Social Anxiety Disorder (Social Phobia)
Symptoms and Treatment 2007
Nothing for Sale! Welcome and Enjoy!
August 2007
Welcome to my website! My name is Chad Miller. Shy kid and Social Anxiety Disorder (formerly called Social Phobia) since teens, my Social Anxiety became pretty severe by late high school. At 26 I finally found out the name "Social Phobia" and that it was medically treatable. Substantial improvement in the quality of life is within the reach of most all with untreated Social Anxiety Disorder. Current research is being done to promote earlier diagnosis and treatment (onset in the childhood or teenage years is common).
Abstract on Symptoms and Treatment of Social Anxiety Disorder:
Journal of Clinical Psychiatry 2001;62 Suppl 12:24-9
Comorbidity, Neurobiology, and Pharmacotherapy of Social Anxiety Disorder.
Pollack MH, Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston 02114
Social anxiety disorder is a common psychiatric illness that imposes persistent functional impairment and disability on persons who have the disorder. The disorder is characterized by a marked and persistent fear of social or performance situations in which embarrassment may occur. It is the most prevalent of any anxiety disorders and is the third most common psychiatric disorder after depression and alcohol abuse. Social anxiety disorder typically begins during childhood with a mean age at onset between 14 and 16 years and is sometimes preceded by a history of social inhibition or shyness. Persons who have social anxiety disorder either endure or avoid social situations altogether because the fear of embarrassment causes such intense anxiety; such avoidance may ultimately interfere with occupational and/or social functioning and lead to significant disability. The duration of social anxiety disorder is frequently lifelong, and there is a high degree of comorbidity with other psychiatric disorders. Social anxiety disorder is a serious illness that frequently runs a chronic course and is associated with significant morbidity. Patients should be treated aggressively using pharmacotherapeutic agents that can be tolerated over the long term. Cognitive-behavioral therapy should also be considered in treatment planning. Efforts to increase the recognition of social anxiety disorder as a common, distressing, and disabling condition are critical. This article discusses the comorbidity, neurobiology, and pharmacotherapy of social anxiety disorder.
(End of abstract)
Symptoms of Social Anxiety Disorder:
Social Anxiety Disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" when it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include most any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, etc. Physical symptoms include "mind going blank", fast heartbeat, blushing, stomach ache. Cognitive distortions are a hallmark, and learned about in CBT. Thoughts are often self-defeating and inaccurate.
Neurobiology of Social Anxiety Disorder:
Dysregulation of neurotransmitter function in the brain is thought to play a key role in Social Phobia (SP). Specifically, dopamine (DA), serotonin (SE), and GABA dysfunction are hypothosized in most cases of moderate to severe SP, in varying degrees depending on the individual. My experience has been completely consistent with this hypothesis. I have responded very well to certain drugs boosting levels of these specific neurotransmitters. The MAOI antidepressant "phenelzine" (Nardil) uniquely boosts levels of all three - and is probably the single most effective (single drug) treatment for Social Phobia.
There is strong evidence for dopamine dysfunction in SP. Comorbidies with other DA hypofunction disorders such as atypical depression, dysthymia, attention deficit disorder (ADD), and alcoholism are common. It has been noted that those with generalized Social Phobia have a 5 times greater risk of developing Parkinson's Disease in later life. (Parkinson's Disease is caused by abnormally low levels of dopamine). Liebowitz observed in comparison studies between the TCA "imipramine" (Tofranil) and the MAOI "phenelzine" (Nardil) that while phenelzine was extremely effective in treating Social Anxiety, imipramine showed no efficacy - with the primary difference in the two drugs being the marked pro-DA effect of Nardil. Recent studies also show low levels of sex steroid "pregnenolone sulphate" in those with generalized Social Phobia and GAD (generalized anxiety disorder). Low PS levels are linked with abnormal dopamine function and passivity.
Since the 1990's, evidence has emerged that an area of the brain called the striatum is different in patients with generalized Social Anxiety Disorder. More recent studies have switched focus to the amygdala, where evidence of abnormality accumulates. The amygdala is a core "primitive" part of the brain where many "automatic" animal type functions are regulated or controlled, such as fear and startle response, anxiety, sex, and aggression.
Research Past and Present:
Current research trends lean towards earlier recognition and treatment of SP. As the "world's most neglected anxiety disorder" becomes more understood by the public, Social Anxiety Disorder will begin to be diagnosed far more frequently in the pre-teen or teen years, resulting in earlier treatment, more "normal" social development, and less later life complications. In my case, during my 3rd grade year I had a 2 months bout of "school phobia", which commonly predicts SP in adulthood. Although Nardil and Klonopin existed at that time, the psychiatric diagnosis of Social Phobia did not. It was not until the early 1990's that key studies began for the medication treatment of SP. Liebowitz (Nardil), and Davidson (Klonopin) were the early pioneers towards highly effective SP medication treatment. Nardil and Klonopin remain the most reliably effective medications to treat Social Anxiety Disorder.
