Social anxiety disorder

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Social anxiety disorder (SAD, SAnD) (DSM-IV300.23), also sometimes called socialphobia (SP),^[1]is an anxiety disorder characterized by intensefear in social situations^[1]causing considerable distress and impaired ability to function in atleast some parts of daily life. The diagnosis can be of a specificdisorder (when onlysome particular situations are feared) or a generalized disorder.Generalized social anxiety disorder typically involves a persistent,intense, chronic fear of being judged by othersand of being embarrassed or humiliated by one's own actions. These fears canbe triggered by perceived or actual scrutiny from others. While thefear of social interaction may be recognized by the person as excessiveor unreasonable, overcoming it can be quite difficult. About 13.3% ofthe general population may meet criteria for social anxiety disorder atsome point in their lives, according to the highest survey estimate,with the male:female ratio being 2:3.^[2]

Physical symptoms often accompanying social anxiety disorder includeexcessive blushing, sweating (hyperhidrosis),trembling,palpitations, nausea,and stammering. Panicattacks may also occur under intense fear and discomfort. An early diagnosis may help minimize the symptoms and thedevelopment of additional problems, such as depression. Some sufferers may use alcoholor other drugsto reduce fears and inhibitions at social events. It is common forsufferers of social phobia to self-medicate in this fashion, especially ifthey are undiagnosed, untreated, or both; this can lead to alcoholism orother kinds of substance abuse.

A person with the disorder may be treated with psychotherapy,medication, or both. Research has shown cognitivebehavior therapy, whether individually or in a group, to beeffective in treating social phobia. The cognitive and behavioralcomponents seek to change thought patterns and physical reactions toanxiety-inducing situations. Attention given to social anxiety disorderhas significantly increased in the UnitedStates since 1999 with the approval and marketing of drugs for itstreatment. Prescribed medicationsinclude several classes of antidepressants: selective serotoninreuptake inhibitors (SSRIs) such as Zoloft, Prozac, and Paxil, serotonin-norepinephrinereuptake inhibitors (SNRIs) and monoamineoxidase inhibitors (MAOIs). Other commonly used medications include beta-blockers and benzodiazepines (whichare more and more being restricted to short-term use due to sideeffects), as well as newer antidepressants, such as mirtazapine.An herbcalled kavahas also attracted attention as a possible treatment,^[3]although safety concerns exist,^[4][5]especially given the unregulated nature of herbs in the United States.

Contents

• 1 History
• 2 Symptoms
  • 2.1 Cognitive aspects
  • 2.2 Behavioral aspects
  • 2.3 Physiological aspects
• 3 Prevalence
• 4 Comorbidity
• 5 Causes and perspectives
  • 5.1 Genetic and family factors
  • 5.2 Social experiences
  • 5.3 Social/cultural influences
  • 5.4 Evolutionary context
  • 5.5 Neurochemical and neurocognitive influences
  • 5.6 Substance induced
  • 5.7 Psychological factors
• 6 Treatment
  • 6.1 Psychotherapy
  • 6.2 Pharmacological treatments
    • 6.2.1 SSRIs
    • 6.2.2 Other drugs
• 7 See also
• 8 References
• 9 Further reading
• 10 External links

[edit] History

Literary descriptions of shyness can be traced back to the days of Hippocratesaround 400 B.C. Hippocrates described someone who "through bashfulness,suspicion, and timorousness, will not be seen abroad; loves darkness aslife and cannot endure the light or to sit in lightsome places; his hatstill in his eyes, he will neither see, nor be seen by his good will.He dare not come in company for fear he should be misused, disgraced,overshoot himself in gesture or speeches, or be sick; he thinks everyman observes him."^[6]

Charles Darwin wrote about the physiology and social context ofblushing and shyness. The first mention of a psychiatric term, socialphobia (phobie des situations sociales), was made in the early1900s.^{[citation needed]}Psychologists used the term "socialneurosis" to describe extremely shy patients in the 1930s. Afterextensive work by Joseph Wolpe on systematic desensitization,research in phobias and their treatment grew. The idea that socialphobia was a separate entity from other phobias came from the Britishpsychiatrist Isaac Marks, in the 1960s. This was accepted bythe American PsychiatricAssociation and was first officially included in the third editionof the Diagnostic and Statistical Manual of Mental Disorders. Thedefinition of the phobia was revised in 1989 to allow comorbidity with avoidant personality disorder,and introduced generalized social phobia.^[7]Social phobia had been largely ignored prior to 1985.

