AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Social phobia, also called social anxiety disorder, is an anxiety disorder involving intense distress in response to public situations. Individuals with social phobia typically experience symptoms resembling panic during a social encounter. These situations may include speaking in public, using public restrooms, eating with other people, or social contact in general. Patients fear being humiliated or embarrassed by their actions and may become intensely anxious, with increased heart rate, diaphoresis, and other signs of autonomic arousal. These physical symptoms may cause additional anxiety, often leading to a conditioned fear response that reinforces the anxiety of public situations.

Social phobia is considered a disorder if it is severe enough to adversely affect social or occupational functioning. That is, individuals with true social phobia go to great lengths to avoid social situations, usually to their own detriment. The fear of embarrassment is ego dystonic, and patients with social phobia are distressed by their symptoms.

Pathophysiology

The pathophysiology of social phobia is unclear. However, theories have arisen based on the efficacy of pharmacologic agents used to treat social phobia. Thus, serotonergic functioning might be involved because serotonergic reuptake inhibitors help alleviate symptoms. Similarly, some researchers believe in an adrenergic etiology because of the success of propranolol therapy. Neurocircuitry involving the amygdala, a structure involved in fear, may be involved.

Frequency

United States

According to the US national comorbidity survey from 1994, social phobia is the third most common psychiatric disorder in the United States. Prevalence has been estimated at 7%. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals.

International

Lifetime incidence is estimated at 7-12%.

Mortality/Morbidity

Social phobia often leads to extreme social isolation in children and can be a precursor to depression. In adults, academic and occupational functioning also may be affected; often, people with social phobia have significant trouble forming relationships with others.

Sex

In the general population, females are affected more often than males; however, in clinical samples, cases involving males are more prevalent. The reasons for this prevalence are unknown.

Age

Social phobia typically manifests in early adolescence (ie, aged 11-12 years) but may appear in younger children or older adults. Untreated childhood social phobia typically continues into adulthood.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for social phobia are as follows:

• The person has a marked and persistent fear of one or more social or performance situations in which he or she is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Children must show evidence of the capacity for age-appropriate social relationships with familiar people, and the anxiety must occur in peer settings, not just in interactions with adults.
• Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. In children, the anxiety may be expressed as crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
• The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.
• The feared social or performance situations are avoided or are endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared social or performance situation interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships; alternatively, the patient has marked distress about having the phobia.
• In individuals younger than 18 years, the duration is at least 6 months.
• The fear or avoidance is not due to the direct physiological effects of a substance (eg, drug of abuse, medication) or a general medical condition and is not better accounted for by another mental disorder (eg, panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, pervasive developmental disorder, schizoid personality disorder).
• If a general medical condition or another mental disorder is present, the fear in one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others is unrelated to it; for example, the fear is not of stuttering, trembling in persons with Parkinson disease, or exhibiting abnormal eating behavior in persons with anorexia nervosa or bulimia nervosa.
• The phobia is specified as generalized if the fears include most social situations; also consider the additional diagnosis of avoidant personality disorder.
• Associated features include depressed mood; somatic/sexual dysfunction; addiction; and anxious, fearful, or dependent personality.

Physical

A thorough Mental Status Examination should be included, with the following areas specifically assessed:

• General appearance: The patient may be noticeably uncomfortable or anxious in the office. The patient may be hesitant or have difficulty speaking. However, in one-on-one situations, the patient may not demonstrate significant social anxiety.
• Mood/affect: Because depression is commonly comorbid with social phobia, the patient may report depressed or anxious mood and may appear to have a depressed or anxious affect.
• Speech: The patient may speak softly and with hesitancy.
• Thought processes: Thought processes are usually normal, and thinking is goal directed.
• Perception: Auditory or visual hallucinations are not elements of social phobia.
• Thought content: The patient may be preoccupied with what others are thinking about him or her. Delusions are not present, but preoccupation with the scrutiny of others may approach delusional levels. True paranoia or fixed delusions are not consistent with social phobia.
• Cognition: Cognition is normal.
• Suicidal/homicidal ideation: This is not common with social phobia per se, but the social isolation associated with social phobia can lead to despair, depression, and suicidal ideation.