Treatments for Social Anxiety Disorder:
Psychological Treatment:
Among possible psychological treatments for Social Anxiety Disorder, the best studied are CBT (Cognitive Behavioral Therapy) and CGBT (Cognitive Group Behavioral Therapy). While CBT and CGBT can often be helpful, medication treatments have been shown to produce more robust and dramatic improvement of symptoms. Patients with mild symptoms (as well as children or adolescents with Social Anxiety), may wish to pursue CBT or CGBT treatment methods as their first approach, while those with more significant or stubborn symptoms may prefer to use CBT as an adjunct to medication treatment. Good CBT therapists for SP are located primarily in larger cities. The best places to look are probably at large University Clinics or Health Centers.
Research suggests that "general" or "supportive" psychotherapy is also helpful for many patients with Social Anxiety Disorder. This is probably especially true in more moderate and severe cases where issues such as low self esteem and other psychological and/or adjustment difficulties may be more pervasive. Currently there is no evidence that CBT is more, or less, effective than other psychotherapy techniques in the treatment of Social Anxiety. There are no clear guidelines, and one is probably best off trusting their own instincts of what is best for them.
Medication Treatment:
Medication treatment is the "tried and true" method to effectively treat Social Anxiety Disorder. Research trials for the treatment of Social Anxiety are still limited primarily to "monotherapy" treatment (one drug by itself). In actual practice, it is often the case that 2 or more medications are used in combination (polypharmacy). There are likely to be many different treatments (single drug or combinations) which are helpful for a given individual. Experimentation affords one an opportunity to find out which treatments are most satisfactory for them. Despite increasing recognition of "the world's most neglected anxiety disorder" - most Dr's even now in *2007* continue to have relatively little experience (and even less skill) in treating patients with Social Anxiety. Patient self-education continues to play a key role for those wishing to ensure that they receive the appropriate medical intervention they deserve.
A Medication Treatment Algorithm for Social Anxiety:
One reasonable algorithm of trial is as follows:
(Goal is typically effectiveness and tolerability over the long term):
1) Antidepressant
a) SSRI, Effexor, moclobomide ... else try ...
b) MAOI (Nardil)
2) Benzodiazepine
a) Klonopin (alone)
b) Klonopin + Antidepressant (any above)
c) Xanax
3) May wish to augment (add) any of following: (Note: Most of these unstudied for SP)
a) Provigil (modafinil): Mild stimulant. Very low doses 20-100mg/day, divided
b) Ritalin SR (methylphenidate): Stimulant. Very low doses 1.25-10mg/day, divided
c) caffeine: Mild stimulant.
d) Depakene (valproate): Anticonvulsant, may be sedating
e) Neurontin (gabapentin): Anticonvulsant, may be sedating
f) Keppra (levetiracetam): Anticonvulsant, may be sedating
g) Aricept (donepezil): Cholinesterase inhibitor. Very low doses 1.25-2.5/day. Reduce dose if taking other meds.
CERTAIN COMBINATIONS OR SINGLE DRUGS DANGEROUS: CHECK WITH DOCTOR FOR ALL TREATMENT RECOMMENDATION
SSRI's
SSRI Monotherapy INEFFECTIVE in 75%-85% of Patients with Social Phobia
Unfortunately, while the SSRI's are very useful for a variety of depressive and anxiety disorders, even drug company sponsored double blind clinical trials show they FAIL to produce ANY positive response in 75-85% of those who take them in monotherapy for the treatment of SP. In addition, the patients who do respond typically see only mild improvement of SP symptoms. SSRI ads and abstracts often fraudulently claim inflated response rates of 50% or more in the treatment of SP (where did the FDA go?) since these ads fail to subtract the placebo response from drug response (the result is the actual "net" response rate which is *always* used to determine the true, reportable response rate).
A typical SSRI abstract is shown here for a treatment study using Lexapro (escitalopram) for SP. This abstract does show placebo response ... allowing for the observation that 85% of patients FAILED TO SHOW ANY RESPONSE (54%-39% = 15% were responders). Reading the abstract and ignoring the numbers, it may appear as if we have really found something special here to treat SP! The authors conclude that Lexapro was "efficacious" and "well tolerated" (hmmm) - as they will for any "on patent" SSRI (ie; profitable) which shows any measurable effect at all.
