When does shyness become a disorder?
Social anxiety disorder is highly prevalent but often hidden. Early recognition and effective treatment could reduce the risk for additional psychiatric disorders and accompanying morbidities.
SAD and major depression frequently coexist,4,11,12 challenging clinicians to distinguish social reticence and withdrawal accompanying depression from the fearful avoidance that typifies SAD. SAD usually precedes depression. Asking if the patient experienced social anxiety prior to the onset of depression can help identify SAD with comorbid depression.
Alcohol-related disorders are twice as likely to occur in those affected by SAD as in those not affected. The risk for females increases more than it does for males.2-4 SAD most often precedes alcohol abuse. Studies show that about 30% of patients receiving treatment for alcohol abuse/dependence have SAD. If it remains undetected, the risk of rapid relapse is high. That’s because patients are highly unlikely to participate in psychosocial treatments that help sustain post-treatment abstinence, such as the Alcoholics Anonymous 12-step program. A recent study found that both social anxiety and alcohol abuse disorders improve when SAD in alcoholics is treated.13
A substantially higher percentage of adults with SAD, especially women, have histories of prior childhood sexual and/or physical abuse than the general population.14 Recent studies both in women following rape and in combat veterans with posttraumatic stress disorder (PTSD) suggest that those with perceived life-threatening events are at higher risk for developing secondary SAD than are individuals who experience less severe trauma.15,16 We do not yet know if secondary SAD in trauma victims is different in character or response to treatment.
Individuals with certain medical conditions can develop symptoms resembling SAD. These include stuttering, benign essential tremor,17 Parkinson’s disease, disfiguring burn injuries, and possibly irritable bowel syndrome. Such patients are technically excluded from being diagnosed with SAD, though they would meet criteria if the diagnostic rules were suspended. A limited body of literature and clinical experience suggests that symptoms secondary to physical conditions may respond to the same treatment as SAD in medically healthy persons. A treatment trial for selected patients with SAD symptoms associated with medical conditions may provide significant benefits. Clearly more research is needed in this area.
- “Being embarrassed or looking stupid are among my worst fears.”
- “Fear of embarrassment causes me to avoid doing things or speaking to people.”
- “I avoid activities in which I am the center of attention.”
Connor et al, Depress Anxiety 2001;14:137
A recently developed self-rating scale, the Social Phobia Inventory (SPIN), assesses the spectrum of cognitive, behavioral, and physiological symptoms associated with SAD.18 Three of the 17 SPIN items have been found to identify generalized SAD with a high degree of sensitivity (Box 5).
The 3 main goals of SAD treatment are
- Acute reduction and control of pathological anxiety and related phobic avoidance;
- Adequate treatment of depression or other comorbid conditions;
- Long-term management of the social phobia.
Significant advances in treatment have emerged over the past 2 decades. We now know that cognitive behavioral therapy (CBT), medication, and their combination are efficacious.
Social situations involving speaking or performance are usually predictable, and nongeneralized SAD is thus amenable to use of a beta-blocker or benzodiazepine (Box 6). Beta-blockers are often adequate for control of tremor and increased heart rate. Some patients may also benefit more from judicious use of a benzodiazepine prior to the event.
In contrast, generalized SAD is less predictable, and continual treatment is recommended. Ideally, a medication regimen would be easily tolerated long-term, and would have antidepressant effects and a broad spectrum of efficacy against commonly coexisting disorders. Because of the significant risk for depression in individuals with SAD, first-line antidepressant treatment is preferred when possible over other medications.
The selective serotonin reuptake inhibitors (SSRIs) are now considered the first-line pharmacological treatment for social phobia. Paroxetine was the first to receive FDA approval for generalized SAD.19 Large multicenter studies supporting the efficacy of two other SSRIs—sertraline and fluvoxamine—have been reported.12 The SSRIs also appear to work against the other psychiatric disorders with which SAD commonly co-occurs, such as panic disorder, major depression, generalized anxiety disorder, and PTSD.
The empirical database is very limited, but it appears that SSRI treatment for a significant percentage of patients with SAD may require higher doses (up to twice the amount) than are usually needed for depression.10 Approximately 50% to 65% of patients with generalized SAD respond to any given SSRI. In our experience, failure to respond to one SSRI does not preclude response to a second SSRI.
The irreversible monoamine oxidase (MAO) inhibitor phenelzine was the first antidepressant shown to be useful for SAD. Tranylcypromine is less well studied, but also appears to be effective. The significant side effects (weight gain, orthostatic hypotension, insomnia) and inconvenience of administration have reduced use of these agents.