After a call to action by psychiatrist Michael Liebowitz and clinical psychologistRichard Heimberg, there was an increase in attention toand research on the disorder. The DSM-IV gave social phobia thealternative name social anxiety disorder. Research on the psychology andsociology of everyday social anxiety continued. Cognitive Behaviouralmodels and therapies were developed for social anxiety disorder. In the1990s, paroxetine became the first prescription drug inthe U.S. approved to treat social anxiety disorder, with othersfollowing.

Social phobia in many cases can be an extremely debilitatingdisorder, especially because one who struggles with it often suffersalone.

[edit] Symptoms

[edit] Cognitive aspects

In cognitive models of social anxiety disorder,social phobics experience dread over how they will be presented to others. Theymay be overly self-conscious, pay highself-attention after the activity, or have high performance standardsfor themselves. According to the social psychology theory of self-presentation, a sufferer attemptsto create a well-mannered impression on others but believes he or sheis unable to do so. Many times, prior to the potentiallyanxiety-provoking social situation, sufferers may deliberately go overwhat could go wrong and how to deal with each unexpected case. After theevent, they may have the perceptionthey performed unsatisfactorily. Consequently, they will reviewanything that may have possibly been abnormal or embarrassing. Thesethoughts do not just terminate soon after the encounter, but may extendfor weeks or longer.^[8]Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlookand many studies suggest that socially anxious individuals remember morenegative memories than those less distressed.^[7]

An example of an instance may be that of an employee presenting tohis co-workers. During the presentation, the person may stutter a word,upon which he or she may worry that other people significantly noticedand think that their perceptions of him or her as a presenter have beentarnished. This cognitive thought propels further anxiety whichcompounds with further stuttering, sweating, and, potentially, a panicattack.

[edit] Behavioral aspects

Social anxiety disorder is a persistent fear of one or moresituations in which the person is exposed to possible scrutiny by othersand fears that he or she may do something or act in a way that will behumiliating or embarrassing. It exceeds normal "shyness" as it leads toexcessive social avoidance and substantial social or occupationalimpairment. Feared activities may include almost any type of socialinteraction, especially small groups, dating,parties, talking to strangers, restaurants, etc. Possible physicalsymptoms include "mind going blank", fast heartbeat, blushing, stomach ache, nausea andgagging. Cognitive distortions are a hallmark, and learned about in CBT(cognitive-behavioral therapy). Thoughts are often self-defeating andinaccurate.

The fear ofmaking telephone calls is typical, both answering and picking up,due to conversing's social nature.^{[citation needed]} It mayappear early in childhood.

According to psychologist B.F. Skinner, phobias are controlled by escape and avoidance behaviors. For instance, a student may leave theroom when talking in front of the class (escape) and refrain from doingverbal presentations because of the previously encountered anxietyattack (avoid). Major avoidance behaviors could include an almostpathological/compulsive lying behavior in order to preserve self-imageand avoid judgement in front of others. Minor avoidance behaviors areexposed when a person avoids eyecontact and crosses arms to avoid recognizable shaking.^[7]A fight-or-flight response is thentriggered in such events. Preventing these automatic responses is at thecore of treatment for social anxiety.

[edit] Physiological aspects

Physiological effects, similar to those in other anxiety disorders,are present in social phobics. Faced with an uncomfortable situation,children with social anxiety may display tantrums,weeping, clinging to parents, and shuttingthemselves out.^[9]In adults, it may be tears as well as experiencing excessive sweating, nausea, shaking,and palpitations as a result of the fight-or-flightresponse. The walk disturbance (where you are so worried about how youwalk that you lose balance) may appear, especially when passing a groupof people. Blushing is commonly exhibited by individualssuffering from social phobia.^[7]These visible symptoms further reinforce the anxiety in the presence ofothers. A 2006 study found that the area of the brain calledthe amygdala,part of the limbic system, is hyperactive when patients are shown threateningfaces or confronted with frightening situations. They found thatpatients with more severe social phobia showed a correlation with the increased response in theamygdala.^[10]