For more on this topic see "SSRI Failure in SP".
The Positives of SSRI's: Treating Conditions Associated with Primary Social Phobia
Several SSRI's and SNRI's (collectively termed the "SRI's" on this website) have in recent years gained FDA approval in the treatment of Social Anxiety Disorder. During this time the SRI's have also come to be labeled the "first line treatment" for Social Anxiety Disorder in the general medical community.
Two SSRI's (Paxil and Zoloft) and one SNRI (Effexor XR) - are the only FDA approved drugs for SP at this time. Because of these recent FDA approvals and a relatively low risk of serious adverse events related to overdose and drug interactions, the SRI's are quite easy and legally safe for general physicians and psychiatrists to prescribe. Most Dr's will now initially prescribe an SRI when a previously untreated patient presents with symptoms of Social Anxiety Disorder.
Even though SRI's usually fail to reduce symptoms of SP, their usefulness in SP is increased by the fact that they ARE effective (as are most other antidepressants) in treating a number of depressive and anxiety disorders which commonly accompany Social Anxiety Disorder. Examples are dysthymia, depression, panic disorder, general anxiety (GAD), and obsessive compulsive disorder (OCD). Thus, SSRI's work best when one of these other disorders is the "primary" problem - but not so well (usually not at all) when Social Anxiety Disorder is the primary problem.
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With the exception of Prozac, SSRI's are used predominantly by women in long term treatment, who tolerate and respond to them better than males. This is probably due in part to the anti-androgenic effects of the SSRI's (ie; increase in prolactin, reductions in dopamine).
Fortunately, despite the severe limitations of the SSRI's (taken alone) in treating *primary* Social Anxiety Disorder, the great majority of those with even severe SP can find effective ways to treat it, as we will see.
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Prozac (fluoxetine): The "activating" SSRI with the least side effects - particularly for males. Considered an "atypical SSRI", with effects somewhere in between the SNRI "Effexor" and the other SSRI's.
Zoloft (sertraline): May be activating or sedating. Common side effects: sexual dysfunction, apathy.
Paxil CR (paroxetine): May be sedating. Common side effects: sexual dysfunction , apathy, weight gain.
"Paxil CR" was released in early 2004 when the patent on "Paxil" expired, to acquire a new patent and retain inflated prices on the newer CR version. There is no known difference in efficacy between generic and "CR". There is limited need for a "CR" version since the half life of generic Paxil is near ideal; with an FDA recommended once daily dosing.
Celexa (citalopram): May be activating or sedating. Common side effects: sexual dysfunction, apathy.
Lexapro (escitalopram): May be activating or sedating. Common side effects: sexual dysfunction, apathy.
Lexapro was released in 2002 when the patent expired on Celexa (same manufacturer) to acquire a new patent and retain inflated prices on the newer version. Lexapro contains the same active ingredient as Celexa (escitalopram) with no known clinical differences between the two medications.
"New generation" Antidepressants
These include Effexor XR, Cymbalta, Wellbutrin SR, Remeron and Serzone. They each have fairly different characteristics from each other and from the SSRI's. Used alone, any of them may be mildly helpful for primary SP. Augmentation may modify the effects of any of these to create a more effective SP treatment.
Effexor XR (venlafaxine): Effexor is an "SNRI" (serotonin and norepinephrine reuptake inhibitor). The NE reuptake results in a more activating and energizing profile than that of the SSRI's. Effexor is usually only mildly helpful for primary SP when taken alone. It is a powerful antidepressant which is ironically also effective for GAD (Effexor often increases anxiety in patients with primary Social Anxiety Disorder).
Cymbalta (duloxetine): Cybalta, like Effexor, is an "SNRI" (serotonin and norepinephrine reuptake inhibitor). Cymbalta, released in 2005, differs from Effexor mainly in that it is comparatively more noradrenergic. Cymbalta is not likely to be any more useful for primary Social Anxiety Disorder than Effexor XR ... if anything less so.
Wellbutrin XR (bupropion): Wellbutrin boosts DA and NE, with little effect on SE. It is activating and does not cause weight gain or sexual side effects. It is more similar to stimulants (especially Ritalin) - then to SRI's. It is effective in depression and dysthymia, and one study shows possible efficacy in SP. In practice it tends to leave most with SP still feeling quite anxious. The addition of a serotonergic axiolytic (especially Xanax) can be effective.
