Social phobias:Treatment


 * Social phobias: Outcome studies
 * Social phobias: Treatment protocols
 * Social phobias: Treatment considerations
 * Social phobias: Evidenced based treatment
 * Social phobias: Theory based treatment
 * Social phobias: Team working considerations
 * Social phobias: Followup

A person with the disorder may be treated with therapy, medication, or both. Research has shown cognitive behavior therapy, whether individually or in a group, to be effective in treating social phobics. The cognitive and behavioral components seek to change thinking patterns and physical reactions to anxious situations. This may be done through a technique called role playing. Prescribed medication consists of a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). Such treatment has a high response rate, low risk of dependancy but has been criticized for its adverse side-effects and possible increase in suicide risk.

Attention given to social anxiety disorder has significantly increased since 1999 with the approval of drugs for its treatment. Marketing campaigns by pharmaceutical companies may be largely responsible for driving this.

Arguably the most important clinical point to emerge from studies of comorbid social anxiety disorder is the necessity for early diagnosis and treatment. Social anxiety disorder remains underrecognized in primary care practice, with patients presenting for treatment only after the onset of complications such as major depression or substance use disorders. Up to 80 percent of those treated for social phobia say they've gotten their anxiety under control, according to the Anxiety Disorders Association of America. Improvement is lower for those with more severe social phobia and with comorbid disorders, such as avoidant personality disorder and depression. 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 anxiety symptoms.

Research supported by the NIMH has shown that there are two effective forms of treatment available for social phobia (and anxiety disorders): certain medications and a specific form of short-term psychotherapy called cognitive-behavioral therapy (CBT), the central component being gradual exposure therapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes.

SSRIs
Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are considered the first choice by doctors in defusing fears associated with social phobia and related anxiety disorders. These drugs are designed to elevate the level of the neurotransmitter serotonin. The first drug formally approved by the Food and Drug Administration was paroxetine, sold as Paxil. Compared to older forms of medication, there is little 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 paroxetine was shown to result in clinically meaningful improvement in 55% of patients with generalized social anxiety disorder, compared with 23.9% 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% 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 anxiety disorder.

Other drugs
Although SSRIs are often the first choice for treatment, other prescription drugs are also commonly issued.

Benzodiazepines are a more potent alternative to SSRIs. The drug is often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are prescribed for long-term use, there is much concern over the development of drug tolerance, dependency and recreational abuse. Benzodiazepines, such as Xanax augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects may begin to appear within days or hours.

In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitors (MAOIs) were frequently used in the treatment of social anxiety by researchers such as Michael Liebowitz. Irreversible MAOIs, most notably phenlzine, has been more efficacious than benzodiazepines in the short-term (8-12 weeks). Relapse is common, which may result in long-term usage. Because of the dietary restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is limited. Reversible inhibitors of monoamine oxidase subtype A (RIMAs) also inhibit monoamine oxidase. In contrast with MAOIs, reversibility means that they can inhibit the enzyme only temporarily. Because their action is short-lived and selective, they have a better safety profile than the older MAOI drugs. A special diet does not need to be strictly adhered to.

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 shaking of anxiety and can be taken before a public performance.

Psychotherapy
Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia, is cognitive-behavioral therapy (CBT) (Burns, 1999). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. A person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her. The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is gradual exposure, in which people confront the things they fear in a structured, sensitive manner. This is done with support and guidance when the therapist feels the patient is ready and only with the permission of the patient and at the pace the patient wishes. Cognitive-behavior therapy for social phobia also includes anxiety management training, such as teaching people techniques such as deep breathing to control their levels of anxiety.

Cognitive behavioral group therapy (CBGT), founded upon research done by Richard Heimberg, is a similar psychotherapeutic approach. It is generally held for 12 weekly sessions which run for two or three hours. A range of 4-10 patients and two therapists are involved in sharing individual experiences, participating in simulated exposures, and completing homework assignments in the goal of replacing irrational and automatic negative thoughts in social situations. A sample homework assignment might include reading a book or initiating a conversation with an acquaintance. Even in CBGT, sufferers are treated individually. Each person is exposed to different levels of anxious situations, depending on the severity of their illness.

These two types of cognitive behavior therapy have proven effective in reducing anxiety among social phobics. A 1998 study by Heimberg and Michael Liebowitz and a 2004 experiment showed the efficacy of CBGT.