Causes

Genetic factors may contribute to social phobia. Pedigree analyses suggest that first-degree relatives of probands with social phobia are 3 times more likely to have social phobia than controls. However, specific genes have not been isolated. An inhibited temperament in childhood has been linked with the development of social phobia in adolescence.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Agoraphobia without history of panic disorder
Separation anxiety disorder
Generalized anxiety disorder
Specific phobia
Schizoid personality disorder
Avoidant personality disorder
Anxiety disorder not otherwise specified
Performance anxiety, stage fright, and shyness
Substance abuse/dependence

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Basic laboratory studies are prudent and might include a serum CBC count with differential, an electrolyte evaluation, liver function tests, and thyroid function tests.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

A combination of pharmacotherapy and psychotherapy is usually indicated for persons with social phobia.

• Pharmacotherapy
• • Selective serotonin reuptake inhibitors (SSRIs): SSRIs are quickly becoming the standard first-line medication for social phobia. Paroxetine received US Food and Drug Administration (FDA) approval for this indication in 1999 and was the first SSRI to gain such approval. In 2003, sertraline received FDA approval for short- and long-term (20-wk) treatment of social phobia in adults. Venlafaxine, a serotonin/norepinephrine reuptake inhibitor, was also approved for the treatment of social phobia in 2003. Studies suggest that other SSRIs also may be effective. No FDA medications are approved to treat social phobia in children younger than 18 years; however, numerous open and controlled studies support the efficacy of SSRIs in this population.
  • Benzodiazepines: Benzodiazepines may be effective for social phobia, but they are more dangerous (lesser safety profile). Alprazolam and clonazepam have been used successfully.
  • Buspirone: Some studies suggest efficacy in persons with social phobia.
  • Gabapentin: New studies suggest efficacy.
  • Propranolol: Beta-blockers have been used to block the autonomic response in persons with social phobia. Preventing symptoms such as tremor and increased heart rate may lead to successful performance in social situations despite anxiety.
  • Monoamine oxidase inhibitors (MAOIs): Phenelzine has been demonstrated to be effective in controlled studies. The dietary restrictions required when taking MAOIs reduces their popularity. Moclobemide, a newer reversible MAOI, has had some efficacy in persons with social phobia.
• Psychotherapy
• • Behavioral: Behavioral psychotherapies, such as gradual desensitization, may be useful in persons with social phobia. This technique involves gradually exposing the patient to simulated situations that normally cause anxiety in the patient. By mastering the situation without anxiety, the patient is eventually able to tolerate more situations that previously induced anxiety.
  • Cognitive: Cognitive and insight-oriented therapies have proved useful in treating social phobia. Individuals with social phobia often have significant cognitive distortions related to what other people could be thinking about them that might respond to restructuring.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goal of pharmacotherapy is to reduce morbidity.

Drug Category: Selective serotonin reuptake inhibitors

Emerging as the DOC because of their clinical efficacy, ease of use, and excellent safety profile with relatively few adverse effects. Benzodiazepines are effective but require caution because of their lower safety margin and addiction potential. Benzodiazepines can be administered during the 4-6 weeks before SSRIs become effective. Buspirone is clinically efficacious, and studies indicate that gabapentin is also effective.

Drug Name	Fluoxetine (Prozac)
Description	Enhances serotonin activity because of selective reuptake inhibition at neuronal membrane. Available in susp.
Adult Dose	20-60 mg PO qd Geriatric patient: 10-20 mg PO qd, titrate to 20-60 mg PO qd
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; do not administer within 14 d of MAOI therapy
Interactions	Potentiates effects of TCAs, SSRIs, phenothiazines, carbamazepine, flecainide, class 1c antiarrhythmics, and quinidine; serotonergic agents (eg, MAOIs, tryptophan, sibutramine, other appetite suppressants) may induce serotonin syndrome
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in CNS disorder, hepatic dysfunction, breastfeeding, children <18 y, and initiating/discontinuing other antidepressants; common adverse effects include restlessness, sexual dysfunction, GI upset, sleep disturbance, and headache

Drug Name	Sertraline (Zoloft)
Description	FDA approved for social phobia. Enhances serotonin activity because of selective reuptake inhibition at neuronal membrane.
Adult Dose	50-200 mg PO qd Geriatric patient: 25 mg PO qd, titrate to 50-200 mg/d PO
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; do not administer within 14 d of MAOI therapy
Interactions	Potentiates effects of TCAs, SSRIs, phenothiazines, carbamazepine, flecainide, class 1c antiarrhythmics, and quinidine; serotonergic agents (eg, MAOIs, tryptophan, sibutramine, other appetite suppressants) may induce serotonin syndrome
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in CNS disorder, cardiac disease, hepatic or renal dysfunction, other antidepressants, breastfeeding, and children <18 y; common adverse effects include fatigue, sexual dysfunction, GI upset, and sleep disturbance