[edit] Prevalence

(children)^[12]

(children)^[12]

(children)^[12]

When prevalence estimates were based on theexamination of psychiatric clinic samples,social anxiety disorder was thought to be a relatively rare disorder.The opposite was instead true; social anxiety was common but many wereafraid to seek psychiatric help, leading to an understatement of theproblem.^[7]Prevalence rates vary widely because of its vague diagnostic criteriaand its overlapping symptoms with other disorders. There has been somedebate on how the studies are conducted and whether the illness trulyimpairs the respondents as laid out in the official criteria.Psychologist Dr. RayCrozier argues, "it is difficult to ascertain whether the personbeing interviewed adheres to the DSM-III-R criteria or whether they aremerely exhibiting poor social skills or shyness."^[15]

The National Comorbidity Survey ofover 8,000 American correspondents in 1994 revealed a 12-month andlifetime prevalence rates of 7.9 percent and 13.3 percent making it thethird most prevalent psychiatric disorder after depression and alcoholdependence and the most apparent of the anxiety disorders.^[16]According to U.S. epidemiological datafrom the National Institute of MentalHealth, social phobia affects 5.3 million adult Americans in anygiven year. Cross-cultural studies have reached prevalence rates withthe conservative rates at 5 percent of the population.^[17][18]However, other estimates vary within 2 percent and 7 percent of theU.S. adult population.^[19][20]

Onset of social phobia typically occurs between 11 and 19 years ofage. Onset after age 25 is rare. Social anxiety disorder occurs infemales nearly twice as often as males, although men are more likely toseek help.^[20]The prevalence of social phobia appears to be increasing among white,married, and well-educated individuals. As a group, those withgeneralized social phobia are less likely to graduate from high schooland are more likely to rely on government financial assistance or havepoverty-level salaries.^[21]Surveys carried out in 2002 show the youth of England,Scotland,and Waleshave a prevalence rate of 0.4 percent, 1.8 percent, and 0.6 percent,respectively.^[22]The prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2percent in June 2004 with women (4.6 percent) reporting more than men(3.8 percent).^[23]In Australia,social phobia is the 8th and 5th leading disease or illness for malesand females between 15–24 years of age as of 2003.^[24]Because of the difficulty in separating social phobia from poor socialskills or shyness, some studies have a large range of prevalence.^[25]The table also shows higher prevalence in Brazil.

[edit] Comorbidity

There is a high degree of comorbiditywith other psychiatric disorders. Social phobia often occurs alongsidelow self-esteem and clinical depression, due to lack ofpersonal relationships and long periods of isolation from avoidingsocial situations. To try to reduce their anxiety and alleviatedepression, people with social phobia may use alcohol or other drugs,which can lead to substance abuse. It isestimated that one-fifth of patients with social anxiety disorder alsosuffer from alcohol dependence.^[26]The most common complementary psychiatric condition is unipolardepression. In a sample of 14,263 people, of the 2.4 percent of personsdiagnosed with social phobia, 16.6 percent also met the criteria for clinical depression.^[27]Besides depression, the most common disorders diagnosed in patientswith social phobia are panic disorder (33 percent), generalized anxiety disorder(19 percent), post-traumaticstress disorder (36 percent), substance abuse disorder (18 percent),and attempted suicide (23 percent).^[28]In one study of social anxiety disorder among patients who developedcomorbid alcoholism, panic disorder, or depression, social anxietydisorder preceded the onset of alcoholism, panic disorder and depressionin 75 percent, 61 percent, and 90 percent of patients, respectively. Avoidant personality disorderis also highly correlated with social phobia.^[29]Because of its close relationship and overlapping symptoms with otherillnesses, treating social phobics may help understand underlyingconnection in other psychiatric disorders.

There is research indicating that social anxiety disorder is oftencorrelated with bipolar disorder.^[30]Some researchers believe they share an underlyingcyclothymic-anxious-sensitive disposition.^[31]In addition, studies show that more socially phobic patients treatedwith anti-depressant medication develop hypomaniathan non-phobic controls.^[32][33]This can be seen as the medication creating a new problem, and also hasthis adverse effect in a proportion of those without social phobia.

