Social anxiety phobia (social phobia)

Question 1

Social anxiety disorder - dx

Answer 1

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples = social interactions (e.g. having a conversation, meeting unfamiliar people), being observed (e.g. eating, drinking) and performing in front of others (e.g. giving a speech).
(In children, the anxiety must occur in peer settings and not just during interactions with adults)
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. will be humiliating or embarrassing; will lead to rejection or offend others)
C. The social situations almost always provoke fear or anxiety.
(In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking or failing to speak in social situations)
D. The social situations are avoided or endured with intense fear or anxiety
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context
F. The fear, anxiety or avoidance is persistent, typically lasting for 6mo or more
G. The fear, anxiety or avoidance causes clinically significant distress or functional impairment (social, occupational)
H. Not caused by substance or another medical condition
I. Not better explained by another mental disorder (e.g. panic disorder, body dysmorphic disorder, ASD)
J. If another medical condition is present (e.g. Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety or avoidance is clearly unrelated or excessive

Question 2

Social anxiety disorder - mx (overview - 3)

Answer 2

Two subtypes:
1. Generalised social anxiety = fear of numerous social situations, including both performance and interactional situations
2. Non-generalised social anxiety = fear of one or just a few situations of performance types
___
3. Treatment is quite different for the two types

Question 3

Social phobia (generalised) - mx

Answer 3

1. Tx of choice = cognitive behavioural therapy (CBT) incorporating exposure-based therapy, social skills training and cognitive therapy
2. For many people, CBT alone is not sufficient to reduce symptoms to a manageable level, so a combination of pharmacotherapy and psychological intervention is needed

Pharmacotherapy

3. SSRIs = first-line (e.g. citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline). If not effective, try venlafaxine
4. MAOIs (e.g. phenelzine) = most powerful pharmacotherapy for generalised social anxiety disorder. Restricted to specialist psychiatric practice because of adverse effect profile, significant interactions with many other drugs and the need to avoid all foods containing tyramine
5. Pharmacotherapy may need to be continued for 6-12mo. After this period, the dose should be slowly reduced, and if possible, the drug stopped. Make every effort to use psychological interventions

Question 4

Social anxiety disorder (non-generalised) - mx

Answer 4

Psychological interventions

1. Control hyperventilation + provide other measures to deal with panic symptoms. Relaxation training, social skills training
2. CBT (including cognitive strategies)

Pharmacotherapy

3. Goal = reducing physiological symptoms (sympathetic overactivity - tremor, palpitations, sweating)
4. Propanolol 10-40mg orally, 30-60 mins before social event or performance - advise pts to take a trial dose at home to assess any possible adverse effects. Avoid in asthma, severe peripheral vascular disease, and in some cases of HF. Use with caution in pts with diabetes
5. Short-acting BZD - can be taken just before the performance situation