Drug Name	Fluvoxamine (Luvox)
Description	Enhances serotonin activity because of selective reuptake inhibition at neuronal membrane.
Adult Dose	100-300 mg PO qd; if >100 mg, divided bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; do not administer within 14 d of MAOI therapy
Interactions	Potentiates effects of TCAs, SSRIs, phenothiazines, carbamazepine, flecainide, class 1c antiarrhythmics, and quinidine; serotonergic agents (eg, MAOIs, tryptophan, sibutramine, other appetite suppressants) may induce serotonin syndrome
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in CNS disorder, cardiac disease, hepatic or renal dysfunction, other antidepressants, breastfeeding, and children <18 y; common adverse effects include fatigue, sexual dysfunction, GI upset, and sleep disturbance

Drug Name	Citalopram (Celexa)
Description	Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Although SSRIs have not been compared with one another, based on metabolism and adverse effects, citalopram is considered SSRI of choice for patients with head injury. SSRIs are antidepressants of choice because of their minimal anticholinergic effects. All are equally efficacious. Choice depends on adverse effects and drug interactions.
Adult Dose	20-60 mg PO qd; 10 mg/d initially, titrate by 10 mg/wk
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; concurrent MAOI therapy
Interactions	May be potentiated by azole antifungals, omeprazole, or macrolides; serotonin syndrome may be induced by buspirone, tramadol, MAOIs, or nefazodone; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk prior to SSRIs
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in cirrhosis, suicidal tendencies, SIADH, DM, and breastfeeding; common adverse effects include fatigue and sexual dysfunction

Drug Category: Serotonin/norepinephrine reuptake inhibitors

These agents inhibit neuronal serotonin and norepinephrine reuptake.

Drug Category: Benzodiazepines

By binding to specific receptor sites, appear to potentiate effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.

Drug Name	Alprazolam (Xanax)
Description	Extremely short half-life. Fastest onset of action and also may have most addiction potential.
Adult Dose	0.25 mg PO tid/qid, titrate to 0.75-4 mg/d PO divided tid/qid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; pregnancy; breastfeeding; CNS depression; narrow-angle glaucoma
Interactions	Carbamazepine and disulfiram decrease effects; toxicity increases with cimetidine, lithium, contraceptives, and CNS depressants (including alcohol)
Pregnancy	D - Unsafe in pregnancy
Precautions	Withdrawal symptoms, including seizures, may occur upon abrupt discontinuation

Drug Name	Lorazepam (Ativan)
Description	Sedative hypnotic with short onset of effects and relatively long half-life.
Adult Dose	0.5 mg PO bid/tid, titrate to 0.5-10 mg/d PO divided bid/tid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; pregnancy; breastfeeding; CNS depression; narrow-angle glaucoma; severe hypotension
Interactions	Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease

Drug Name	Diazepam (Valium)
Description	Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Individualize dosage and increase cautiously to avoid adverse effects. Relatively long half-life.
Adult Dose	5 mg PO qd, titrate to 2-40 mg/d PO divided bid/qid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; pregnancy; breastfeeding; CNS depression; narrow-angle glaucoma; severe hypotension
Interactions	Increased toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)

Drug Category: Antianxiety medications (other)

Drug Category: Anticonvulsants

Are used if known to have anxiolytic properties.

Drug Name	Phenelzine (Nardil)
Description	MAOI most commonly used for anxiety disorders. Usually reserved for patients who do not tolerate or whose conditions do not respond to TCA or SSRI antidepressants.
Adult Dose	300-2400 mg/d PO bid/tid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may significantly increase norethindrone levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in severe renal disease

Drug Name	Moclobemide (Moclamine)
Description	Reversible inhibitor of monoamine oxidase type A. Because of selectivity and reversibility, dietary restrictions are not required while taking this medication; hypertensive crises are rare. Not available in the United States.
Adult Dose	300-450 mg PO qd
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; children; presence of adrenal gland tumor; concurrent administration with pain killers or other types of antidepressants
Interactions	Concurrent administration with tricyclic antidepressants may increase chances of serious adverse effects; cimetidine may increase toxicity of moclobemide
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in liver or thyroid dysfunction; may cause headache, sleep disturbances, dizziness or confusion

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Complications

• Social phobia has a wide range severity. It may be mild and associated with minimal distress, or it may be severe to the point of causing marked disability. Extreme avoidance behavior (ie, avoiding contact with others and being unable to maintain employment) sometimes complicates this condition.
• Substance abuse, particularly the abuse of alcohol, sedatives, or narcotics, can also make treatment more difficult because benzodiazepines may not be appropriate or may need to be used with extreme caution in patients with substance dependency.