Remeron (mirtazapine): Remeron enhances NE activity and has mixed SE effects (enhances 5ht(1) transmission but antagonizes 5ht(2) and 5ht(3) receptors). Remeron also has strong antihistamine effects, which may explain it's prominent sedative effects. Overall, Remeron usually causes significant sedation and/or irritability, and is infrequently used.
TCA's
The TCA's (tricyclic) antidepressants are ineffective in the treatment of primary SP. TCA's emerged in the 1950's along with the MAOI's, and while there are still about 10 of them marketed in the USA, their use has been substantially replaced by the newer antidepressants.
Tofranil (imipramine): This once popular TCA was often used for depression, panic, and GAD.
MAOI's
The MAOI "Nardil" is definitely the MOST powerful and effective antidepressant for Social Phobia.
Nardil (phenelzine): Nardil usually works great for SP! It the "Gold Standard" antidepressant for SP. Nardil is excellent for many other anxiety and depressive disorders also. Reports of Nardil side effects are frequently exaggerated, particularly since Nardil's side effects typically take 2-4 months to diminish or disappear. After several months Nardil tends to cause less side effects than SRI's across comparable dose ranges, with the exception of Prozac. Dietary retrictions are quite minimal based on current information but incorrect and non-updated PDR information is used in most descriptions at present in books and online. (Hopefully an official list will be added here soon). Effective dose range for SP is usually 60-90mg/day. Nardil is usually initiated at a low dose, and increased gradually over a period of several weeks to months. A common error is starting too high or increasing too quickly, and working with a Dr. experienced in prescribing MAOI's is important. MAOI related "hypertensive crisis" is rare in responsible patients, and the risk is certainly overemphasized in most medical literature. Many experts consider the MAOI's to be underutilized. Although it has been reported that the MAOI's have seen a small resurgance in recent years, it is likely they will continue to be used sparingly by MD's. This could change if/when the FDA approves the "selegiline patch" (see below on Eldepryl/selegiline).
MAOI DIET: With some reservation, I link temporarily to a to an MAOI diet I thought was weak, but at least better than the PDR. I recommend sticking to the first 'diet' listed on the page linked to (there are multiple diets listed on this particular page). Please *read carefully* under "foods to avoid" as you will see that what is written is that many of these foods *are* OK or moderation is recommended for that food. I do still disagree with most restrictions in "Avoid". IMO most of them should not be there or should be modified (ie; domestic bottled beer is OK, much more than 1/2 cup with Nardil monotherapy), and no mention that certain cheeses are not a tyramine risk at all (ie; processed cheese). Meat (except liver), soup, many others - these are OK and should *not* be on an "Avoid" list. Note also the large number of "OK" foods (the third and last section of this diet). That section is the most accurate of the three.Parnate (tranylcypromine): Parnate is not as effective as Nardil for SP, but occasionally may work well. Effects are variable, but people with Social Phobia most likely to benefit are those who also have significant depression and fatigue. Augmentation with a benzodiazepine (ie; Klonopin) can be useful in cases of excess agitation or stimulation.
Emsam / Eldepryl (selegiline): On February 28, 2006, the FDA approved selegiline (in a special patch form which carries the brand name (EMSAM) - for the treatment of major depression. The main advantage of the patch (transdermal) delivery over oral tablets are an elimination of the (albeit remote) risk of a "hyptensive crisis" which can rarely occur upon non-adherance to a few dietary restrictions. The elimination of dietary restrictions with Emsam hopefully will lead to an increase of Dr's taking a second look at the "old" MAOI's, which remain the most powerful antidepressants and whose risks are overstated by drug companies eager to sell their patented (profitable) SRI's. We have little experience with selegiline used as an antidepessant except that we know it works, and works well, as do the other MAOI's. Other uses for selegiline in psychiatry and neurology (especially) continue to be discovered as well. Prior to 2006, selegiline was used primarily for use in the treatment of Parkinson's Disease, where it is taken at low doses (oral 5-10mg per day) to boost the effects of L-DOPA, a powerful mainstay dopamine agonist treatment in Parkinson's Disease. (At very low doses selegiline selectively boosts dopamine in the brain). The approval of Emsam by the FDA is good news. It means that Dr's can feel safe in prescribing an MAOI to patients which is officially cleared by the FDA as not requiring any dietary retrictions.
Aurorix (moclobemide): During the mid 1990's 2 early studies in South America showed high rates of efficacy for moclobemide in the treatment of SP. Unfortunately, two larger North American studies in the late 1990's showed no efficacy at all. While study data is conflicting, real world evidence is that moclobemide is no more effective in the treatment of SP than are the SSRI's. Moclobemide does have some advantages (and disavantages) relative to the SSRI's. Moclobomide is equally effective as an antidepressant and causes no sexual side effects or sedation. However, moclobemide is less effective than the SSRI's in the treatment of most anxiety disorders.
