhde TW, Cimbolic P, Arnkoff DB, Vittone BJ, Tancer ME, et al. Cognitive-behavioral and pharmacological treatments of social phobia. A controlled study. Arch Gen Psychiatry 1991;48: 938-45.
(13.) Liebowitz MR, Schneier F, Campeas R, Hollander E, Hatterer J, Fyer A, et al. Phenelzine vs atenolol in social phobia. A placebo-controlled comparison. Arch Gen Psychiatry 1992;49:290-300.
(14.) Versiani M, Nardi AE, Mundim FD, Alves AB, Liebowitz MR, Amrein R. Pharmacotherapy of social phobia. A controlled study with moclobemide and phenelzine. Br J Psychiatry 1992;161: 353-60.
(15.) van Vliet IM, den Boer JA, Westenberg HG. Psychopharmacological treatment of social phobia: clinical and biochemical effects of brofaromine, a selective MAO-A inhibitor. Eur Neuropsychopharmacol 1992;2:21-9.
(16.) Schneier FR, Goetz D, Campeas R, Fallon B, Marchall R, Liebowitz MR. Placebo-controlled trial of moclobemide in social phobia. Br J Psychiatry 1998;172:70-7.
(17.) Versiani M, Nardi AE, Mundim FD, Pinto S, Saboya E, Kovacs R. The long-term treatment of social phobia with moclobemide. Int Clin Psychopharmacol 1996;11(suppl 13):83-8.
(18.) Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Bobes J, Beidel DC, et al. Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 1998;59(suppl 17):54-60.
(19.) Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, Bushnell W, Gergel I. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA 1998;280:708-13.
(20.) Stein DJ, Berk M, Els C, Emsley RA, Gittelson L, Wilson D, et al. A double-blind placebo controlled trial of paroxetine in the management of social phobia (social anxiety disorder) in South Africa. S Afr Med J 1999;89(4):402-6.
(21.) Stein MB, Fyer AJ, Davidson JR, Pollack MH, Wiita B. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study. Am J Psychiatry 1999;156(5):756-60.
(22.) Katzelnick D, Kobak KA, Greist JH, Jefferson JW, Mantle JM, Serlin RC. Sertraline for social phobia: a double-blind, placebo-controlled crossover study. Am J Psychiatry 1995;152:1368-71.
(23.) van Vliet IM, den Boer JA, Westenberg HG. Psychopharmacological treatment of social phobia: a double-blind placebo-controlled study with fluvoxamine. Psychopharmacol [Berl] 1994;115:128-34.
(24.) Bouwer C, Stein DJ. Use of the selective serotonin reuptake inhibitor citalopram in the treatment of generalized social phobia. J Affect Disord 1998; 49;79-82.
(25.) Davidson JR, Potts N, Richichi E, Krishnan R, Ford SM, Smith R. Treatment of social phobia with clonazepam and placebo. J Clin Psychopharmacol 1993;13:423-8.
(26.) Turner SM, Beidel DC, Jacob RG. Social phobia: a comparison of behavior therapy and atenolol. J Consult Clin Psychol 1994;62:350-8.
(27.) Pande AC, Davidson JR, Jefferson JW, Janney CA, Katzelnick DJ, Weisler RH, et al. Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol 1999;19(4):341-8.
(28.) Van Ameringen M, Mancini C, Oakman JM. Nefazodone in social phobia. J Clin Psychiatry 1999; 60(2):96-100.
(29.) Munjack DJ, Bruns J, Baltazar PL, Brown R, Leonard M, Nagy M. A pilot study of buspirone in the treatment of social phobia. J Anx Disord 1991;5:87-98.
(30.) Schneier FR, Saoud JB, Campeas R, Fallon BA, Hollander E, Coplan J, et al. Buspirone in social phobia. J Clin Psychopharmacol 1993;13:251-6.
(31.) van Vliet IM, den Boer JA, Westenberg HG, Pian KL. Clinical effects of buspirone in social phobia: a double-blind placebo-controlled study. J Clin Psychiatry 1997;58:164-8.
(32.) Van Ameringen M, Mancini C, Wilson C. Buspirone augmentation of selective serotonin reuptake inhibitors (SSRIs) in social phobia. J Affect Disord 1996;39:115-21.
(33.) Simpson HB, Schneier FR, Campeas RB, Marshall RD, Fallon BA, Davies S, et al. Imipramine in the treatment of social phobia. J Clin Psychopharmacol 1998;18:132-5.