Prognosis

• Mild social phobia is associated with a good prognosis and may have a benign course.
• Severe avoidance behavior and substance abuse are often associated with a guarded prognosis.

Patient Education

• Patient and family education are important for helping resolve symptoms and preventing a relapse of symptoms. Family support may be helpful in behavioral desensitization techniques and in decreasing the social isolation of the patient. Patients and families should be educated regarding the nature, prognosis, and treatment of the disorder.
• For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles Anxiety, Panic Attacks, and Hyperventilation.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Exercise caution when prescribing benzodiazepines to patients with comorbid substance abuse disorders.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Altamura AC, Pioli R, Vitto M, Mannu P. Venlafaxine in social phobia: a study in selective serotonin reuptake inhibitor non-responders. Int Clin Psychopharmacol. Jul 1999;14(4):239-45. [Medline].
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. 4th ed. Washington, DC: American Psychiatric Association; 2000.
• Beidel DC. Social anxiety disorder: etiology and early clinical presentation. J Clin Psychiatry. 1998;59 Suppl 17:27-32. [Medline].
• Connor KM, Davidson JR, Potts NL, et al. Discontinuation of clonazepam in the treatment of social phobia. J Clin Psychopharmacol. Oct 1998;18(5):373-8. [Medline].
• Heimberg RG, Stein MB, Hiripi E, Kessler RC. Trends in the prevalence of social phobia in the United States: a synthetic cohort analysis of changes over four decades. Eur Psychiatry. Feb 2000;15(1):29-37. [Medline].
• Katzelnick DJ, Kobak KA, Greist JH, et al. Sertraline for social phobia: a double-blind, placebo-controlled crossover study. Am J Psychiatry. Sep 1995;152(9):1368-71. [Medline].
• Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. Jan 1994;51(1):8-19. [Medline].
• Nutt DJ, Bell CJ, Malizia AL. Brain mechanisms of social anxiety disorder. J Clin Psychiatry. 1998;59 Suppl 17:4-11. [Medline].
• Pande AC, Davidson JR, Jefferson JW, et al. Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol. Aug 1999;19(4):341-8. [Medline].
• Stein DJ, Westenberg HG, Yang H, et al. Fluvoxamine CR in the long-term treatment of social anxiety disorder: the 12- to 24-week extension phase of a multicentre, randomized, placebo-controlled trial. Int J Neuropsychopharmacol. Dec 2003;6(4):317-23. [Medline].
• Stein MB. Neurobiological perspectives on social phobia: from affiliation to zoology. Biol Psychiatry. Dec 15 1998;44(12):1277-85. [Medline].
• Stein MB, Liebowitz MR, Lydiard RB, et al. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA. Aug 26 1998;280(8):708-13. [Medline].
• Stein MB, Chavira DA. Subtypes of social phobia and comorbidity with depression and other anxiety disorders. J Affect Disord. Sep 1998;50 Suppl 1:S11-6. [Medline].
• Stein MB, Goldin PR, Sareen J, et al. Increased amygdala activation to angry and contemptuous faces in generalized social phobia. Arch Gen Psychiatry. Nov 2002;59(11):1027-34. [Medline].
• Velosa JF, Riddle MA. Pharmacologic treatment of anxiety disorders in children and adolescents. Child Adolesc Psychiatr Clin N Am. Jan 2000;9(1):119-33. [Medline].
• Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry. 1999;60 Suppl 9:9-13. [Medline].
• Westenberg HG. The nature of social anxiety disorder. J Clin Psychiatry. 1998;59 Suppl 17:20-6. [Medline].
• Zaider TI, Heimberg RG. Non-pharmacologic treatments for social anxiety disorder. Acta Psychiatr Scand Suppl. 2003;72-84. [Medline].

Article Last Updated: Mar 28, 2006