[edit] Causes and perspectives

Researchinto the causes of social anxiety and social phobia is wide-ranging,encompassing multiple perspectives from neuroscienceto sociology.Scientists have yet to pinpoint the exact causes.Studies suggest that genetics can play a part in combination withenvironmental factors.

[edit] Genetic and familyfactors

It has been shown that there is a two to threefold greater risk ofhaving social phobia if a first-degree relative also has the disorder.This could be due to genetics and/or due to children acquiring socialfears and avoidance through processes of observational learning or parental psychosocialeducation. Studies of identical twins brought up (via adoption)in different families have indicated that, if one twin developed socialanxiety disorder, then the other was between 30 percent and 50 percentmore likely than average to also develop the disorder.^[34]To some extent this 'heritability' may not be specific – for example,studies have found that if a parent has any kind of anxiety disorder orclinical depression, then a child is somewhat more likely to develop ananxiety disorder or social phobia.^[35]Studies suggest that parents of those with social anxiety disorder tendto be more socially isolated themselves (Bruch and Heimberg,1994; Caster et al., 1999), and shyness in adoptive parents issignificantly correlated with shyness in adopted children (Daniels andPlomin, 1985);

Adolescents who were rated as having an insecure (anxious-ambivalent)attachment with their mother as infants were twice as likely to developanxiety disorders by late adolescence,^[36]including social phobia.

A related line of research has investigated 'behavioural inhibition'in infants – early signs of an inhibited and introspective or fearfulnature. Studies have shown that around 10–15 percent of individuals showthis early temperament, which appears to be partly due to genetics.Some continue to show this trait in to adolescence and adulthood, andappear to be more likely to develop social anxiety disorder.^[37]

[edit] Social experiences

A previous negative social experience can be a trigger to socialphobia.^[38][39]perhaps particularly for individuals high in 'interpersonal sensitivity'. For around half ofthose diagnosed with social anxiety disorder, a specific traumatic or humiliating social eventappears to be associated with the onset or worsening of the disorder;^[40]this kind of event appears to be particularly related to specific (performance) social phobia,for example regarding public speaking (Stemberg et al., 1995).As well as direct experiences, observing or hearing about the sociallynegative experiences of others (e.g. a faux pas committed by someone),or verbal warnings of social problems and dangers, may also make thedevelopment of a social anxiety disorder more likely.^[41]Social anxiety disorder may be caused by the longer-term effects of notfitting in, or being bullied, rejected or ignored(Beidel and Turner, 1998). Shy adolescents or avoidant adults have emphasised unpleasantexperiences with peers^[42]or childhood bullying or harassment(Gilmartin, 1987). In one study, popularity was found to be negativelycorrelated with social anxiety, and children who were neglected by theirpeers reported higher social anxiety and fear of negative evaluationthan other categories of children.^[43]Socially phobic children appear less likely to receive positivereactions from peers^[44]and anxious or inhibited children may isolate themselves.^[45]

[edit] Social/culturalinfluences

Cultural factors that have been related tosocial anxiety disorder include a society's attitude towards shyness andavoidance, affecting ability to form relationships or accessemployment or education, and shame.^[46]One study found that the effects of parenting are different dependingon the culture – American children appear more likely to develop socialanxiety disorder if their parents emphasize the importance of other'sopinions and use shame as a disciplinary strategy (Leung et al.,1994), but this association was not found for Chinese/Chinese-Americanchildren. In China,research has indicated that shy-inhibited children are more acceptedthan their peersand more likely to be considered for leadership and consideredcompetent, in contrast to the findings in Western countries.^[47]Purely demographic variables mayalso play a role – for example there are possibly lower rates of socialanxiety disorder in Mediterranean countries and higher ratesin Scandinavian countries, and it has beenhypothesized that hot weather and high density may reduce avoidance andincrease interpersonal contact.

