Anxiety Disorder, Social

SOURCE

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.

CONDITION/DISORDER SYNONYM

• Social phobia.

DEFINITION

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

ETIOLOGY

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

PATHOPHYSIOLOGY

• 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.

EPIDEMIOLOGY

• One-year prevalence rate is 8.0%.

RISK FACTORS

• Family history of disorder.

• Female sex.

• Negative life experiences.

• New social or work demands.

CLINICAL PRESENTATION

• 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.

SIGNS AND SYMPTOMS

• 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.

DIAGNOSIS

MEANS OF CONFIRMATION AND DIAGNOSIS

• Fear and avoidance interfering with daily routine or social/occupational functioning.

DESIRED OUTCOMES

• Reduce physiologic symptoms and phobic avoidance.

• Increase participation in desired social activities.

• Improve quality of life.

TREATMENT: GENERAL APPROACH

• 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 ...