(34.) Heimberg RG, Jester HR. Cognitive behavioral treatments: literature review. In: Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, eds. Social phobia: diagnosis, assessment, and treatment. New York: Guilford, 1995:261-309.
(35.) Juster HR, Heimberg RG. Social phobia: longitudinal course and long-term outcome of cognitive-behavioral treatment. Psychiatr Clin North Am 1995;18:821-42.
(36.) Liebowitz MR, Heimberg RG, Schneier FR, Hope DA, Davies S, et al. Cognitive-behavioral group therapy vs phenelzine therapy for social phobia: long-term outcome. Arch Gen Psychiatry [In press.]
Diagnostic Criteria for Social Phobia
A. A marked and persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people or to
possible scrutiny by others. The individual fears that he or she will act
in a way (or show anxiety symptoms) that will be humiliating or
embarrassing. note: In children, there must be evidence of the capacity
for age-appropriate social relationships with familiar people and the
anxiety must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes anxiety,
which may take the form of a situationally bound or situationally
predisposed panic attack. note: In children, the anxiety may be expressed
by crying, tantrums, freezing, or shrinking from social situations with
C. The person recognizes that the fear is excessive or unreasonable.
note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are
endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social
or performance situation(s) interferes significantly with the person’s
normal routine, occupational (academic) functioning or social activities
or relationships, or there is marked distress about having the phobia.
F. In individuals under 18 years of age, the duration is at least six months.
G. The fear or avoidance is not due to the direct physiologic effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition and is not better accounted for by another mental disorder
(e.g., panic disorder with or without agoraphobia, separation anxiety
disorder, body dysmorphic disorder, a pervasive developmental disorder or
schizoid personality disorder).
H. If a general medical condition or another mental disorder is present, the
fear in Criterion A is unrelated to it; (e.g., the fear is not of
stuttering, trembling in Parkinson’s disease or exhibiting abnormal eating
behavior in anorexia nervosa or bulimia nervosa.)
Generalized: if the fears include most social situations (also consider the
additional diagnosis of avoidant personality disorder).
Common Fears in Social Phobia
Public speaking or performing
Making “small talk”
Small group discussion
Asking questions in groups
Meeting or talking with strangers
Being watched doing something (e.g., eating, writing)
Attending social gatherings
Using the telephone
Using public restrooms
Interacting with “important” people
Indirect evaluation (e.g., test taking)
Clinical Dimensions of Social Phobia
The following are some of the ways in which patients with social phobia may
vary in symptom presentation:
Generalized versus specific fears or avoidance
Severe versus mild physiologic reactivity to social encounters
Socially skilled versus unskilled
Fear of familiar versus unfamiliar social situations
Fear of formal versus informal social situations
Fear of group versus individual social interactions
Presence versus absence of preoccupation with and fear of specific
anxiety sensations (e.g., blushing, shaking)
Obstacles to Effective Treatment of Social Phobia
Patient avoids treatment because of fear, shame or stigma.
Screening devices for assessing social phobia are unavailable.
Assessment and treatment are misdirected toward specific symptoms
(e.g., somatic complaints) or comorbid conditions (e.g., depression,
substance use problems) rather than toward the social phobia syndrome.
Affordable and expert care is unavailable.
Physician or patient lacks knowledge about effective treatment options.
Patient or physician trivializes phobia or views it as characterologic
and unchangeable (e.g., patient is “just shy”).