Problems in developing social skills, or 'social effectiveness', maybe a cause of some social anxiety disorder, through either inability orlack of confidence to interact socially and gain positivereactions and acceptance from others. The studies have been mixed,however, with some studies not finding significant problems in socialskills^[48]while others have.^[49]What does seem clear is that the socially anxious perceive their ownsocial skills to be low.^[50]Itmay be that the increasing need for sophisticated social skills informing relationships or careers, and an emphasis on assertiveness andcompetitiveness, is making social anxiety problems more common, at leastamong the 'middle classes'.^[51]An interpersonal or media emphasis on 'normal' or 'attractive' personalcharacteristics has also been argued to fuel perfectionism and feelings ofinferiority or insecurity regarding negative evaluation from others. Theneed for social acceptance or social standing has been elaborated inother lines of research relating to social anxiety^[52]

[edit] Evolutionary context

A long-accepted evolutionary explanation of anxiety is that itreflects an in-built 'fight or flight' system, which errs on the side ofsafety. One line of research suggests that specific dispositions tomonitor and react to social threats may have evolved, reflecting thevital and complex importance of social living and social rank in humanancestral environments. Charles Darwin originally wrote about the evolutionary basisof shyness and blushing, and modern evolutionary psychology andpsychiatry also addresses social phobia in this context.^[53]It has been hypothesized that in modern day society these evolvedtendencies can become more inappropriately activated and result in someof the cognitive 'distortions' or 'irrationalities' identified incognitive-behavioral models and therapies^[54]

[edit]Neurochemical andneurocognitive influences

Some scientists hypothesize that social phobia is related to animbalance of the brain chemical serotonin.A recent study report increased Serotoninand Dopaminetransporter binding in psychotropic medication-naive patients withgeneralized social anxiety disorder.^[55]Sociabilityis also closely tied to dopamine neurotransmission. Low D2 receptor bindingis found in people with social anxiety.^[56]The efficacy of medications which affect serotonin and dopamine levelsalso indicates the role of these pathways. There is also increasingfocus on other candidate transmitters, e.g. Norepinephrine, which may beover-active in social anxiety disorder, and the inhibitory transmitterGABA.

Individuals with social anxiety disorder have been found to have ahypersensitive amygdala, for example in relation to social threatcues (e.g. someone might be evaluating you negatively), angry or hostilefaces, and while just waiting to give a speech.^[57]Recent research has also indicated that another area of the brain, the 'Anterior cingulate cortex', whichwas already known to be involved in the experience of physical pain,also appears to be involved in the experience of 'social pain', forexample perceiving group exclusion.^[58]

[edit] Substance induced

While alcoholinitially helps social phobia, excessive alcohol misuse can worsensocial phobia symptoms and can cause panic disorder to develop or worsenduring alcohol intoxication and especially during alcohol withdrawal syndrome.This effect is not unique to alcohol but can also occur with long termuse of drugs which have a similar mechanism of action to alcohol such asthe benzodiazepines whichare sometimes prescribed as tranquillisers.^[59]Benzodiazepines possess anti-anxiety properties and can be useful forthe short-term treatment of severe anxiety. Like the anticonvulsants,they tend to be mild, well tolerated, and extremely safe.Benzodiazepines are usually administered orally for the treatment ofanxiety; however, occasionally lorazepam or diazepam may be givenintravenously for the treatment of panic attacks.^[60]

The World Council of Anxiety does not recommend benzodiazepines forthe long term treatment of anxiety due to a range of problems associatedwith long term use of benzodiazepines including tolerance, psychomotor impairment, cognitive and memoryimpairments, physical dependence and a benzodiazepine withdrawalsyndrome upon discontinuation of benzodiazepines.^[61]Despite increasing focus on the use of antidepressants and other agentsfor the treatment of anxiety, benzodiazepines have remained a mainstayof anxiolytic pharmacotherapy due to their robust efficacy, rapid onsetof therapeutic effect, and generally favorable side effect profile.^[62]Treatment patterns for psychotropic drugs appear to have remainedstable over the past decade, with benzodiazepines being the mostcommonly used medication for panic disorder.^[63]

