Social anxiety disorder (SAD) or social phobia what is it and how is it treated?

Social phobia is understood as a widespread disease, included, along with agoraphobia, in the group of anxiety-phobic disorders and representing a persistent unmotivated fear of performing any public actions (for example, public speaking), actions accompanied by attention from outsiders (fear of using catering places, public toilets, the inability to do something while being watched, etc.), or even just communicating with strangers and persons of the opposite sex. In general, social phobia is expressed in the fear of being in the spotlight, manifested in painful fears of negative assessments of others and in avoiding such situations.

Short information about social phobia (social anxiety disorder)

In its manifestations, social phobia resembles panic disorder, differing mainly in the presence of a clear and stable, as a rule, the only, situational cause or social situation that causes this state and triggers a cascade of physical reactions, which at the height of their manifestation can be indistinguishable from panic attacks (facial flushing, heart palpitations, sweating, hand tremors, respiratory failure, etc.).

In the absence of timely diagnosis and adequate therapy, social phobia leads to a decrease in working capacity. Starting in early adolescence and being unrecognized, the disease can continue throughout the patient's life.

Incidence of social phobia

The prevalence of social phobia among the population varies from 3 to 13%. However, patients suffering from social phobia are relatively rare in the field of vision of psychiatrists. Only 5% of patients with uncomplicated social phobias use specialized care. Most often, those suffering from this disorder, when contacting a doctor, focus on concomitant complexes of symptoms mainly associated with mood disorders. Among patients who are not covered by therapeutic measures, persons with subthreshold (almost imperceptible to others) social phobias prevail, which do not significantly affect daily activity.

Time of onset of social phobia

Social phobia usually appears during adolescence and early adulthood. Often, the appearance of a phobia coincides with adverse psychogenic or social influences. At the same time, only special situations (answering at the blackboard, passing exams, public speaking, appearing on stage) or contact with a certain group of people (teachers, educators, examiners, representatives of law enforcement agencies, persons with higher social status, or belonging to the opposite sex). Communication with relatives and close friends does not cause fear.

Signs, manifestations, and risk factors of social phobia

The anxiety of expectation of unfavorable situations from the patient's point of view and avoidance behavior are also indispensable attributes of social phobia and most often arise in connection with the possibility of getting into the spotlight. Many signs of social phobia, such as fear of public speaking, are also found in healthy people, so the diagnosis of social phobia is made only if anxiety causes significant discomfort, and phobic experiences are assessed as excessive and unreasonable.

Social phobia can occur intermittently or tend to develop chronically. Patients suffering from this disease, usually live alone. Most often it is observed in single women. Social phobia is often combined with depression, as well as with other disorders of the anxiety-phobic series (simple phobias, agoraphobia, and panic disorder), affective pathology, alcoholism, drug addiction, and eating disorders. The combination of any other mental disorder and social phobia worsens the prognosis and increases the risk of suicide attempts.

Social phobia can be both isolated and generalized disorder. The first of these include monophobia, accompanied by relative restrictions in the field of professional or social activity (fear of public speaking, communication with superiors, performing work operations in the presence of others, eating in public places). In essence, isolated social phobias represent the fear of non-fulfillment in front of people of habitual actions associated with anxious expectations of failure (expectation neurosis), and, as a consequence, avoidance of specific life situations. At the same time, there are no difficulties in communication outside of such key situations. This group of phobias also includes ereitophobia - the fear of blushing, showing awkwardness or confusion in society, in the company of people of the opposite sex. Accordingly, shyness and embarrassment appear in people, accompanied by internal stiffness, muscle tension, tremors, palpitations and other unpleasant sensations.

Therapy of social phobia

The development of severe mental health disorders, the formation of inadequate ways of adaptation and the occurrence of painful conditions associated with social anxiety can be prevented or reduced with early effective treatment. As a rule, the decision to prescribe a special course of therapy for social phobia is made in cases where symptoms of the disease or avoidance behavior are associated with significant psychosocial disturbances. Treatment is offered to every patient whose avoidant behavior affects professional activity or social life, whose fears interfere with a normal life, or whose ability to form social bonds is significantly impaired.