Food Restrictions During Monoamine Oxidase Inhibitor Therapy
Foods to be avoided
Cheese (except for cream cheese, cottage cheese and
American processed cheese)
Broad (fava) bean pods
Aged overripe fruit (e.g., bananas)
Pickled herring, anchovies, sardines
Salami, sausage, pepperoni, bologna, liver, Spam, canned ham;
any smoked, pickled or fermented meat, fish or protein product
Chianti and other red wines, sherry, vermouth, liqueurs, tap or draft beer
Foods to be used in moderation
White wine, ale, bottled beer, foods cooked in wine
Soybean paste (tofu)
Cream cheese, cottage cheese, American processed cheese
Foods and beverages that contain aspartame
Selected Advantages and Disadvantages
of Major Treatment Modalities for Social Phobia
CBT SSRIs MAOIs BZDs
Established efficacy X X X X
Maintenance of gains X
Antidepressant effects X X
Favorable side effect
profile X X X
Not habit-forming X X X
Generic form available X X
Delayed onset X X X
Withdrawal syndrome X[[double dagger]] X
Sedation X[[double dagger]] X
Orthostatic hypotension X
Dietary restrictions X
Sexual dysfunction X X X
Weight gain X[[double dagger]] X
Multiple dosing/sessions X X X
High cost X X[[double dagger]]
Limited availability X
Established efficacy X[*]
Maintenance of gains
Favorable side effect
Not habit-forming X
Generic form available X
Sedation X[[double dagger]]
Sexual dysfunction X
CBT = cognitive behavior therapy; SSRI = selective serotonin
reuptake inhibitors; MAOIs = monoamine oxidase inhibitors;
BZDs = benzodiazepines.[*]–As-needed use for specific social/performance fears.[[dagger]]–Contraindications include asthma, sinus bradycardia and
greater than first-degree heart block, cardiogenic shock
and some cases of congestive heart failure.[double dagger]–In some cases.
Drugs Used in Treating Social Phobia
Phenelzine (Nardil) 45 to 90 mg per day
Tranylcypromine (Parnate) 40 to 60 mg per day
Fluoxetine (Prozac) 10 to 100 mg per day
Paroxetine (Paxil) 20 to 60 mg per day
Sertraline (Zoloft) 50 to 200 mg per day
Fluvoxamine (Luvox) 50 to 150 mg per day
Citalopram (Celexa) 40 mg per day
Alprazolam (Xanax) 2 to 10 mg per day
Lorazepam (Ativan) 2 to 6 mg per day
Clonazepam (Klonopin) 1 to 3 mg per day
Buspirone (Buspar) 35 to 60 mg per day
Propranolol (Inderal) 40 mg as needed
Nadolol (Corgard) 40 to 80 mg as needed
Atenolol (Tenormin) 50 to 100 mg as needed
Drugs Cost (generic)[[dagger]]
Phenelzine (Nardil) $1.50
Tranylcypromine (Parnate) 2.00
Fluoxetine (Prozac) 2.50 (1.50)
Paroxetine (Paxil) 2.00
Sertraline (Zoloft) 2.50
Fluvoxamine (Luvox) 2.50
Citalopram (Celexa) 2.00
Alprazolam (Xanax) 2.00 (1.50 to 2.00)
Lorazepam (Ativan) 1.50 (.85 to 1.00)
Clonazepam (Klonopin) 0.50 (0.75 to 1.00)
Buspirone (Buspar) 4.50
Propranolol (Inderal) 0.50 (0.20 to 0.40)
Nadolol (Corgard) 1.50 (1.00 to 1.50)
Atenolol (Tenormin) 1.00 (0.50 to 1.00
MAOIs = monoamine oxidase inhibitors; SSRIs = selective serotonin reuptake
inhibitors.[*]–Dosages as used in trials for treatment of social phobias may vary
somewhat from dosage ranges listed in Physicians’ Desk Reference (PDR) for
treatment of panic disorder and depression.[[dagger]]–Estimated cost to the pharmacist based on average wholesale
prices (rounded to the nearest half dollar) for one day of treatment at
the lowest dosage level in Red book. Montvale, N.J.: Medical Economics
Data, 1999. Cost to the patient will be greater, depending on prescription
Components of Cognitive Behavior Therapy for Social Phobia
Anxiety management skills
May involve controlled breathing, relaxation and other calming techniques
Social skills training
May involve verbal and nonverbal skills that facilitate social effectiveness,
such as initiating and maintaining conversation, making appropriate eye
contact and asserting oneself appropriately
Involves learning to identify, challenge and change fearful thinking that
overestimates social threat, underestimates one’s ability to manage social
demands and catastrophizes the consequences of social miscues
Gradual exposure to feared situations
Involves gradual reentry into feared social situations to reduce the anxiety
that they engender
Role of the Family Physician in the Management of Social Phobia
Identify the syndrome through screening and assessment.
Educate the patient about the disorder (e.g., it is common and responsive to
Educate the patient about the benefits and risks of available treatment
options (pharmacologic and psychologic).
Initiate and manage indicated pharmacotherapy or make a referral to a
psychiatrist specializing in anxiety disorders.
Make a referral to or work in conjunction with a specialist in cognitive
Provide support and instill hope.
COPYRIGHT 1999 American Academy of Family Physicians
COPYRIGHT 2008 Gale, Cengage Learning