Social anxiety disorder (SAD)
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impairing ability to function in at least some aspects of daily life.[4]: 15 These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.
Physical symptoms often include excessive blushing, excessive sweating, trembling, palpitations, rapid heartbeat, muscle tension, shortness of breath,[5] and nausea. Stammering may be present, along with rapid speech. Panic attacks can also occur under intense fear and discomfort. Some affected individuals may use alcohol or other drugs to reduce fears and inhibitions at social events. It is common for those with social phobia to self-medicate in this fashion, especially if they are undiagnosed, untreated, or both; this can lead to alcohol use disorder, eating disorders or other kinds of substance use disorders. SAD is sometimes referred to as an illness of lost opportunities where "individuals make major life choices to accommodate their illness".[6][7] According to ICD-10 guidelines, the main diagnostic criteria of social phobia are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms.[8] Standardized rating scales can be used to screen for social anxiety disorder and measure the severity of anxiety.
The first line of treatment for social anxiety disorder is cognitive behavioral therapy (CBT).[9] Medications such as SSRIs are effective for social phobia, especially paroxetine.[10][11][non-primary source needed] CBT is effective in treating this disorder, whether delivered individually or in a group setting.[12] The cognitive and behavioral components seek to change thought patterns and physical reactions to anxiety-inducing situations. The attention given to social anxiety disorder has significantly increased since 1999 with the approval and marketing of drugs for its treatment. Prescribed medications include several classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs).[13] Other commonly used medications include beta blockers and benzodiazepines.
Medications
Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are the first choice of medication for generalized social phobia but a second-line treatment.[4]: 191 Compared to older forms of medication, there is less risk of tolerability and drug dependency associated with SSRIs.[152]
Paroxetine and paroxetine CR, sertraline, escitalopram, venlafaxine XR and fluvoxamine CR (Luvox CR) are all approved for SAD and are all effective for it, especially paroxetine.[10] All SSRIs are somewhat effective for social anxiety except fluoxetine which was equivalent to placebo in all clinical trials.[153] Paroxetine was able to change personality and significantly increase extraversion.[154][155]
In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55% of patients with generalized social anxiety disorder, compared with 23.9% of those taking placebo.[156] An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, or a placebo. The first four sets saw improvement in 50.8 to 54.2 percent of the patients. Of those assigned to receive only a placebo, 31.7% achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.[157] In double-blind, placebo-controlled trials other SSRIs like fluvoxamine, escitalopram and sertraline showed reduction of social anxiety symptoms, including anxiety, sensitivity to rejection and hostility.[158]
Citalopram also appears to be effective.[159]
General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior. Treatment safety during pregnancy has not been established.[160] In late 2004 much media attention was given to a proposed link between SSRI use and suicidality [a term that encompasses suicidal ideation and attempts at suicide as well as suicide]. For this reason, [although evidential causality between SSRI use and actual suicide has not been demonstrated] the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor.[161] Recent studies have shown no increase in rates of suicide.[162] These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder.
In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls. The hypomania can be seen as the medication creating a new problem.[163][164]
for their efficacy and their proven side effects.[172]
Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine[173][174][175] have shown similar effectiveness to the SSRIs. In Japan, Milnacipran is used in the treatment of Taijin kyofusho, a Japanese variant of social anxiety disorder.[176] The atypical antidepressants mirtazapine and bupropion have been studied for the treatment of social anxiety disorder, and rendered mixed results.[177][178][179]
Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.
A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia.[180] DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory.[181]
Kava-kava has also attracted attention as a possible treatment,[182] although safety concerns exist.[183][184]
