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. http://accesspharmacy.com/content.aspx?aid=7989670.
Accessed May 25, 2012.
- 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
- 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
- One-year prevalence rate is 7.1%.
- Family history of disorder
- Female sex
- Negative life experiences
- New social or work demands
- 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.
- Fear of being scrutinized by others, embarrassed, and
- 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
- Fear and avoidance interfering with daily routine or social/occupational
- 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
- 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
- CBT and social skills training are effective in children.
- See Figure 1 for treatment algorithm.
- 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 ...