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SOURCE

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Source: Melton ST, Kirkwood CK. Anxiety disorders: generalized anxiety, panic, and social anxiety disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146065193.

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CONDITION/DISORDER SYNONYM

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  • Social phobia.

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DEFINITION

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  • Intense, irrational, and persistent fear of being negatively evaluated in social or performance situation. Exposure to feared situation usually provokes panic attack.

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ETIOLOGY

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  • Combination of vulnerability (eg, genetic predisposition, childhood adversity) and stress (eg, occupational, traumatic experience).

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PATHOPHYSIOLOGY

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  • Noradrenergic model:

    • Autonomic nervous system hypersensitive, overreacts to various stimuli.

    • Chronic noradrenergic overactivity downregulates α2-adrenoreceptors.

    • Patients with social anxiety disorder (SAD) appear to have hyperresponsive adrenocortical response to psychological stress.

  • γ-Aminobutyric acid (GABA) receptor model:

    • Underactivity of GABA systems or downregulated central benzodiazepine receptors.

    • Reduced benzodiazepine binding in left temporal lobe.

  • 5-HT model: excessive 5-HT transmission or overactivity of stimulatory 5-HT pathways.

  • Potential abnormalities in amygdala, hippocampus, and various cortical regions.

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EPIDEMIOLOGY

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  • One-year prevalence rate is 8.0%.

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RISK FACTORS

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  • Family history of disorder.

  • Female sex.

  • Negative life experiences.

  • New social or work demands.

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CLINICAL PRESENTATION

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  • Fear about one or more social situations where the individual is exposed to possible scrutiny by others.

    • Fear and anxiety is out of proportion with the actual threat posed and typically lasts 6 or more months.

  • Types.

    • Generalized: fear and avoidance of wide range of social situations.

    • Performance: fear limited to speaking or performing in public.

  • Chronic disorder, with mean age of onset in mid-teens.

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SIGNS AND SYMPTOMS
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  • Fear of being scrutinized by others, embarrassed, and humiliated.

  • Some feared situations include eating or writing in front of others, interacting with authority figures, speaking in public, talking with strangers, using public toilets.

  • Physical symptoms: blushing, “butterflies in stomach,” diarrhea, sweating, tachycardia, trembling.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Fear and avoidance interfering with daily routine or social/occupational functioning.

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DESIRED OUTCOMES

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  • Reduce physiologic symptoms and phobic avoidance.

  • Increase participation in desired social activities.

  • Improve quality of life.

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TREATMENT: GENERAL APPROACH

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  • Patients often respond more slowly and less completely than patients with other anxiety disorders.

  • After improvement, at least 1 year of maintenance treatment recommended to maintain improvement and decrease relapse rate.

  • Long-term treatment may be needed if unresolved symptoms, comorbidity, early onset, or prior history of relapse.

  • Cognitive behavioral therapy (CBT) as effective as pharmacotherapy but may have greater likelihood of maintaining response after treatment termination.

  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have equal efficacy, based on ...

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