Many patients with social phobia have never heard of such a disease. They may consider their symptoms to be extreme shyness or special personality traits, so they should be reassured that long-term treatment can help.

There are a number of complementary approaches to convince the patient of the need for treatment:

- Explain to the patient that the symptoms observed in them should be interpreted as a social phobia;
- Emphasize that social phobia is a well-studied disease and that it responds well to treatment;
- Explain that phobic avoidance of painful situations is caused by unmotivated anxiety, and medication can reduce it;
- Explain that drug treatment is not addictive, will not become addictive, and once stopped, will not cause withdrawal symptoms.

In addition, the following can significantly help the patient in observing medical recommendations: a description of the treatment regimen; establishing a real time frame for a possible improvement in their condition; the promise to regularly review the treatment regimen to optimize it.

Traditionally, social phobia has been viewed as a condition more suitable for psychotherapeutic correction. However, its isolation as an independent diagnostic category contributed to the development of medication mediated methods of treatment.

Medicines that have a healing effect in social phobia include drugs that neutralize the effects of the monoamine oxidase enzyme in the central nervous system, MAO inhibitors. Other drugs used to treat social phobia include benzodiazepines, beta-blockers, and selective serotonin reuptake inhibitors (SSRIs) (for instance, Paroxetine).

Pharmacotherapy should be started with one of the most effective and safest drugs available. For example, representatives of the MAO inhibitors group (pyrazidol, moclobemide, etc.), demonstrating high efficiency (65 - 80%) and the absence of significant side effects even with prolonged (up to 6 months) use. In addition, the use of these drugs leads to a significant decrease in the number and frequency of pathological episodes, as well as the severity of anticipation anxiety.

After the initial treatment period (1 to 2 months), doctors evaluate the clinical efficacy of therapy. If the patient's symptoms persist to a significant extent, the doctor may increase the dose to the most effective one or prescribe a drug of another group.

Benzodiazepines are less effective drugs that are suitable, however, for the treatment of social phobia. Among them, clonazepam should be noted, which also has an effect that activates the production of serotonin.

Alprazolam (Xanax) shows fairly high effectiveness in social phobia, actively suppressing anxiety, and improving the mood of patients. According to some reports, a positive reaction to the treatment of social phobia with benzodiazepines is observed in 70 - 75% of people receiving these drugs. However, their treatment of social phobia has some drawbacks, and not the least of them is the danger of developing physical dependence in patients who receive this therapy for a long time.

A number of other medications can be used for social phobia. The most promising of these are buspirone (a non-benzodiazepine anxiolytic), Paxil (Paroxetine), and Fluvoxamine (selective serotonin reuptake inhibitors).

There is little evidence that beta-blockers have any beneficial effect on the underlying disease in social phobia. However, they can be taken periodically to relieve tremors, palpitations, and tachycardia, which are often experienced by patients with social phobia in certain situations that force them to be active. For this reason, many patients with social phobia, if necessary, can take drugs such as propranolol and other drugs of this series.

In general, it should be noted that one of the main conditions for the successful treatment of social phobia is the extremely slow rate of increasing the doses of drugs.

It must also be borne in mind that, despite the rapid drop in the severity of anxiety and somatic manifestations of the disease during treatment, as well as a decrease in the sensitivity of patients to public situations, the stereotype of avoidance behavior usually persists for many months, which requires a mandatory additional psychotherapeutic work.

The goal of psychological help is to help patients cope with negative attitudes, such as the belief in the inevitability of failure or failure in social situations - attitudes that are believed to underlie social phobia. Since one of the main goals of psychotherapy is to help patients cope with their anxiety, group forms of treatment are especially useful for social phobia.

Post by: Christopher Ames, MD, pshychiatrist, Medibank, Sydney, New South Wales, Australia