Benzodiazepines
Long term use of benzodiazepines remains controversial. About 10 are available but Klonopin is by far the most effective for SP. Xanax is sometimes helpful also.
Klonopin (clonazepam): Klonopin is extremely effective for SP and usually works great. Klonopin can be taken either "as needed" or everday. "As needed" (prn) use can be done up to twice per week, and will usually provide excellent effect within 30 minutes, lasting several hours to 1 day (typical dose .25-.75mg). Taken "long term", Klonopin may be used alone, although sometimes a non-sedating antidepressant is added if depression also exists. Effective dose in long term use usually ranges from 1-5 mg/day (dose should be raised slowly over a period of weeks to months). If energy is sub-par but there is no "depression", the addition of low dose stimulant (caffeine, Provigil) may be helpful. Klonopin works so well that taking too much can result in "disinhibition", similar to the opposite of SP. Other phobias, excessive worrying and fear are likely to diminish also.
Xanax XR (alprazolam): Occasionally may be helpful, especially for women. Alprazolam has a short half life which may limit its utility in long term use. This problem may have been lessened with an "XR" version released in the USA in 2003. Males in particular may find Xanax XR to be too sedating.
Myths About Benzodiazepines:
* "Benzodiazepines are addictive": FALSE for non drug addicts with anxiety disorders.
* "Benzodiazepines are hard to quit": FALSE (for SP, not GAD). Taper slow. Can cross-taper gabapentin if desired.
* "Benzodiazepine dose keeps escalating": FALSE. Dose stabilizes after a few months with continued efficacy.
Possible Drawbacks of Long Term Benzodiazepine Use:
* Depression may be aggrevated.
* Reduced mental sharpness may occur.
* Reduced motivation may occur.
Non-Benzodiazepine 'Anxiolytics' (anti-anxiety agents)
This is a "catch all" section for medications which have anti-anxiety properties but which are not classified as antidepressants, benzodiazepines, anticonvulsants, etc.
Buspar (buspirone): Buspar was approved by the FDA specifically for the treatment of Generalized Anxiety Disorder. Unfortunately Buspar is completely ineffective in the treatment of primary Social Anxiety Disorder. Even an official "Social Phobia Committee" of doctors stated that Buspar (which IS still on patent) "has no place in the treatment of Social Anxiety Disorder". Real world experience confirms that Buspar is of no use in the treatment of primary generalized SP. It may be helpful for those who have *primary* GAD, however, it is not even used much for that purpose.
Inderal (propranolol): Propranolol is a medication used to help lower blood pressure. Propranolol may be helpful in *discrete* Social Phobias (a milder type of SP where only a small number of social situations cause difficulty - ie; public speaking). Propranolol blocks the "fight or flight" response - but little else - and has been shown to be of no benefit in *generalized* primary Social Phobia.
Propranolol has long been used by musicians and other performers who have "butterflies" or other mild physical symptoms of "stage fright". Propranolol is also used frequently off-label to treat essential tremor.
Neurontin (gabapentin): See "Anticonvulsants"
Anticonvulsants
A number of new anticonvulsants have been, or will be, released between 2000-2010, and several of them have been considered as possible treatments for Social Anxiety Disorder. None of the newer anticonvulsants (some of which do have some general anti-anxiety qualities) appear to be of much use in the treatment of primary generalized SP. Neurontin (gabapentin) and Lyrica (pregabalin) fall into this category, and Keppra appears likely to as well. Many newer anticonvulsants like gabapentin and pregabalin are not even especially effective anti-seizure medications, and manufacturers are aggressively seeking alternative, FDA approved (patented) uses for them.
Valproate (valproic acid):
Neurontin (gabapentin): Occasionally slightly effective for SP. Common side effects: sedation, apathy, impaired cognition, imbalance. The manufacturer has recently been under legal attack on charges relating to "lack of efficacy" and "aggressive illicit marketing".
Lyrica (pregabalin): Very similar to gabapentin, but with a longer halflife. As with gabapentin, occasionally slightly effective. Common side effects: sedation, apathy, impaired cognition, imbalance.
Keppra (levetiracetam):
Lamictal (lamotrigine):
Resources
Research and Medication:
Search Pubmed
Medications for SP
Books:
Social Phobia: From Shyness to Stagefright John Marshall, 1995
Essential Guide to Psychiatric Drugs Jack Gorman, 1997, 3rd rev.
Feeling Good David Burns, 1999
Site Author: Chad Miller, 2000-2007
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