Approximately half of patients attending mental health services forconditions including anxiety disorders such as panic disorder or social phobia are the result of alcoholor benzodiazepine dependence.^{[citation needed]}Sometimes anxiety pre-existed alcoholor benzodiazepine dependence but the alcohol or benzodiazepinedependence act to keep the anxiety disorders going and oftenprogressively making them worse. Many people who are addicted to alcoholor prescribed benzodiazepines when it is explained to them they have achoice between ongoing ill mental health or quitting and recovering fromtheir symptoms decide on quitting alcohol and/or their benzodiazepines.It was noted that every individual has an individual sensitivity levelto alcohol or sedative hypnotic drugs and what one person can toleratewithout ill health another will suffer very ill health and that evenmoderate drinking can cause rebound anxiety syndromes and sleepdisorders. A person who is suffering the toxic effects of alcohol orbenzodiazepines will not benefit from other therapies or medications asthey do not address the root cause of the symptoms. Symptoms maytemporarily worsen however, during alcohol withdrawal or benzodiazepinewithdrawal.^[64]

[edit] Psychological factors

Research has indicated the role of 'core' or 'unconditional' negativebeliefs (e.g. I am inept) and 'conditional' beliefs nearer to thesurface (e.g. If I show myself, I will be rejected). They are thought todevelop based on personality and adverse experiences and to beactivated when the person feels under threat.^[65]One line of work has focused more specifically on the key role ofself-presentational concerns.^[66][67]The resulting anxiety states are seen as interfering with socialperformance and the ability to concentrate on interaction, which in turncreates more social problems, which strengthens the negative schema. Also highlighted has been ahigh focus on and worry about anxiety symptoms themselves and how theymight appear to others.^[68]A similar model^[69]emphasizes the development of a distorted mental representation oftheir self and over-estimates of the likelihood and consequences ofnegative evaluation, and of the performance standards that others have.Such cognitive-behavioral models consider the role of negatively-biasedmemories of the past and the processes of rumination after an event, andfearful anticipation before it. Studies havealso highlighted the role of subtle avoidance and defensive factors, andshown how attempts to avoid feared negative evaluations or use 'safetybehaviors' (Clark & Wells, 1995) can make social interaction moredifficult and the anxiety worse in the long run. This work has beeninfluential in the development of Cognitive Behavioral Therapy forsocial anxiety disorder, which has been shown to have efficacy.

[edit] Treatment

The most important clinical point to emerge from studies of socialanxiety disorder is the benefit of early diagnosis and treatment. Socialanxiety disorder remains under-recognized in primarycare practice, with patients often presenting for treatment onlyafter the onset of complications such as clinical depression or substanceabuse disorders.

Research has provided evidence for the efficacyof two forms of treatment available for social phobia: certainmedications and a specific form of short-term psychotherapy called Cognitive-behavioraltherapy (CBT), the central component being gradual exposuretherapy.

[edit] Psychotherapy

Research has shown that cognitive behavioral therapy(CBT) can be highly effective for several anxiety disorders,particularly panic disorder and social phobia.^[70]CBT, as its name suggests, has two main components, cognitive andbehavioral. In cases of social anxiety, the cognitive component can helpthe patient question how they can be so sure that others arecontinually watching and harshly judging him or her. The behavioralcomponent seeks to change people's reactions to anxiety-provokingsituations. As such it serves as a logical extension of cognitivetherapy, whereby people are shown proof in the real world that theirdysfunctional thought processes are unrealistic. A key element of thiscomponent is gradual exposure, in which the patient is confronted by thethings they fear in a structured, sensitive manner. Gradual exposure isan inherently unpleasant technique; ideally it involves exposure to afeared social situation that is anxiety provoking but bearable, for aslong as possible, two to three times a week. Often, a hierarchy offeared steps is constructed and the patient is exposed each stepsequentially. The aim is to learn from acting differently and observingreactions. This is intended to be done with support and guidance, andwhen the therapist and patient feel they are ready. Cognitive-behavioraltherapy for social phobia also includes anxiety management training,which may include techniques such as deep breathing and musclerelaxation exercises, which may be practiced 'in-situ'. CBT can also be conducted partly in group sessions, facilitating the sharing ofexperiences, a sense of acceptance by others and undertaking behavioralchallenges in a trusted environment (Heimberg).

