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Source: Melton ST, Kirkwood CK. Anxiety Disorders I: 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. 8th ed. Accessed May 25, 2012.

  • Social phobia

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

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

  • 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.

  • One-year prevalence rate is 7.1%.

  • Family history of disorder
  • Female sex
  • Negative life experiences
  • New social or work demands

  • Types
    • Generalized: Fear and avoidance of wide range of social situations
    • Nongeneralized: Fear limited to one or two situations (e.g., performing, public speaking)
  • 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.

Means of Confirmation and Diagnosis

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

  • Reduce physiologic symptoms and phobic avoidance.
  • Increase participation in desired social activities.
  • Improve quality of life.

  • 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 effective in children ages 6–17 years. Monitor individuals up to 24 years old closely for increased risk of suicidality.

  • CBT: Exposure therapy, cognitive restructuring, relaxation training, and social skills training.
  • Even after response, most patients continue to have residual symptoms.
  • CBT and social skills training are effective in children.

  • See Figure 1 for treatment algorithm.
  • SSRIs
    • Paroxetine, sertraline, and fluvoxamine extended-release first-line for generalized SAD.
    • Citalopram and fluoxetine may also be effective.
    • Onset of effect is 4–8 weeks; maximum benefit often requires 12 weeks or longer.
    • Initiate doses similar to ...

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