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Social anxiety disorder - Treatment

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TreatmentEdit

The most important clinical point to emerge from studies of social anxiety disorder is the benefit of early diagnosis and treatment. Social anxiety 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.

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

PsychotherapyEdit

Research has shown that cognitive behavioral therapy (CBT) can be highly effective for several anxiety disorders, particularly specific phobias, obsessive compulsive disorder, panic disorder and social anxiety disorder.[1] CBT, as its name suggests, has two main components, cognitive and behavioral. In cases of social anxiety, the cognitive component can help the patient question how they can be so sure that others are continually watching and harshly judging them. The behavioral component seeks to change people's reactions to anxiety-provoking situations. As such it serves as a logical extension of cognitive therapy, whereby people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component was gradual exposure, in which the patient was confronted by the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique; and had high drop out rates. Ideally it involves exposure to a feared social situation that is anxiety provoking but bearable, for as long as possible, two to three times a week. Often, a hierarchy of feared steps is constructed and the patient is exposed each step sequentially. Now modern CBT treatments have been enhanced by focussing treatment on cognitive process, e.g., behavioral experiment with attentional focus, video feedback experiments, addressing fears of negative evaluation, identifying and removing safety seeking behaviors, etc. The aim is to learn from acting differently and observing reactions. This is intended to be done with support and guidance, and when the therapist and patient feel they are ready. Cognitive-behavioral therapy for social phobia for few patients now includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced 'in-situ'. These early interventions, for some, can be useful but for most can become safety seeking behaviors (and thus unhelpful) so need to be suggested in a considered case conceptualization (i.e., individualized understanding of the cognitive and behavioral factors that are maintaining the problem). CBT can also be conducted partly in group sessions, 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 anxiety.[2] However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.[3]

Additionally, a recent study has suggested that interpersonal therapy, a form of psychotherapy primarily used to treat depression, may also be effective in the treatment of social phobia.[4]

Pharmacological treatmentsEdit

SSRIsEdit

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia. These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the Food and Drug Administration was paroxetine, sold as Paxil in the U.S. or Seroxat in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency.[5] However, their efficacy and increased suicide risk has been subject to controversy.

In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55 percent of patients with generalized social anxiety disorder, compared with 23.9 percent of those taking placebo.[6] An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, or 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.[7]

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.[8] 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.[9] Recent studies have shown no increase in rates of suicide.[10] These tests, however, represent those diagnosed with depression, not necessarily with social anxiety 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 drugsEdit

Although SSRIs are often the first choice for treatment, other prescription drugs are also used, 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 anxiety. 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.[11] 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 such as alprazolam and clonazepam are an alternative to SSRIs. These drugs are often used for short-term relief of severe, disabling anxiety.[12] Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is some concern over the development of drug tolerance, dependency and misuse. It has been recommended that benzodiazepines are only considered for individuals who fail to respond to safer medications.[13] Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.

The novel antidepressant mirtazapine has been proven effective in treatment of social anxiety disorder.[14] This is especially significant due to mirtazapine's fast onset and lack of many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction).

In Japan, the serotonin-norepinephrine reuptake inhibitor (SNRI), Milnacipran is used in the treatment of Taijin kyofusho a Japanese variant of social anxiety disorder.

Some people with a form of social phobia 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 anxiety 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 exposure therapy facilitates the effects of exposure therapy of social phobia.[15] 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.[16] It has been shown that administering a small dose acutely 1 hour before exposure therapy can facilitate extinction learning that occurs during therapy.

referencesEdit

  1. Jonathan R. T. Davidson, MD; Edna B. Foa, PhD; et al. Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia 1998. Retrieved March 1, 2006.
  2. Mersch et al., 1991
  3. Stravynski & Amado, 2001
  4. Lipsitz et al, 1999
  5. ed. by Stuart A. Montgomery ...; Stuart Montgomery, Hans Den Boer (2001). SSRIs in Depression and Anxiety, 109–111, John Wiley and Sons.
  6. Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, Bushnell W, Gergel I (August 1998). Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA 280 (8): 708–13.
  7. Davidson JR, Foa EB, Huppert JD, et al (October 2004). Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Arch. Gen. Psychiatry 61 (10): 1005–13.
  8. eMedicine med/3121
  9. Federal Drug and Administration. Class Suicidality Labeling Language for Antidepressants. 2004. Retrieved February 24, 2006.
  10. Group Health Cooperative. Study refutes link between suicide risk, antidepressants January 1, 2006. Retrieved February 24, 2006.
  11. Crozier, page. 475-477.
  12. (Jul 1999). Facing the challenge of social anxiety disorder.. Eur Neuropsychopharmacol 9 Suppl 3: S93–9.
  13. (2004). [Neurobiology and pharmacotherapy of social phobia]. Encephale 30 (4): 301–13.
  14. Muehlbacher M, Nickel MK, Nickel C, et al. (2005). Mirtazapine reduces social anxiety and improves quality of life in women with social phobia. J Clin Psychopharmacol 25 (6): 580–583.
  15. Hofmann SG, Meuret AE, Smits JA, et al (March 2006). Augmentation of exposure therapy with D-cycloserine for social anxiety disorder. Arch. Gen. Psychiatry 63 (3): 298–304.
  16. Hofmann SG, Pollack MH, Otto MW (2006). Augmentation treatment of psychotherapy for anxiety disorders with D-cycloserine. CNS Drug Rev 12 (3–4): 208–17.

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