Some studies have suggested social skills training can help withsocial anxiety.^[71]However, it is not clear whether specific social skills techniques andtraining are required, rather than just support with general socialfunctioning and exposure to social situations.^[72]

Additionally, a recent study has suggested that interpersonal therapy,a form of psychotherapy primarily used to treat depression, may also beeffective in the treatment of social phobia.^[73]

[edit] Pharmacologicaltreatments

[edit] SSRIs

Selective serotoninreuptake inhibitors (SSRIs), a class of antidepressants, areconsidered by many to be the first choice medication for generalisedsocial phobia. These drugs elevate the level of the neurotransmitterserotonin, among other effects. The first drug formally approved by the Food and Drug Administrationwas paroxetine,sold as Paxil in the U.S. or Seroxat in the UK. Compared to older forms ofmedication, there is less risk of tolerability and drug dependency.^[74]However, their efficacy and increased suicide risk has beensubject to controversy.

In a 1995 double-blind, placebo-controlledtrial, the SSRI paroxetine was shown to result in clinically meaningfulimprovement in 55 percent of patients with generalized social anxietydisorder, compared with 23.9 percent of those taking placebo.^[75]An October 2004 study yielded similar results. Patients were treatedwith either fluoxetine, psychotherapy, fluoxetine andpsychotherapy, placebo and psychotherapy, or a placebo. The first foursets saw improvement in 50.8 to 54.2 percent of the patients. Of thoseassigned to receive only a placebo, 31.7 percent achieved a rating of 1or 2 on the ClinicalGlobal Impression-Improvement scale. Those who sought both therapyand medication did not see a boost in improvement.^[76]

General side-effectsare common during the first weeks while the body adjusts to the drug.Symptoms may include headaches, nausea, insomniaand changes in sexual behavior. Treatment safety during pregnancy hasnot been established.^[77]In late 2004 much media attention was given to a proposed link betweenSSRI use and juvenile suicide. Forthis reason, the use of SSRIs in pediatric cases of depression is nowrecognized by the Food and Drug Administration as warranting acautionary statement to the parents of children who may be prescribedSSRIs by a family doctor.^[78]Recent studies have shown no increase in rates of suicide.^[79]These tests, however, represent those diagnosed with depression, notnecessarily with social anxiety disorder. However, it should be notedthat due to the nature of the conditions, those taking SSRIs for socialphobias are far less likely to have suicidal ideation than those withdepression.

[edit] Other drugs

Although SSRIs are often the first choice for treatment, otherprescription drugs are also used, sometimes only if SSRIs fail toproduce 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. Theirefficacy appears to be comparable or sometimes superior to SSRIs orbenzodiazepines. However, because of the dietary restrictions required, high toxicity in overdose, and incompatibilities withother drugs, its usefulness as a treatment for social phobics is nowlimited. Some argue for their continued use, however, or that a specialdiet does not need to be strictly adhered to.^[80]A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A(RIMAs) inhibit the MAO enzyme only temporarily, improving the adverse-effectprofile but possibly reducing their efficacy.

Benzodiazepines such as alprazolamand clonazepam are an alternative to SSRIs. Thesedrugs are often used for short-term relief of severe, disabling anxiety.^[81]Although benzodiazepines are still sometimes prescribed for long-termeveryday use in some countries, there is much concern over thedevelopment of drug tolerance, dependency and recreational abuse. It has beenrecommended that benzodiazepines are only considered for individuals whofail to respond to safer medications.^[82]Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter inthe brain; effects usually begin to appear within minutes or hours.

The novel antidepressant mirtazapinehas been proven effective in treatment of social anxiety disorder.^[83]This is especially significant due to mirtazapine's fast onset and lackof many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction).

In Japan, the serotonin-norepinephrinereuptake inhibitor (SNRI), Milnacipranis used in the treatment of Taijin kyofusho a Japanese variant of social anxietydisorder.

Some people with a form of social phobia called performance phobiahave been helped by beta-blockers, which aremore commonly used to control high blood pressure. Taken in low doses,they control the physical manifestation of anxiety and can be takenbefore a public performance.

A novel treatment approach has recently been developed as a result oftranslational research. It has been shown that a combination of acutedosing of d-cycloserine (DCS) withexposure therapy facilitates the effects of exposure therapy of socialphobia.^[84]DCS is an old antibiotic medication used for treatingtuberculosis 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.^[85]It has been shown that administering a small dose acutely 1 hour beforeexposure therapy can facilitate extinction learning that occurs duringtherapy.